History, physical assessment, vital signs and exact time of symptom onset determined.
For suspected stroke symptoms less than 4.5 hours
Triage patient with suspected stroke as EMERGENT or RESUSCITATIVE as condition warrants. Involve Emergency Department (ED) physician if at any time the patient becomes unstable, or the neurologist notifies the ED that he/she will be delayed. Patients arriving to the ED via ambulance as a “Stroke Protocol”.
See Appendix: Stroke Protocol.
Initiate medical directive:
- Administer oxygen by nasal prong or face mask. Initiate pulse oximetry protocol to maintain saturated oxygen greater than or equal to 92% (delivery device as per goal-oriented oxygen (O2 ) therapy protocol and patient preference). If patient has a history of chronic obstructive pulmonary disease (COPD) maintain oxygen saturation between 88-92%.
- Enters Hyperacute Stroke Study in Powerchart [entails CT(Computerized Tomography) head, CTA (CT Angiography) head and neck, CT perfusion if patient has an abnormal creatinine and/or GFR less than and/or equal to 30, or patient has allergy to contrast this may not be done. If patient has a hemorrhagic stroke it may not be possible to obtain a complete study. It may also depend on the discretion of the treating physician].
- Initiate intravenous access of 0.9% sodium chloride to keep vein open with a minimum 18 gauge needle, preferably in the antecubital fossa of the non-paretic arm for CT; and second IV(intravenous) reserved for Alteplase [tPA(tissue plasminogen activator)] preferably not in the antecubital but in the forearm, and should be an 18 gauge or 20 gauge.
- Continuous cardiac monitoring.
- Obtain glucose meter reading
- Obtain vital signs and neurological vital signs every 15 minutes. Obtain baseline temperature
- Draw blood samples (Stroke Care Set) which includes: complete blood count, electrolytes, urea, creatinine, International Normalized Ratio(INR), Partial Thromboplastin Time(PTT), random glucose, Creatine Kinase(CK), troponin.
- Obtain STAT 12-lead electrocardiogram(EKG).
- No food, fluid, or medications by mouth until a dysphagia screening has been completed
- Establish End-of-Life Care goals.