Code Stroke, tPA Administration & Stroke Unit Care for GCC Nurses
🧠BE-FAST Stroke Recognition Mnemonic
Any sudden onset of these signs = suspect stroke. Act immediately. Time is brain — 1.9 million neurons die every minute during ischaemic stroke.
B
Balance
Sudden loss of balance or coordination. Unable to walk, sudden dizziness, falling. Ask: "Can you walk normally?"
E
Eyes
Sudden vision change, double vision (diplopia), or loss of vision in one or both eyes. Ask: "Are you seeing clearly?"
F
Face Drooping
Ask patient to smile. Does one side droop? Is the face numb or uneven? Assess facial symmetry immediately.
A
Arm Weakness
Ask patient to raise both arms. Does one drift downward? Is there numbness, weakness, or inability to raise?
S
Speech Difficulty
Is speech slurred, strange, or absent? Can the patient repeat "The sky is blue"? Assess for aphasia and dysarthria.
T
Time to Act
Note the time symptoms were LAST SEEN NORMAL. Activate Code Stroke immediately. Every second counts.
⏱Stroke vs TIA
TIA (Transient Ischaemic Attack): Symptoms resolve within 24h (typically <1 hour) with no infarction on diffusion-weighted MRI (DWI). Do NOT dismiss — high early stroke risk!
ABCD2 score predicts 2-day stroke risk after TIA (0–7 points)
High-risk TIA (ABCD2 ≥4) — urgent same-day neurology review
Start antiplatelet therapy immediately after TIA if no haemorrhage
10% of TIA patients have stroke within 90 days — half within 48h
Stroke peaks in 40s–50s in GCC — 10–15 years earlier than Western populations. High index of suspicion in younger adults.
Risk Factor Burden
Hypertension, Type 2 diabetes, dyslipidaemia, and smoking are highly prevalent. Metabolic syndrome common in GCC adult population.
Cultural Considerations
Sedentary lifestyle, high-calorie traditional diet, late hospital presentation. Language barriers with expatriate workforce nurses and patients.
🚨Code Stroke Time Targets
Time is brain. Every minute of large-vessel occlusion = 1.9 million neurons lost. These are maximum target times from patient arrival.
25min
Door-to-CT
Non-contrast CT brain to rule out haemorrhage — must precede any thrombolysis decision
60min
Door-to-Needle (tPA)
IV Alteplase administration — ideally within 4.5 hours of last-seen-well
90min
Door-to-Groin (Thrombectomy)
Mechanical thrombectomy for large-vessel occlusion — up to 24h in selected patients
Document the time: Last-seen-well time, arrival time, CT time, thrombolysis decision time, needle time. Nursing documentation of these timestamps is medico-legally critical.
👩⚕️Nurse's Role in Code Stroke
Immediate Actions (0–10 min)
Check BGL immediately — rule out hypoglycaemia as stroke mimic
IV access ×2 (18G or larger), non-affected arm if possible
Bloods: FBC, coagulation screen, U&E, glucose, group & save
12-lead ECG — atrial fibrillation is a major embolic stroke cause
BP both arms simultaneously or sequentially — document both
SpO₂ — O₂ only if SpO₂ <94%; avoid routine supplemental O₂
Assessment & Documentation
Perform and document NIHSS score at baseline
Nil by mouth — do NOT give oral medications or water until swallow assessed by stroke team
GCS, pupil assessment, vital signs
Last-seen-well time — critical for thrombolysis eligibility
Medication history — anticoagulants, antiplatelets, insulin
Obtain consent for CT, CTA, and potential thrombolysis
💉Thrombolysis — IV Alteplase (tPA) Nursing
Dosing Protocol
Total dose: 0.9 mg/kg (maximum 90 mg) Bolus: 10% of total dose IV over 1 minute Infusion: Remaining 90% over 60 minutes Window: Within 4.5 hours of last-seen-well
Absolute Contraindications
Haemorrhage on CT scan
BP >185/110 (uncontrolled — treat first)
Recent major surgery or trauma (<14 days)
Active anticoagulation (INR >1.7, dabigatran/rivaroxaban)
Platelet count <100,000
Prior intracranial haemorrhage
Blood glucose <2.8 or >22.2 mmol/L
BP Monitoring Schedule During & After tPA
Time Period
Frequency
BP Target
Action if Above Target
During infusion (0–60 min)
Every 15 minutes
<180/105
Pause infusion, labetalol IV or hydralazine IV, call physician
Post-infusion (1–2h)
Every 15 minutes
<180/105
Labetalol 10–20mg IV bolus, repeat to max 300mg
2–8 hours post
Every 30 minutes
<180/105
Hydralazine 10mg IV if labetalol unavailable
8–24 hours post
Every 60 minutes
<180/105
Continue monitoring; escalate if persistent elevation
Symptomatic ICH (sICH): Sudden deterioration, new severe headache, nausea/vomiting, BP spike, or worsening NIHSS during or after tPA.
