Key in management is determining timing of onset and ruling out hemorrhage.
Arrange stat I head CT by calling neurorads (pager 39991). Acute stroke takes precedence over all other imaging in the queue.
Ruling out hemorrhage is essential to determining treatment.
Consult the stroke service via pager 34CVA (34282), who will determine role of thrombolysis or anticoagulation.
Call neurosurgery consult early if you suspect a bleed clinically (anticoagulation, brain metaseses, seizure, headache, etc.) Arrange to reverse anticoagulation/coagulopathy if present (order FFP).
Coma/unresponsiveness or inability to protect airway are indications for intubation.
Intubation may also be indicated for blood pressure control in the setting of hemorrhage, or hyperventilation for treatment of increased ICP.
Non-hemorrhagic acute stroke management
Thrombolysis. IV tPA remains the treatment of choice for acute stokes within 3 hours of onset of symptoms (0.9 mg/kg total dose, max dose 90 mg, contraindicated if age >80 or SBP>180). Intra-arterial tPA or clot removal may be delivered via interventional neuroradiology catheterization within 6 hours.
Anticoagulation. IV heparin without a bolus is given with thrombolysis. It is also often indicated if thrombolysis cannot be given. Heparin may be bolused if the neurological deficits appear to be fluctuating or brainstem ischemia is suspected.