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Ischemic stroke checklist

Initial evaluation

• Perform primary survey.
• Determine the time of onset of symptoms and assess severity with NIHSS.
• Call for immediate neurology consult or activate stroke team.
• Establish IV access.
• Continuous cardiac monitoring
• Start supplemental O2 to keep SpO2 > 94%.
• Obtain POC glucose and treat immediately if < 60 mg/dL or > 400 mg/dL.
• Order immediate head CT (without contrast).
• Stabilize patient prior to neuroimaging as needed.
• Intubation and mechanical ventilation for airway protection or respiratory failure
• Blood pressure management for acute ischemic stroke for shock or hypertensive emergency
• Begin ICP management for cerebral herniation syndromes.
• Consider further imaging (e.g., MRI or CTA with or without perfusion protocol) without delaying reperfusion therapy.
• Evaluate inclusion and exclusion criteria for thrombolysis in consultation with neurology.
• If thrombolysis is indicated:
• Lower blood pressure to < 185/110 mm Hg.
• Administer thrombolytic therapy (per neurologist).
• Evaluate indications for mechanical thrombectomy in discussions with stroke specialists.

After stabilization

• Admit preferentially to stroke unit (medicine or neurology) or ICU for first 24 hours.
• Continue blood pressure management and other neuroprotective measures (e.g., euglycemia, normothermia).
• Perform serial neurological assessments.
• Identify and treat the underlying cause: ECG, laboratory studies, neurovascular studies.
• Ensure supportive care: e.g., NPO and dysphagia screening, VTE prophylaxis, physical and occupational therapy.
• Identify and treat any complications (e.g., seizures, neurogenic fever).
• Start secondary stroke prevention measures (e.g., antiplatelet therapy, statins).
• Obtain 24-hour follow-up imaging, if indicated (post thrombolysis).