Angioedema (1–5% with tPA): Tongue, lip, or oropharyngeal swelling — risk of airway compromise.
Action: Stop infusion → IM Adrenaline 0.5mg → IV Chlorphenamine → IV Hydrocortisone → Anaesthetics alert for potential intubation
🦵Mechanical Thrombectomy — Nursing Role
Pre-Procedure Preparation
Consent documentation and patient/family education
Groin site assessment — bilateral femoral pulses baseline
Ensure IV access patent, bloods sent including coagulation
Foley catheter insertion (procedure duration and contrast load)
Remove jewellery, nail polish, dentures
Handover to interventional suite with SBAR communication
Post-Procedure Monitoring
Groin puncture site: check for haematoma, bleeding q15min ×4
Distal pulses both feet — compare to baseline
Leg colour, temperature, sensation, movement hourly
NIHSS score post-procedure — document any improvement or decline
Head CT at 24h to assess for haemorrhagic transformation
Bed rest with leg flat for 4–6 hours post femoral access
Stroke Unit Care saves lives. Evidence shows that organised stroke unit care (compared to general ward care) reduces death and dependency by 25%, independent of age, sex, or stroke severity.
🔍Neurological Observations — First 24 Hours
Frequency: GCS + NIHSS + pupils + limb power every 1 hour for first 24h, then every 2–4h if stable. Any deterioration = immediate escalation.
Orthostatic hypotension common — check sitting/standing once mobilising
Resume antihypertensives at 24h if ischaemic stroke, BP permitting
🍬Blood Glucose & Temperature
Target BGL: 7–10 mmol/L. Both hyperglycaemia AND hypoglycaemia worsen stroke outcomes. Avoid tight glycaemic control (risk of hypoglycaemia).
BGL 4-hourly (or continuous CGM if available)
Insulin infusion if persistent BGL >10 mmol/L
Dextrose (IV or oral) if BGL <4 mmol/L
Fever (>37.5°C) worsens outcomes — increases metabolic demand of ischaemic penumbra. Give paracetamol 1g QID. Investigate source: chest, urine, IV sites. Cooling blanket if >38.5°C.
👄Swallow Assessment — Critical Safety
NOTHING by mouth — no water, food, medications, or oral hygiene — until formal swallow screen is completed. Aspiration pneumonia is a leading cause of post-stroke death.
Bedside Swallow Screen (3-Step)
Step 1: Alertness — patient must be awake and cooperative
Step 2: Voluntary cough — must be able to cough on command
Step 3: Water swallow test — 5mL, 10mL, 50mL — observe for coughing, wet voice, O₂ desaturation (>2% drop)
Fail any step → SALT referral, NGT insertion, IV fluids
Dysphagia Management
SALT assessment → modified texture diet (IDDSI framework Level 4–6)
Thickened fluids (Level 1–3 depending on assessment)
Upright 90° positioning for all oral intake
NGT for medications if swallow failed — PEG if dysphagia persists >2–4 weeks
Bed position: HOB 0–30° flat for first 24h in ischaemic stroke (increases cerebral perfusion). Raise to 30° after 24h and if pneumonia risk is high.
