How should I manage a suspected acute stroke patient who is found asleep, including airway, breathing, circulation, last known well time, and eligibility for thrombolysis?

Management of Suspected Acute Stroke Patient Found Asleep

When a patient is found asleep with suspected stroke symptoms, establish the "last known well" time as when they were last seen normal before going to sleep, immediately stabilize airway-breathing-circulation, and transport urgently to a CT-capable stroke center—these patients may still be eligible for reperfusion therapy using advanced imaging criteria even beyond traditional time windows. 1, 2

Immediate Airway, Breathing, and Circulation Assessment

Airway Management

• Assess for compromised airway or bulbar dysfunction immediately; intubate if Glasgow Coma Scale ≤8 or if the patient cannot protect their airway due to impaired consciousness or brainstem involvement. 1, 3
• Patients with decreased consciousness or posterior circulation strokes are at highest risk for airway compromise due to loss of protective reflexes. 3
• Triage as CTAS Level 1 (highest priority) if airway, breathing, or cardiovascular function is compromised; otherwise CTAS Level 2. 1

Breathing and Oxygenation

• Provide supplemental oxygen only if oxygen saturation falls below 94%—routine oxygen in non-hypoxic patients provides no benefit. 1, 3
• Monitor continuously with pulse oximetry, as hypoxia occurs in approximately 63% of stroke patients within 48 hours. 3

Circulation

• Check blood pressure immediately but do not treat hypertension in the field unless systolic BP ≥220 mmHg, as cerebral perfusion may be pressure-dependent in acute stroke. 2
• Establish cardiac monitoring to detect arrhythmias (particularly atrial fibrillation) that may influence acute management. 1, 2
• Correct hypotension and hypovolemia to maintain systemic perfusion necessary to support organ function. 1

Establishing Last Known Well Time: The Critical Determinant

The "last known well" time is the single most important piece of information for determining treatment eligibility—for wake-up strokes, this is when the patient was last seen normal before going to sleep, NOT when they were found with symptoms. 1, 2

Documentation Requirements

• Record the exact time the patient was last observed to be neurologically normal (typically bedtime). 1
• If a specific time cannot be determined within 15 minutes, use standardized time parameters: 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
• Obtain this information from the patient if able; otherwise from family members or witnesses who last saw the patient normal. 1, 2

Wake-Up Stroke Eligibility for Thrombolysis

• Up to 30% of strokes occur during sleep, and these patients may still be candidates for reperfusion therapy using advanced imaging criteria (DWI-FLAIR mismatch on MRI or perfusion imaging). 4, 5
• Patients eligible for intravenous thrombolysis within 4.5 hours of known or presumed symptom onset should be prioritized. 1
• Some patients may be eligible for endovascular thrombectomy up to 24 hours from last known well when highly selected by neurovascular imaging. 1

On-Scene Assessment and Rapid Transport

Neurological Assessment

• Perform a rapid stroke screen using a validated tool (FAST, CPSS, or similar) to confirm stroke suspicion. 2
• Document baseline neurological deficits using a validated stroke scale (NIHSS or Canadian Neurological Scale) to quantify severity. 2
• Record Glasgow Coma Scale score for handover to receiving hospital. 1

Critical Laboratory and Vital Sign Data

• Check capillary blood glucose immediately—hypoglycemia (<60 mg/dL or <3.3 mmol/L) must be treated with IV dextrose as it mimics stroke and contraindicates thrombolysis. 1, 2
• Establish IV access with normal saline (avoid dextrose-containing fluids unless hypoglycemic). 2
• Document current medications, particularly anticoagulants (warfarin, DOACs) and antiplatelet agents, as these affect reperfusion therapy eligibility. 2

Scene Time Target

• Keep on-scene time ≤15 minutes—do not delay transport for additional interventions that can be performed en route. 1, 2
• All non-essential treatments (IV placement, blood draws) should be completed during transport, not on scene. 1

Pre-Hospital Notification and Transport

Direct Transport Protocol

• Transport immediately to the nearest stroke-capable center with CT imaging and thrombolysis capability, bypassing non-stroke hospitals. 1, 2
• For suspected large vessel occlusion (severe deficits, aphasia, visual field deficits, neglect), consider direct transport to a comprehensive stroke center with endovascular thrombectomy capability. 1

Pre-Notification Content

While en route, provide detailed pre-notification to activate "Code Stroke" at the receiving hospital, including: 1, 2

• Last known well time (when patient went to sleep)
• Time patient was found with symptoms
• Current neurological deficits and stroke scale score
• Glasgow Coma Scale score
• Vital signs and oxygen saturation
• Blood glucose level
• Anticoagulation status
• CTAS triage level
• Estimated time of arrival

Blood Pressure Management During Transport

For Potential Thrombolysis Candidates

• If the patient may be eligible for IV thrombolysis (≤4.5 hours from last known well or eligible by imaging), maintain systolic BP <185 mmHg and diastolic BP <110 mmHg. 2
• If BP exceeds these thresholds, administer labetalol 10 mg IV or initiate nicardipine infusion (starting at 5 mg/h, titrated by 2.5 mg/h every 5–15 minutes, maximum 15 mg/h). 2

For Non-Thrombolysis Candidates

• Treat hypertension only if systolic BP >220 mmHg or diastolic BP >120 mmHg. 2
• If treatment is required, lower BP by only 15–25% within the first 24 hours to avoid worsening cerebral ischemia. 2

Common Pitfalls to Avoid

• Never assume wake-up stroke patients are ineligible for therapy—advanced imaging can identify candidates up to 24 hours from last known well. 1, 4, 5
• Do not delay transport to obtain imaging at a non-CT facility; rapid transport supersedes any on-site intervention without imaging capability. 2
• Do not withhold transport for "mild" or improving symptoms, as large vessel occlusions can present with fluctuating deficits. 2
• Avoid aggressive blood pressure reduction below target values, as this may worsen cerebral perfusion in acute stroke. 2
• Do not postpone establishing last known well time—this single data point determines all subsequent treatment decisions. 1

Expected Outcomes and Time Targets

• Target door-to-needle time at receiving facility is ≤30 minutes (median) and ≤60 minutes (90th percentile). 1
• Each 15-minute reduction in door-to-needle time is associated with a 5% decrease in in-hospital mortality. 2
• Endovascular thrombectomy is effective within 6 hours for most large vessel occlusion patients and up to 24 hours for selected patients meeting advanced imaging criteria. 1, 2