Stroke: Assessment in the Emergency Department

Immediate General Assessment and Stabilization in the Emergency Department

Some hospitals aren’t equipped or experienced to handle acute stroke victims. EMS providers must choose health care facilities with stroke centers. If an acute stroke victim is taken to an under-equipped hospital, the facility should have a policy in place for quick, convenient patient transfer to a suitable institution.¹

Hospitals with stroke units should have detailed provider roles to care for acute stroke patients. Specialists decide on a treatment strategy for the patient (e.g. fibrinolytic therapy or endovascular therapy). A stroke unit increases the survival rate, functional outcomes, and quality of life for acute stroke patients.

General Assessment

1. ABCs
2. Oxygen
3. IV Access and Blood Sampling
4. Glucose Monitoring
5. Neurologic Assessment
6. Activate the Stroke Team
7. Order a CT Scan
8. 12-Lead ECG

When the patient arrives, emergency department (ED) personnel have 10 minutes to perform a patient assessment. The general assessment checks the patient’s airway, breathing, and circulation. Providers check the baseline set of vital signs. An intravenous line must be inserted and blood samples may be obtained during this process. Blood tests include random blood sugar, CBC, electrolytes, and coagulation factors at a minimum.

Clinicians next perform a neurological assessment, using The National Institutes of Health Stroke Scale (NIHSS).

After performing the NIHSS and determining the patient’s neurological status, ED personnel activate the Stroke Team, composed of experienced healthcare providers and a neurology specialist who consults and makes treatment decisions per hospital protocols.²

Next, the patient has a CT scan of the brain. Immediate diagnosis by an expert radiologist is necessary and determines whether the patient is experiencing an acute ischemic stroke or an acute hemorrhagic stroke. 

Providers may perform a 12-lead ECG to determine if the patient has an arrhythmia or an acute myocardial infarction, which may cause an embolic stroke.

Related Video – General Stroke Care

Neurologic Assessment

The Stroke Team — composed of qualified nurses, neurovascular consultants, and emergency physicians — performs the neurological assessment, including a focused patient history and physical examination. They accurately determine the time of stroke symptom onset. The stroke team uses assessment tools such as the NIH Stroke Scale (NIHSS) or the Canadian Neurological Scale (CNS). 

To accurately determine symptom onset, providers must confirm the time from multiple informants, asking them the last time they perceived the patient to be normal. The neurologic assessment should not exceed 25 minutes.

Stroke Scale

Read: Immediate Ischemic Stroke Therapies

CT Scan: Ischemia versus Hemorrhage

The treatment differs for ischemic stroke versus hemorrhagic stroke.

Treatment intervention differs as to whether the patient experiences an ischemic or hemorrhagic stroke.³ Providers determine this by performing a non-contrast CT scan of the head. It may determine the presence of anatomical defects within the brain that caused the stroke, such as an aneurysm.

If the institution lacks a CT scan machine, they must immediately transfer the patient to an equipped hospital. Clinicians stabilize the patient before transfer. Providers withhold all anticoagulation medications until hemorrhagic stroke is ruled out.

CT scan images must be completed within 25 minutes of patient arrival in the ED. A radiologist should interpret them within 45 minutes. CT perfusion, CT angiography, or brain MRI also help with the diagnosis. However, they should not delay fibrinolytic treatments if indicated.

CT scan for ischemic stroke (left) and hemorrhagic stroke (right).

Ischemic Route

If a CT scan confirms if the stroke is due to ischemia and with no intracerebral hemorrhage is present, fibrinolytic therapy eligibility is assessed. If providers can’t administer fibrinolytic therapy such as rTPA (recombinant tissue plasminogen activator), they may administer aspirin. If the patient can’t swallow, an aspirin suppository is used.⁴

Hemorrhagic Route

A neurosurgeon consultation is performed If the CT scan confirms the stroke is hemorrhagic. Providers prepare the patient for stroke unit or intensive care unit admission, with the possibility of surgery preparation.

Related Video – Immediate Therapies in Stroke

Summary

EMS must transport stroke victims to a hospital equipped to treat a stroke. Once there, the ED general assessment should not take more than 10 minutes. A Stroke Team, composed of health professionals and a neurologist, examines the patient. Treatment differs depending on if the patient has an ischemic or hemorrhagic stroke, which is determined via CT scan.