Immediate Stroke Protocol Management

Prehospital Recognition and Emergency Response

The American Heart Association recommends that any person witnessing stroke symptoms must immediately call 9-1-1, and EMS should use the FAST (Face, Arms, Speech, Time) screening tool to identify stroke, as EMS transport with prenotification increases the likelihood of receiving IV thrombolysis by 3-fold and reduces door-to-needle times 1
The International Journal of Stroke suggests that exact time of symptom onset or last known normal time is critical for treatment eligibility, and current medications, particularly anticoagulants, should be reported 2
Visible stroke signs, such as face drooping, arm weakness, and speech difficulty, should be identified by EMS 3
Patient location and current condition changes since symptom onset should be reported by EMS 2, 3

The American College of Emergency Physicians recommends that all suspected stroke patients require immediate clinical evaluation with a target door-to-imaging time of ≤25 minutes and door-to-needle time of ≤60 minutes for eligible patients 2, 1
A rapid neurological examination using the NIHSS scale should be performed to quantify stroke severity 2, 4, 1
Vital signs assessment, including heart rate/rhythm, blood pressure, temperature, and oxygen saturation, should be performed 2, 4
Capillary blood glucose check should be performed, and blood work, including electrolytes, glucose, CBC, INR/aPTT, creatinine/eGFR, and troponin, should be drawn 2, 4, 1

The American Heart Association recommends that blood pressure should be reduced to <185/110 mmHg before administering IV alteplase to avoid hemorrhagic complications 2, 1
Post-thrombolysis, blood pressure should be maintained at <180/105 mmHg for at least 24 hours 5
For non-thrombolysis candidates, blood pressure should only be lowered when SBP >220 mmHg or DBP >120 mmHg, as aggressive reduction may worsen ischemia 2

The American College of Cardiology recommends that IV alteplase (tPA) is the standard of care for eligible patients within 4.5 hours of symptom onset 1
Absolute requirements for IV alteplase include symptom onset <4.5 hours, blood pressure <185/110 mmHg, no evidence of hemorrhage on CT, and target door-to-needle time ≤60 minutes 1

The International Journal of Stroke suggests that new-onset seizures at stroke onset or within 24 hours should be treated with short-acting medications, such as lorazepam IV, if not self-limited 2
A single self-limiting seizure occurring within 24 hours of stroke should not be treated with long-term anticonvulsants, but monitored for recurrent seizure activity 2

The American College of Emergency Physicians recommends that neurological assessments using the NIHSS scale should be performed every 15 minutes for 2 hours, then every 30 minutes for 6 hours, then hourly for 16 hours to monitor for hemorrhagic transformation, cerebral edema, and neurological deterioration 1, 5
Patients should be kept NPO until a formal swallowing screen is completed to prevent aspiration pneumonia 5