Stroke Explained: BE-FAST to Thrombolytics | Last Known Well, BP Targets, Thrombectomy

Stroke: every treatment runs on a clock 0:00

0:00 In a stroke, brain cells are dying by the minute, and every treatment we have runs on a clock. The job: spot it, time it, scan it, and get the patient to the right treatment. This is exam education. Your local protocol decides destination, timing and doses.

Spot it: BE-FAST 0:20

0:23 Stroke symptoms usually start suddenly. Use BE-FAST. B is balance: sudden trouble walking or a weak leg. E is eyes: sudden vision loss or double vision.

0:38 F is face: ask them to smile and look for a droop. A is arm: eyes closed, arms out for ten seconds, and watch for drift. S is speech: slurred or wrong words. And T is time, which really means last known well.

0:58 In one study, FAST alone missed about one in seven ischemic strokes. Adding balance and eyes cut the misses to under one in twenty. Other red flags: a sudden severe headache, sudden confusion or an altered mental status.

Last known well 1:15

1:17 Last known well is the last time someone saw the patient normal. It is not when they were found, and not when they woke up with the deficit. Normal at bedtime at ten, wakes up weak at seven: last known well is 10 PM. Write down the time, and who gave it to you. Every treatment window is counted from that time.

Check the glucose 1:41

1:43 Low blood sugar can look exactly like a stroke, so check the glucose on every suspected stroke. under 60, treat it, then reassess the patient. Other mimics: seizures, sepsis, migraine and intoxication.

Clot or bleed: scan first 2:01

2:03 Most strokes, about four in five, are ischemic: a clot blocks an artery. The rest are hemorrhagic: a vessel bleeds into the brain. A bleed is more likely with headache, vomiting or a falling level of consciousness. But no bedside exam can rule a bleed in or out.

2:23 So imaging comes first: a non contrast CT, or an MRI, before any clot buster. Early on, an ischemic stroke can look normal on CT. Its first job is finding blood. CT angiography then looks for a large vessel occlusion, the kind a catheter can pull out.

Medics: field and destination 2:44

2:46 Medics: use a validated stroke scale. Smile, arm drift for ten seconds, and a phrase like you can't teach an old dog new tricks. Then a severity screen for a large vessel occlusion. On the LAMS, zero to five, four or more points that way.

3:04 Clues include forced gaze to one side, aphasia and neglect. Get last known well and who saw it, the glucose, whether they take a blood thinner, and any recent trauma, surgery, bleeding or seizure. Call the stroke alert early, including a suspected large vessel occlusion, and keep scene time short. Destination follows your local stroke plan.

3:29 Centers range from stroke ready, to primary, to thrombectomy capable, to comprehensive. The model guideline: under 4.5 hours may be eligible for a lytic. A positive severity screen under 24 hours may be eligible for thrombectomy, so consider a thrombectomy capable center, per the plan. Do not treat high blood pressure in the field.

3:53 Oxygen only to reach 94 to 98%. Head of the stretcher up 15 to 30 degrees if the systolic is over 100, neck neutral. Monitor, and a 12-lead if you can.

Thrombolytics: alteplase and tenecteplase 4:06

4:09 A thrombolytic is a clot buster. It dissolves the clot and reopens the artery. The window is within 4.5 hours of last known well. The drug labels still say three hours; guidelines and exams use 4.5.

4:24 Alteplase: 0.9 milligrams per kilogram, maximum 90. 10% as a bolus over one minute, the rest over an hour. Tenecteplase: 0.25 milligrams per kilogram, maximum 25, as a single IV push. The 2026 US guideline accepts either drug.

4:47 Before either one: no blood on the scan, a glucose checked, and a blood pressure under 185/110. The big exclusions: active bleeding, recent serious head trauma or brain or spine surgery, a bleeding disorder, platelets under 100,000, or an INR over 1.7.

Thrombectomy 5:09

5:11 Thrombectomy means a catheter goes up to the brain and pulls the clot out of a large vessel. It works up to six hours for most patients, and in selected patients up to 24 hours when imaging shows brain still worth saving. If they qualify for a lytic, give it first, and don't wait to see if it works before calling for thrombectomy. Only some hospitals can do it, which is why destination matters.

Blood pressure targets 5:38

5:41 Blood pressure. For a lytic: under 185/110 before it starts. Then under 180/105 during, and for 24 hours after a lytic or thrombectomy. No lytic and no thrombectomy? Usually leave it.

5:58 Only at 220/120 or more, lower it about 15% in the first day. Why permissive? The pressure helps push blood to the brain around the clot. And after a successful thrombectomy, pushing the systolic below 140 is not recommended.

6:16 For a brain bleed with a systolic between 150 and 220: bring it down to about 140, but not below 130. And if the bleed is on a blood thinner, reverse it. Two common drugs. Labetalol: 20 milligrams IV over two minutes, then 40 or 80 every ten minutes, up to 300.

6:38 Not in asthma, severe bradycardia, heart block beyond first degree, or overt heart failure. Nicardipine: a drip, started at five milligrams an hour, up by 2.5 every 5 to 15 minutes, maximum fifteen. On a peripheral line, change the site every twelve hours. And after IV labetalol, keep the patient lying down; postural hypotension can last up to three hours.

Nurses: after the lytic 7:05

7:07 Nurses: after a lytic, neuro checks and blood pressure every fifteen minutes for two hours, every thirty minutes for six hours, then hourly to 24 hours. New headache, vomiting, a rising blood pressure or a worse exam could be bleeding. Stop the infusion if it's still running, call the team, and get an emergency CT. A rise of four or more on the NIH stroke scale should also get imaging.

7:35 Watch the lips and tongue for angioedema, especially in patients on an ACE inhibitor. No anticoagulants or antiplatelets for 24 hours after a lytic. And nothing by mouth until a swallow screen: no food, no drinks, and no oral meds, even aspirin. If they can eat: sit up as straight as possible, small bites, and stay upright for 30 to 45 minutes afterward.

8:03 Coughing, choking, gurgling or throat clearing during meals means stop and report. Keep the glucose about 140 to 180, and avoid lows.

NIHSS basics 8:14

8:17 The NIH stroke scale has fifteen items and scores zero to 42. Higher is worse. Roughly: 1 to 4 is mild, 5 to 15 moderate, 16 to 20 moderate to severe, and above twenty severe. It grades severity, tracks change over time, and helps guide treatment.

Exam traps 8:39

8:42 The exam traps. One: last known well is never when they were found or when they woke up. Two: check the glucose before you call it a stroke. Three: imaging comes before any clot buster, aspirin or anticoagulant.

9:00 Four: high blood pressure in ischemic stroke is often left alone, and medics don't treat it in the field. Five: nothing by mouth until the swallow screen, meds included. Six: a lytic doesn't replace thrombectomy for a large vessel occlusion. Seven: new headache, vomiting or a worse exam on a lytic is a bleed until proven

Recap 9:26

9:25 otherwise. Recap. Spot it with BE-FAST. Time it from last known well.

9:34 Check the glucose. Scan before you treat. Lytics within 4.5 hours, thrombectomy for a large vessel occlusion up to 24 in selected patients. Blood pressure under 185/110 before, under 180/105 after; 140 for a bleed.

9:54 Nothing by mouth until the swallow screen. ICU Basics, RN Basics and Medic Basics, available on the Apple App Store and Google Play.