What is the protocol for managing a patient presenting with symptoms of a stroke?

Acute Stroke Management Protocol

All patients with suspected stroke must be treated as a medical emergency with the same priority as acute myocardial infarction or major trauma, regardless of symptom severity, with the goal of achieving door-to-needle time ≤60 minutes for thrombolysis-eligible patients. 1, 2

Prehospital Phase

EMS Recognition and Assessment

• Screen all suspected stroke patients using a validated tool incorporating FAST (Face drooping, Arm weakness, Speech difficulty, Time) to rapidly identify stroke symptoms 1
• Perform a second severity assessment screen to identify potential large vessel occlusion candidates for endovascular therapy (look for aphasia, visual changes, neglect) 1
• Measure capillary blood glucose immediately on-scene to exclude hypoglycemia, a common stroke mimic 1
• Minimize on-scene time to ≤20 minutes median for patients within the 4.5-hour treatment window 1

Critical Time Documentation

• Establish the exact time of symptom onset or "last known well" time - this is the single most important piece of information 1
• Document within 15-minute certainty when possible; if unknown, use standardized time blocks (morning 6:00 AM-11:59 AM, afternoon noon-5:59 PM, evening 6:00 PM-11:59 PM, overnight midnight-5:59 AM) 1
• Ensure family/decision-maker accompanies patient or is accessible by phone, especially if patient has language or cognitive impairment 1

Transport Decisions

• Triage as CTAS Level 2 (or Level 1 if airway/breathing/cardiovascular compromise exists) 1
• Transport directly to designated stroke center capable of providing thrombolysis and endovascular therapy 1
• Provide prearrival notification to receiving hospital while en route 1
• Do NOT initiate blood pressure treatment unless systolic BP <90 mmHg (hypotension) 1

Emergency Department Phase

Immediate Triage (0-10 minutes)

• Activate stroke team immediately upon arrival - parallel processing is essential 1, 2, 3
• Triage as Level 2 priority (equivalent to unstable trauma or critical cardiac patient) 1
• Target: physician evaluation within 10 minutes of door arrival 1, 3

Initial Stabilization and Assessment (0-15 minutes)

• Secure airway, breathing, circulation (ABCs) 1, 2, 3
• Administer supplemental oxygen if O₂ saturation <94% to prevent hypoxemia-related secondary brain injury 1, 2, 3
• Establish IV access and draw blood immediately for: CBC, coagulation studies (INR, aPTT), platelets, electrolytes, glucose, creatinine, eGFR, cardiac troponin 1, 2, 3
• Perform neurological examination using NIHSS to determine stroke severity and guide treatment decisions 1, 2, 3
• Measure blood pressure, heart rate/rhythm, temperature, oxygen saturation 1, 2

Urgent Neuroimaging (Target: 25 minutes)

• Non-contrast CT scan is the priority imaging to exclude hemorrhage and assess early ischemic changes 2, 3
• Target: CT completion within 25 minutes, interpretation within 45 minutes of door arrival 1, 3
• Do NOT delay imaging for ECG or chest X-ray unless patient is hemodynamically unstable or has acute cardiac/pulmonary disease 1
• Do NOT wait for laboratory results before proceeding with imaging or treatment decisions (exception: INR if patient on warfarin) 1

Reperfusion Therapy Decision (Target: 60 minutes door-to-needle)

Thrombolysis Eligibility

• Administer IV alteplase (rtPA) 0.9 mg/kg (maximum 90 mg) if patient meets eligibility criteria 2, 3
• Treatment window: within 4.5 hours of symptom onset for most patients 1
• Exclusions from 3-4.5 hour window: age >80 years, oral anticoagulants with INR <1.7, NIHSS >25, history of both stroke and diabetes 1

Blood Pressure Management for Thrombolysis

• Pre-thrombolysis requirement: BP must be <185/110 mmHg 2, 3
• Use labetalol 10-20 mg IV over 1-2 minutes (may repeat once) OR nicardipine IV 5 mg/hr, titrate up by 2.5 mg/hr every 5-15 minutes (maximum 15 mg/hr) 2, 3
• Maintain BP <180/105 mmHg during and for 24 hours after thrombolysis 2, 4, 3
• Monitor BP every 15 minutes for 2 hours, then every 30 minutes for 6 hours, then hourly for 16 hours 4

Endovascular Therapy Consideration

• For large vessel occlusion in anterior circulation: perform mechanical thrombectomy in addition to IV thrombolysis if treatable within 24 hours of symptom onset 3
• Highly selected patients may be eligible up to 24 hours based on advanced neurovascular imaging 1

Post-Treatment Monitoring and Care

Continuous Physiological Monitoring

• Institute automated continuous monitoring of oxygen saturation, arterial blood pressure, heart rhythm, body temperature 2, 3
• Cardiac monitoring for minimum 24 hours to detect atrial fibrillation and life-threatening arrhythmias 2, 3
• Temperature monitoring every 4 hours for first 48 hours, then per routine 2, 3
• Frequent NIHSS assessments (every 15 minutes for 2 hours, then every 30 minutes for 6 hours, then hourly for 16 hours) to detect hemorrhagic transformation, cerebral edema, or seizures 4

Complication Prevention

• Apply intermittent pneumatic compression (IPC) devices immediately for all immobilized patients 2, 3
• Continue IPC until independently mobile, discharge, or 30 days (whichever first) 2, 3
• Add low-molecular-weight heparin (enoxaparin) for high-risk patients; use unfractionated heparin if renal failure 2, 3
• Keep patient NPO until formal swallowing screen completed to prevent aspiration pneumonia 4
• Treat hyperthermia aggressively - elevated temperature worsens stroke outcomes 2, 3

Stroke Unit Admission

• Admit all stroke patients to specialized stroke unit - reduces mortality by 14% at 1 year compared to general medical wards 3
• Target admission to monitored bed within 3 hours 1

Early Rehabilitation

• Initial rehabilitation assessment by specialized therapists within 48 hours 2, 3
• Begin frequent, brief out-of-bed activity within 24 hours (sitting, standing, walking) if no contraindications 2, 3

Critical Pitfalls to Avoid

• Never delay thrombolysis for non-essential tests such as chest X-ray or additional imaging unless specific clinical concerns exist 2
• Never treat single self-limiting seizures with long-term anticonvulsants 2
• Never use anti-embolism stockings alone without IPC or pharmacological prophylaxis 2
• Never allow hyperthermia to persist untreated 2
• Never discharge stroke/TIA patients from ED without diagnostic evaluation, functional assessment, secondary prevention initiation, and ongoing management plan 1

Key Time Benchmarks (NINDS Targets)

Milestone	Target Time
Door-to-physician	10 minutes
Door-to-CT completed	25 minutes
Door-to-CT interpretation	45 minutes
Door-to-needle (thrombolysis)	60 minutes
Neurosurgical expertise available	2 hours
Admitted to monitored bed	3 hours

1, 3