Initial Stroke Management in the Emergency Department
Activate a rapid stroke protocol immediately upon patient arrival with a goal of completing evaluation and initiating treatment within 60 minutes, prioritizing non-contrast CT brain imaging within 25 minutes and thrombolysis decision within 30 minutes of door arrival. 1
Immediate Triage and Stabilization (First 10 Minutes)
Triage stroke patients with the same priority as acute myocardial infarction or major trauma, regardless of symptom severity. 1
ABCs and Vital Signs
- Assess airway, breathing, and circulation immediately – intubate if Glasgow Coma Scale ≤8 or inability to protect airway 1
- Administer supplemental oxygen only if oxygen saturation <94% – routine oxygen in non-hypoxic patients provides no benefit 1
- Establish IV access with normal saline and avoid dextrose-containing solutions unless hypoglycemic 2
- Measure blood pressure, heart rate, temperature, and oxygen saturation 1
- Check fingerstick glucose immediately – hypoglycemia (<50-60 mg/dL) is a stroke mimic and contraindication to thrombolysis 1, 2
Critical Time Documentation
Record the exact time the patient was last known to be at neurological baseline – this single piece of information determines all treatment eligibility 1, 2. For wake-up strokes, document when the patient went to sleep (last known well time), not when symptoms were discovered 2.
Neurological Assessment (Within 10 Minutes)
Perform a focused neurological examination using the NIH Stroke Scale (NIHSS) to quantify stroke severity, guide treatment decisions, and provide prognostic information 1. The NIHSS can be completed rapidly by ED physicians and provides standardized communication with the stroke team 1.
Simultaneously activate the stroke team or stroke expert consultation – do not delay notification while completing the full assessment 1.
Immediate Laboratory Studies
Draw blood samples for the following tests, but do not delay imaging or treatment while awaiting results: 1
- Complete blood count 1
- Electrolytes and creatinine 1
- Random glucose 1
- Coagulation studies (INR, aPTT) 1
- Troponin and cardiac enzymes 1
Document current anticoagulant use (warfarin, direct oral anticoagulants) and recent antiplatelet therapy, as these affect reperfusion eligibility 2.
Emergent Brain Imaging (Goal: Within 25 Minutes)
Order non-contrast CT brain immediately – this is the single most critical diagnostic test and should be completed within 25 minutes of ED arrival for thrombolysis candidates 1. CT remains the most practical initial imaging modality at most institutions 1.
A physician skilled in interpreting CT scans must review the study emergently to exclude hemorrhage and assess for early ischemic changes 1. However, early ischemic changes involving even more than one-third of a hemisphere do not preclude rtPA treatment within 3 hours 1.
For patients presenting within 6 hours of symptom onset, obtain CT angiography to identify large vessel occlusions that may benefit from endovascular thrombectomy 2. Do not delay IV thrombolysis to obtain vascular imaging 1.
Blood Pressure Management
For Thrombolysis Candidates (≤4.5 Hours from Onset)
Blood pressure must be reduced to <185/110 mm Hg before administering rtPA to avoid hemorrhagic complications 1, 2. If BP exceeds this threshold:
- Labetalol 10-20 mg IV over 1-2 minutes, may repeat once, or 1
- Nicardipine IV 5 mg/hr, titrate up by 2.5 mg/hr every 5-15 minutes to maximum 15 mg/hr, then reduce to 3 mg/hr when target reached 1, 2
Avoid aggressive BP reduction below target values – cerebral perfusion may be pressure-dependent in acute stroke 2.
For Non-Thrombolysis Candidates
Treat hypertension only if systolic BP >220 mm Hg or diastolic BP >120 mm Hg 1. Aggressive BP lowering may decrease perfusion pressure and worsen ischemia 1. When treatment is required, lower BP by only 15-25% within the first 24 hours 2.
Do not treat hypotension with aggressive BP lowering in the prehospital or early ED setting unless specific thresholds are exceeded 1.
Cardiac Monitoring and ECG
Obtain a 12-lead ECG to identify acute myocardial infarction or atrial fibrillation as potential stroke causes 1. The ECG does not take priority over CT but should be completed promptly 1.
Initiate continuous cardiac monitoring for the first 24 hours to detect atrial fibrillation and potentially life-threatening arrhythmias 1. Treatment of asymptomatic arrhythmias (bradycardia, premature contractions, AV block) is generally not necessary if the patient is hemodynamically stable 1.
Seizure Management
Treat active seizures with short-acting benzodiazepines (lorazepam IV) if not self-limited 1.
Do not administer prophylactic anticonvulsants for a single seizure at stroke onset – there is no evidence of benefit and potential for harm 1, 2. Monitor for recurrent seizure activity during routine vital sign checks 1.
Tests NOT Routinely Needed
Most stroke patients do not require: 1
- Chest x-ray (unless clinical evidence of acute cardiac or pulmonary disease) 1
- Lumbar puncture (CT has very high yield for detecting hemorrhage) 1
- Toxicology screen or blood alcohol level (unless history is uncertain) 1
Critical Time Targets and Quality Benchmarks
Door-to-imaging time: ≤25 minutes 1
Door-to-needle time for IV thrombolysis: ≤30 minutes (median), ≤60 minutes (90th percentile) 2
Each 15-minute reduction in door-to-needle time decreases in-hospital mortality by 5% 2
Common Pitfalls to Avoid
Do not delay treatment for "mild" or rapidly improving symptoms – large vessel occlusions can present with fluctuating deficits 2.
Do not postpone imaging or treatment to obtain additional diagnostic studies such as MRI, echocardiography, or extensive vascular imaging 1. These can be performed after acute treatment decisions 1.
Do not assume patients beyond 4.5 hours are ineligible for therapy – endovascular thrombectomy may be offered up to 24 hours with appropriate imaging selection 2, 3.
Do not withhold thrombolysis based solely on CT findings of early ischemic changes within the 3-hour window 1.
Stroke Team Activation and Protocol Implementation
Establish an organized multidisciplinary stroke team including ED physicians, neurologists, nurses, and radiology/laboratory personnel available 24/7 1. Use standardized protocols to minimize delays – "Time is Brain" 1.
For sites without in-house stroke expertise, utilize FDA-approved teleradiology and telestroke systems for timely imaging interpretation and treatment decisions 1.