Emergency Management of Acute Stroke

Immediate Priorities in the Emergency Department

The American Heart Association recommends performing non-contrast CT scan or brain MRI immediately upon arrival before any specific stroke treatment to differentiate ischemic stroke from hemorrhagic stroke 1
The American College of Cardiology suggests that blood pressure must be lowered to <185/110 mmHg before initiating IV alteplase if thrombolysis is being considered 1, 2
The American Stroke Association recommends maintaining BP <180/105 mmHg for at least 24 hours after thrombolysis 2, 4
The American Heart Association recommends using labetalol as first-line agent for blood pressure control in acute stroke 2, 4
The American College of Cardiology suggests that if the patient is not receiving thrombolysis, blood pressure should not be treated unless it exceeds 220/120 mmHg 2, 5, 4

The American Diabetes Association recommends initiating treatment for blood glucose >200 mg/dL and targeting a glucose range of 140-180 mg/dL 6, 7
The American Heart Association suggests using intravenous insulin infusion with frequent monitoring and dose adjustments for hyperglycemia management 6, 7

The American Thoracic Society recommends providing supplemental oxygen to maintain oxygen saturation ≥94% 1, 3
The American College of Cardiology suggests that tracheal intubation is indicated only if airway is compromised or ventilation is insufficient due to impaired alertness 1

The American Heart Association recommends initiating IV alteplase (0.9 mg/kg, maximum 90 mg over 60 minutes with 10% as initial bolus) as soon as possible if imaging confirms ischemic stroke and patient presents within 4.5 hours of symptom onset 1

The American College of Cardiology warns against aggressively lowering BP in the first 48-72 hours when not giving thrombolysis, as it can extend infarct size by reducing perfusion to the penumbra 5, 4
The American Heart Association advises against using agents that cause precipitous BP drops, such as sublingual nifedipine or sodium nitroprusside, as rapid reduction compromises cerebral perfusion 5

The American College of Cardiology recommends monitoring BP every 15 minutes during thrombolysis treatment and for 2 hours after, then every 30 minutes for the next 6 hours, and every hour for the next 16 hours 2, 5