CCS Case: Acute Ischemic Stroke — tPA Candidate

Case: Acute Ischemic Stroke — tPA Candidate

Clinical Setup

• Presentation: 67-year-old female with 90 minutes of sudden right-sided weakness, facial droop, and aphasia. Last known well 2 hours ago.
• Location: Emergency Department.

Optimal Order Pathway

1. Immediate Orders (Minute 0–1):
   • Pulse oximetry, continuous cardiac monitoring, BP q15min (do NOT aggressively lower BP unless > 220/120).
   • IV access, Normal saline 0.9% IV @ 75 mL/hr.
   • NPO stat (aspiration precaution until swallow screen).
   • Fingerstick glucose stat (rule out hypoglycemia mimic).
2. Focused Exam (Minute 1–2):
   • Focused neuro exam (NIH Stroke Scale elements: gaze, facial palsy, motor drift, language, neglect).
3. Diagnostics (Minute 2–5):
   • Non-contrast CT head stat (rule out hemorrhage).
   • CBC, BMP, PT/INR, PTT, glucose, ECG 12-lead, troponin.
   • Confirm last-known-well time and tPA contraindications (recent surgery, ICH history, anticoagulant use, platelets, glucose < 50 or > 400).
4. Therapeutics & Consultation (Minute 5–15):
   • Neurology / Stroke team consult stat.
   • If no hemorrhage and no contraindications and within 4.5 hours: Alteplase (tPA) IV per weight-based protocol.
   • Aspirin 325 mg PO only AFTER tPA decision (give within 24–48 h if no tPA; hold first 24 h post-tPA).
   • Statin therapy (high-intensity) once diagnosis confirmed.
   • Advance clock in 15–30 min increments; repeat neuro checks.
5. Disposition (Minute 15–20):
   • Transfer to Stroke Unit / ICU.
   • Order carotid duplex, echocardiogram, telemetry monitoring, swallow evaluation before diet advancement.
6. Final 2 Minutes:
   • Counsel on smoking cessation, blood pressure control, antiplatelet compliance, rehab (PT/OT/speech).
   • Schedule neurology and primary care follow-up.