Early mobilisation: 24–48h post stable ischaemic stroke
Very early mobilisation (<24h) NOT recommended — AVERT trial showed harm
Haemorrhagic stroke: 48–72h or per neurosurgery guidance
Affected limb positioning to prevent shoulder subluxation
Pressure injury prevention — 2-hourly repositioning if not mobile
TED stockings for DVT prevention (LMWH avoided first 24h in ICH)
🩺Haemorrhagic Stroke Differences
Key difference: Thrombolysis and antiplatelet therapy are CONTRAINDICATED in haemorrhagic stroke. Management is largely supportive and surgical.
BP target: SBP <140–160 mmHg (intensive lowering reduces haematoma expansion)
Reverse anticoagulation: Vitamin K + PCC (4-factor) for warfarin; Idarucizumab for dabigatran; Andexanet alfa for factor Xa inhibitors
Surgical consult: Cerebellar ICH >3cm, lobar ICH with deterioration, SAH with hydrocephalus
ICP monitoring: GCS ≤8 or clinical signs of raised ICP — HOB 30°, avoid Valsalva, osmotherapy
Seizure prophylaxis: Only if seizure occurs — not routine in ICH
💊Antiplatelet Therapy (Ischaemic Stroke)
Start immediately after CT confirms no haemorrhage. Do NOT give if thrombolysis is planned (wait 24h post-tPA for antiplatelets).
Aspirin 300mg loading dose immediately (if no tPA, no haemorrhage)
Then Aspirin 75mg daily long-term
DAPT: Aspirin 75mg + Clopidogrel 75mg for 21 days after minor stroke (NIHSS ≤3) or TIA — then single antiplatelet
Clopidogrel 75mg daily as alternative to aspirin (CAPRIE trial)
Antiplatelet NOT needed if starting anticoagulation for AF
🫀AF & Anticoagulation
AF causes 15–20% of all strokes. Anticoagulation (not antiplatelet alone) reduces AF-related stroke risk by 60–70%.
NOACs preferred over warfarin (lower ICH risk, easier monitoring)
Dabigatran, Rivaroxaban, Apixaban, Edoxaban — standard dosing per renal function
Warfarin (INR 2–3) if NOAC contraindicated or mechanical heart valve
Timing after ischaemic stroke: small stroke — 3–4 days; moderate — 6–7 days; large — 12–14 days (haemorrhagic transformation risk)
NEVER anticoagulate in acute haemorrhagic stroke
🧮CHA₂DS₂-VASc Score Calculator (AF Stroke Risk)
Score ≥2 in males or ≥3 in females = anticoagulation recommended. Score 1 in males or 2 in females = consider anticoagulation.
C — Congestive Heart Failure+1
H — Hypertension+1
A² — Age ≥75 years+2
D — Diabetes Mellitus+1
S² — Prior Stroke / TIA / Thromboembolism+2
V — Vascular Disease (MI, PAD, aortic plaque)+1
A — Age 65–74 years+1
Sc — Sex Category (Female)+1
0
CHA₂DS₂-VASc Score
Select risk factors above
📉BP & Statin Therapy
Blood Pressure
Target SBP <130 mmHg after first 2 weeks post-stroke
ACEi (Ramipril, Perindopril) or ARB (Irbesartan) first-line
Add thiazide diuretic or CCB if target not reached
Most important modifiable risk factor for stroke prevention
Statin Therapy
Atorvastatin 40–80mg for all ischaemic stroke / TIA patients
LDL target <1.8 mmol/L (or >50% reduction from baseline)
High-intensity statin even if baseline LDL is normal
Consider adding ezetimibe if LDL target not reached on statin alone
🌙GCC-Specific Prevention Challenges
Ramadan Medication Adjustments: Patients may refuse or alter medication timing. Plan dosing schedule adjustments with physician before Ramadan for stroke prevention medications.
Driving: Do not drive until cleared by medical team — typically 4 weeks minimum, longer if significant deficit
Follow-up: Stroke clinic in 2 weeks, brain imaging review, anticoagulation or antiplatelet review
📝Knowledge Check — 10 MCQ Quiz
Test your acute stroke nursing knowledge. Click an answer to reveal the explanation.
