Option 1: Ischemic stroke

The patient has obvious aphasia and a facial droop. The nurse tells you these have developed in the last few minutes. You ask him to call the front desk and activate a stroke code. As you place continuous cardiac monitors on the patient, you determine that there are no clinical features of airway compromise. Initial vital signs are heart rate 110 beats/minute, blood pressure 200/108 mm Hg, respiratory rate 20 breaths/minute, and SpO₂ 93%.

Question: What do you do next?

Make your choice, then click on the explanation bubble to reveal the answer.

• Order labetalol to bring the blood pressure down immediately.
• Sit tight and wait for the neurologist to come.
• Transport the patient immediately to radiology for head CT.
• Open the computer and find more history for the neurologist.
• Keep moving down your initial management checklist.

Do not treat hypertension in acute stroke unless the blood pressure is markedly elevated (e.g., systolic blood pressure > 220 mm Hg and/or diastolic blood pressure > 130 mm Hg), there is a concurrent medical emergency (e.g., aortic dissection), or fibrinolytic therapy is anticipated (i.e., hemorrhagic stroke has been ruled out by imaging).

These steps were discussed in the main module, but review is always worthwhile. This list should be part of your muscle memory when you care for a patient with a possible acute stroke. Addressing these steps immediately improves patient safety and frees the neurologist for other tasks.

Question: Which steps should you perform while waiting for the CT scanner and/or neurologist?

Make your choices, then click on the explanation bubbles to reveal the answers.

• Finish the primary survey.
• Start supplemental O₂ to keep SpO₂ > 94%.
• Evaluate whether intubation and/or mechanical ventilation are necessary.
• Assess neurological deficit severity with the National Institutes of Health Stroke Scale (NIHSS).
• Establish IV access and send laboratory studies.
• Obtain immediate POC glucose.
• Evaluate for symptoms of increased intracranial pressure (ICP).
• Evaluate the inclusion and exclusion criteria for thrombolysis.

When it's time to apply the NIHSS in real life, don't forget that you can use the integrated clinical calculator.

Start fibrinolytic therapy as soon as possible if:

• Neuroimaging is consistent with an acute ischemic stroke.
• Stroke duration is < 3 hours.
• There are no exclusion criteria for thrombolysis.

Some patients with a stroke duration of 3–4.5 hours are eligible for fibrinolytic therapy. Consider discussing with a neurologist before initiating thrombolysis in these patients.

Question: Which of the following must be done before starting fibrinolytic therapy?

Make your choices, then click on the explanation bubbles to reveal the answers.

• Assessment of exclusion criteria for thrombolysis in acute ischemic stroke
• CXR
• ECG
• Troponin levels
• Point of care glucose

Whenever possible, consult neurology before initiating fibrinolytic therapy.

Question: What are the target parameters for each of the following in patients with acute ischemic stroke?

Think of your answer for each, then click on the explanation bubbles for the answers.

• Blood pressure
• Temperature
• Glucose

Remember the exclusion criteria mentioned above? Activate the table quiz to test your familiarity with absolute versus relative contraindications for thrombolysis.

Exclusion criteria for thrombolysis

Thrombolysis isn't the only reperfusion therapy possible; mechanical thrombectomy is indicated for select patients. See “Treatment of ischemic stroke” for details. This flowchart also provides a nice summary.

Want to explore the other scenario? Jump over to “Option 2: Hemorrhagic stroke.” You can also return to the main module; see “Signal lost wrap-up.”