Prehospital and Emergency Department Care of the Patient With Acute Stroke

Prehospital and emergency department care of the stroke patient must be focused on identification of potential stroke victims, rapid assessment, and prompt initiation of treatment for eligible individuals. Time from initiation of symptoms to first medical contact represents a significant source of delay in care of the stroke patient. Outreach efforts to educate the lay public on stroke symptoms and immediate activation of emergency medical services (EMS) can mitigate these delays. Patients suffering a potential stroke should be transported to the nearest Acute Stroke-Ready Hospital or Primary Stroke Center. In selected cases, it is reasonable to transport patients suspected of having a large vessel occlusion to endovascular thrombectomy (EVT)-capable centers bypassing other centers. EMS prenotification of potential stroke patients is recommended to allow mobilization of emergency department (ED) resources prior to the patient’s arrival. Advanced imaging should be performed as quickly as possible upon arrival to the ED, and efforts should be made to obtain all necessary imaging in one epoch. Delays in obtaining computerized tomography angiography should not delay treatment of patients eligible to receive intravenous tissue plasminogen activator. Multidisciplinary pathways and protocols should be developed to facilitate initiation of thrombolysis and EVT in eligible patients as rapidly as possible. Delays in thrombolysis and EVT are associated with worse outcomes in stroke patients. Management of subarachnoid hemorrhage and intracranial hemorrhage in the ED should focus on reversal of possible coagulopathy, patient stabilization, and management of hypertension often associated with these conditions.