Initial Management of Suspected Stroke Before CT Scan

Immediate Assessment and Stabilization

The American Heart Association recommends assessing airway, breathing, and circulation to identify and address any life-threatening conditions 1
Monitor oxygen saturation and provide supplemental oxygen if hypoxemia is detected (O₂ saturation <94%) 1
Obtain vital signs including blood pressure, pulse, respiratory rate, and temperature at least every 30 minutes during initial evaluation 1
Treat hyperthermia (temperature >99.6°F) as it is associated with poor outcomes in stroke patients 1

Perform a rapid neurological assessment using a standardized stroke scale such as the National Institutes of Health Stroke Scale (NIHSS) to document baseline neurological status and stroke severity 2
Document the exact time when the patient was last known to be well, as this is critical for determining eligibility for thrombolytic therapy 3
Assess for stroke mimics (hypoglycemia, seizures, migraine) through focused history and examination 2

Obtain immediate blood glucose measurement to rule out hypoglycemia as a stroke mimic 2
Order the following laboratory tests, though treatment should not be delayed while awaiting results unless specific concerns exist:

Do not routinely treat hypertension in the setting of acute ischemic stroke unless blood pressure is extremely elevated (>220/120 mmHg) 3
For patients who may be eligible for thrombolytic therapy, blood pressure should be lowered and maintained below 185/110 mmHg prior to treatment 3
Avoid rapid or excessive lowering of blood pressure as this might exacerbate existing ischemia 3

Alert the CT department that a patient with suspected acute stroke is being transported to allow immediate access to the scanner 1
Aim to complete the CT scan within 25 minutes of arrival for patients potentially eligible for thrombolytic therapy 1
Ensure a physician skilled in interpreting CT studies is available to promptly review the images 5, 6

Position the head of the bed at 25-30° until large lobar infarctions, hemorrhage, or other causes of increased intracranial pressure are ruled out by imaging 1
Keep the patient NPO (nothing by mouth) until swallowing ability can be assessed 1
Monitor cardiac rhythm as cardiac abnormalities are prevalent among stroke patients 2

Delaying treatment with intravenous thrombolysis while waiting for advanced imaging beyond non-contrast CT 7, 3
Aggressively treating hypertension in acute ischemic stroke patients not eligible for thrombolytic therapy 3
Administering prophylactic anticonvulsant medications, which is not recommended and may have negative effects on neural recovery 4
Delaying transfer to a comprehensive stroke center for patients with suspected large vessel occlusion who present to primary stroke centers 3