🚨 ACUTE STROKE ALERT - TIME-CRITICAL EMERGENCY

Step 1 - Immediate Recognition

• Balance - any loss?
• Eyes - visual field defect?
• Face - facial droop (ask to smile)?
• Arm - right arm weakness (confirmed)
• Speech - dysphasia/dysarthria? (left MCA territory)
• Time - onset 6 PM, now 7:30 PM

Step 2 - Immediate Actions (Do NOW, in parallel)

A. Activate Code Stroke

• Call stroke team / neurology immediately
• Notify CT scanner - prepare for STAT non-contrast CT head
• Notify pharmacy for potential thrombolysis

B. Primary Survey

C. STAT Blood Tests (draw simultaneously)

• CBC, coagulation (PT/INR/aPTT), platelet count
• BMP (electrolytes, renal function, glucose)
• Troponin
• Type and screen
• Do NOT delay CT scan for results - only glucose and platelet count are needed before alteplase

Step 3 - Neurological Assessment

1. Level of consciousness
2. Best gaze (eye deviation toward left = left hemisphere lesion)
3. Visual fields
4. Facial palsy (is right face also weak? Left MCA territory)
5. Right arm motor (Grade 0-4: 0=no drift, 4=no movement)
6. Right leg motor (is it also weak?)
7. Limb ataxia
8. Sensory
9. Language/Aphasia (left hemisphere = Broca's or Wernicke's area involved?)
10. Dysarthria
11. Extinction/Neglect

Step 4 - Imaging

• Primary goal: rule out hemorrhage (hemorrhagic transformation is a contraindication to thrombolysis)
• Look for: hyperdense MCA sign, early ischemic changes, mass lesion
• Target: CT scan within 25 minutes of arrival, results within 45 minutes

• CT angiography (CTA) of head and neck to identify large vessel occlusion (LVO) for possible mechanical thrombectomy

Step 5 - Thrombolysis Decision (IV Alteplase)

IV Alteplase 0.9 mg/kg (max 90 mg over 60 min, 10% as bolus over 1 min)

✅ Treat within 3 hours if eligible (before 9:00 PM)

✅ Also recommended 3–4.5 hours if ALL of these apply:

• Age ≤80 years
• No history of BOTH diabetes AND prior stroke
• NIHSS score ≤25
• Not on oral anticoagulants
• No imaging showing ischemia >1/3 MCA territory

Key Contraindications to Check Now:

Blood Pressure Management Before Thrombolysis:

• Target BP <185/110 mmHg before giving alteplase
• Use IV labetalol (10-20 mg IV over 1-2 min, repeat q10 min) or nicardipine infusion

Step 6 - Differential Diagnoses to Consider

Step 7 - Parallel Management

• Keep patient NPO (aspiration risk)
• Head of bed >30 degrees (after hemorrhage excluded)
• No hypotonic fluids (worsen cerebral edema)
• Do NOT aggressively lower BP unless >185/110 AND thrombolysis planned (or >220/120 if no thrombolysis)
• Treat hyperthermia (target normothermia - hyperthermia worsens ischemia)
• Cardiac monitoring for 48-72 hours (detect AF, cardiac arrhythmia)

If Large Vessel Occlusion (LVO) Identified on CTA:

• Extended window up to 24 hours from last known well with perfusion imaging (DAWN/DEFUSE-3 criteria)
• Most effective for M1 MCA, ICA, basilar artery occlusions
• Can be given in addition to IV alteplase (bridging therapy)

Key Timelines to Target ("Time is Brain" - ~1.9 million neurons/minute lost in stroke)

Summary - Right Now

1. Activate stroke team immediately
2. STAT fingerstick glucose - rule out hypoglycemia
3. STAT NCCT head - rule out hemorrhage
4. Assess NIHSS
5. Check BP - must be <185/110 for thrombolysis
6. Review contraindications rapidly
7. Give IV alteplase if eligible - patient is within the 3-hour window NOW

Sources: Bradley and Daroff's Neurology in Clinical Practice, p.1405-1406; Rosen's Emergency Medicine (2019 AHA/ASA Guidelines Table 87.5)

Wrist Drop (Radial Nerve Palsy) - Treatment & Medications

Quick Anatomy Recap

Step 1 - Identify the Cause (Treatment is Cause-Directed)

MEDICATIONS

1. Neuropathic Pain / Nerve Recovery Support

2. Anti-inflammatory (if inflammatory/compressive cause)

3. Cause-Specific Medications

Lead Poisoning (if confirmed - classic bilateral wrist drop)

• Penicillamine (D-penicillamine) - oral chelating agent, preferred for lead neuropathy
• CaNa2-EDTA (Calcium disodium EDTA) - IV chelation in severe cases
• Dimercaprol (BAL) - reserved for severe toxicity
• Remove the patient from lead source first

If Diabetes-related Mononeuropathy:

• Tight glycemic control (primary treatment)
• Metformin / insulin as appropriate
• Alpha-lipoic acid 600 mg/day - antioxidant for diabetic neuropathy

NON-PHARMACOLOGICAL TREATMENT (Equally Important)

1. Splinting - Essential

• Cock-up wrist splint (dorsal wrist extension splint) - holds wrist in 30-45° extension
• Prevents contracture of wrist flexors while awaiting nerve recovery
• Worn continuously initially, then during activity as recovery progresses

2. Physiotherapy

• Passive range of motion (ROM) exercises for wrist, fingers, thumb - daily
• Prevent joint stiffness and contracture
• Once recovery begins: active-assisted then active exercises
• Muscle re-education

3. Occupational Therapy

• Functional splinting
• ADL adaptations

SURGICAL OPTIONS (When Indicated)

• Nerve exploration within 3 weeks of injury if:
  • Open fracture with nerve injury
  • Associated vascular injury
  • Iatrogenic palsy (from reduction)
  • Nerve entrapment suspected
• Nerve grafting - if nerve rupture with substance loss
• Tendon transfer surgery - if nerve recovery fails after 12-18 months (e.g., pronator teres to ECRB, FCU to EDC, PL to EPL)

Recovery Timeline

• Most injuries are neuropraxia or axonotmesis - >70% recover spontaneously
• Mean onset of recovery: 7 weeks (range 2 weeks to 6 months)
• Full recovery: 6 months (range 3-12 months)
• Monitor: Tinel's sign advancing along nerve course = good prognostic sign
• If no recovery by 3 months - request nerve conduction studies (NCS/EMG) and consider surgical exploration

Summary Treatment Protocol

IMMEDIATE:
1. Wrist cock-up splint
2. Physiotherapy referral
3. Identify and treat underlying cause

MEDICATIONS:
- B-complex vitamins (B1, B6, B12)
- Gabapentin/Pregabalin for pain
- NSAIDs for acute pain
- Steroids if acute compressive/inflammatory

MONITOR:
- NCS/EMG at 6-8 weeks
- Clinical assessment monthly
- Surgery if no recovery at 3 months

Sources: Gray's Anatomy for Students, p.940; Rockwood & Green's Fractures in Adults 10th Ed, p.789; Adams & Victor's Principles of Neurology 12th Ed, p.1312