1. A 52-year-old man suddenly develops right-sided arm weakness and slurred speech. Your first action should be:
Hypoglycaemia is the most important and treatable stroke mimic. Always check BGL immediately before activating full stroke protocol — this takes 30 seconds and can avoid unnecessary interventions.
2. A patient weighs 80kg. What is the correct tPA (Alteplase) dose for acute ischaemic stroke?
Dose = 0.9mg/kg × 80kg = 72mg. Bolus = 10% (7.2mg) over 1 minute; remaining 90% (64.8mg) over 60 minutes. Note: maximum total dose is 90mg regardless of weight.
3. A patient receiving IV tPA develops sudden worsening of neurological deficit, new severe headache, and BP rises to 210/110. What is your FIRST action?
These are signs of symptomatic intracranial haemorrhage (sICH) — the most feared complication of tPA. Stop the infusion FIRST, then call the physician urgently, arrange urgent CT brain, and prepare for haematological reversal if confirmed.
4. Which blood pressure target is CORRECT for a patient with acute ischaemic stroke who has NOT received tPA and has a BP of 180/95?
In acute ischaemic stroke WITHOUT tPA, permissive hypertension is the standard of care. The ischaemic penumbra relies on elevated blood pressure for collateral perfusion. Only treat if BP >220/120. Aggressive lowering causes harm.
5. A 68-year-old female with AF, hypertension, type 2 diabetes, and a prior TIA 6 months ago. What is her CHA₂DS₂-VASc score?
H(HTN)=1, A²(age 65–74)=1, D(DM)=1, S²(prior TIA)=2, Sc(female)=1 = Total 6. She has a very high stroke risk and anticoagulation is strongly recommended. Age 65–74 scores 1 point (A category), not the 2-point A² category (age ≥75).
6. A post-stroke patient fails the bedside water swallow test. What is the MOST appropriate immediate action?
A failed swallow screen means nil by mouth — no water, food, or oral medications until formal speech and language therapy (SALT) assessment. NGT may be required for medications and nutrition. PEG is considered only after 2–4 weeks of persistent dysphagia.
7. Which of the following is an ABSOLUTE contraindication to IV tPA in acute ischaemic stroke?
BP >185/110 that cannot be controlled IS an absolute contraindication to tPA. Age >80 is a relative consideration (not absolute in current guidelines). Prior stroke >3 months is NOT a contraindication. Severe NIHSS (>25) is a relative contraindication but not absolute.
8. How often should you monitor BP during the first 2 hours of IV tPA infusion?
BP must be monitored every 15 minutes during tPA infusion and for the first 2 hours post-infusion. After that, every 30 minutes for 6 hours, then hourly for 16 hours. Target is <180/105 throughout. Strict documentation is required.
9. For an acute ischaemic stroke patient admitted to the stroke unit, what is the recommended head-of-bed position in the first 24 hours?
Flat (0–30°) positioning in the first 24h increases cerebral perfusion pressure to the ischaemic penumbra. After 24h (or earlier if aspiration risk is high), raise to 30°. This is a key difference from general nursing positioning — always check with stroke team if uncertain.
10. A haemorrhagic stroke patient is on warfarin (INR 3.4). Which reversal agent should be given FIRST?
4-factor PCC (Beriplex, Octaplex) is the preferred agent for urgent warfarin reversal in ICH — faster and more effective than FFP alone. Vitamin K IV is given concurrently for sustained reversal. Idarucizumab reverses dabigatran, not warfarin. Protamine reverses heparin.
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📋Quick Reference — Stroke Nursing Essentials
Code Stroke Time Targets
Door-to-CT: 25 min Door-to-Needle (tPA): 60 min Door-to-Groin (thrombectomy): 90 min
tPA Dose
0.9 mg/kg (max 90mg) Bolus: 10% over 1 min Infusion: 90% over 60 min Window: 4.5h from last-seen-well