General order to do first to stroke patients

Initial measures applied to all stroke patients are necessary to stabilize and assess the patient, and prepare for definitive therapy. All current and, probably, future stroke therapies for both ischemic and hemorrhagic stroke are best implemented as fast as possible, so these things need to be done quickly.

• O2 via nasal cannula (routine oxygen delivery in ischemia might improve outcome).
• Intubation may be necessary if the patient shows arterial oxygendesaturation or cannot “protect” their airway from aspiratingsecretions. However, intubation means that the ability to monitorthe neurological exam is lost. The best approach in such patientsis to prepare to intubate immediately, but before doing so, take a moment to be sure the patient does not spontaneously improve or stabilize with good nursing care (suctioning, head position, etc.).
• Consider putting the head of the bed flat. This can significantly help cerebral perfusion. 
• Consider normal saline bolus 250–500 mL if blood pressure is low.
• If the blood pressure is high, antihypertensive treatment.
• Determining the exact time of onset is critical for establishing eligibility for acute therapies, especially TPA. It is very important to be a detective. You will usually be told a time by the  paramedics or ED triage nurse, but be sure to recheck the information you receive from them. If possible, try to speak personally with first-hand witnesses, nursing home staff, etc.
• In most cases, the onset is not observed – the patient is found with the deficit. In that case, or in patients who awaken with symptoms, the onset time is the time the patient was last seen normal. However, if the patient awoke with symptoms, be sure to ask if the patient was up in the middle of the night for any reason (often to go to the bathroom) – as sometimes this puts the patient in the time window for treatment.
• Examine the patient and do the NIH Stroke Scale. The initial stroke severity is the most important predictor of outcome
• Do a non-contrast head CT. This will immediately rule out hemorrhage as blood is bright on a CT.
• The result will determine the first major branching point in therapeutic decision-making.
• Obtaining the CT is often the major impediment in preparing for thrombolytic therapy, so efforts should be made to shorten “door to CT” time, which should be below 30 minutes.
• In some select centers, emergent MRI can be done very quickly and substitute for CT, but this is the exception.
• If the CT shows no blood, try to get the artery open TPA is the only FDA-approved treatment for ischemic stroke, and you should immediately begin to determine if the patient is eligible for this therapy, and prepare for its administration.