Immediate Stroke Protocol Management

Prehospital Recognition and Activation

The American Heart Association recommends that any person witnessing stroke symptoms must immediately call 9-1-1 and use a validated stroke screening tool, such as the FAST scale, to identify probable stroke signs, with EMS arrival associated with a 3-fold higher likelihood of brain imaging within 25 minutes 4, 2.
The American College of Emergency Physicians suggests that EMS dispatch personnel should use stroke recognition protocols to assign priority response, with only 60% of stroke patients currently using EMS despite clear outcome benefits 6, 2.

The American Heart Association recommends that prehospital providers perform immediate assessment and management of airway, breathing, and circulation (ABCs), apply a validated stroke screening tool, and determine the exact time of symptom onset or last known normal time, with EMS prenotification reducing door-to-needle times by 2 minutes 7, 8, 1, 2, 3.
The American College of Cardiology suggests that EMS providers should check blood glucose immediately and treat if <60 mg/dL, provide supplemental oxygen only if saturation <94%, initiate cardiac monitoring, and establish IV access per local protocol, with the goal of minimizing on-scene time to ≤15 minutes 4, 7, 8, 9.

The American Heart Association recommends that hospitals have an organized protocol with a designated acute stroke team, including physicians, nurses, and laboratory/radiology personnel available 24/7, with the goal of achieving a door-to-needle time of ≤60 minutes in ≥50% of patients 1, 3.
The American College of Emergency Physicians suggests that the stroke team should perform a rapid neurological examination, including NIHSS score, obtain vital signs, check capillary blood glucose, obtain a 12-lead ECG, and draw blood tests, with the goal of achieving a door-to-imaging time of ≤25 minutes 4, 1, 3.

The American Heart Association recommends that IV alteplase (tPA) is the standard of care for eligible patients within 4.5 hours of symptom onset, with absolute requirements including blood pressure <185/110 mmHg, no evidence of hemorrhage on CT, and symptom onset <4.5 hours, and post-tPA monitoring including neurological assessments every 15 minutes for 2 hours 9, 10.

The American College of Emergency Physicians suggests that effective stroke systems require coordination between multiple hospital tiers, including primary stroke centers (PSCs) and comprehensive stroke centers (CSCs), with "drip-and-ship" protocols allowing patients to receive IV tPA at PSC before transfer to CSC 7, 1, 2, 3.

The American Heart Association recommends that door-to-needle time should be ≤60 minutes in ≥50% of patients, with secondary goals including door-to-needle time ≤45 minutes in ≥50% of patients, and EMS prenotification rate >67%, with the goal of reducing door-to-needle times and improving patient outcomes 1, 3, 2.