A Wake-Up Stroke at 06:40 With a Fogged-In Helicopter

Last known well is 22:00, the last time he was seen normal - not 06:30, the time he woke with deficits. Elapsed time at 06:40 is roughly 8 hours 40 minutes.

What that closes

• Standard IV thrombolysis (alteplase or tenecteplase) within 4.5 hours of last known well is not available on routine criteria. A wake-up stroke is not automatically excluded in every system, but enrollment requires advanced imaging selection (for example DWI-FLAIR mismatch or perfusion mismatch) at a center set up for that protocol. That is a stroke-team and imaging decision, not a nurse-initiated one.

What remains open

• Endovascular thrombectomy for a large vessel occlusion, selected by imaging, can be offered well beyond 4.5 hours from last known well in appropriately selected patients. An NIHSS of 14 makes a large vessel occlusion likely enough that CTA is essential, not optional.
• Transfer. A 35-minute ground transfer is entirely reasonable; a grounded helicopter changes the mode, not the destination. Early transfer avoids losing thrombectomy time while waiting for weather.

The nursing judgment

The clock debate must never delay the CT. Get the imaging started, get CTA with it, launch the stroke team and the transfer conversation simultaneously, and let the images determine eligibility and destination.

Initiate

• Point-of-care glucose (142 is acceptable; treat only extremes), two large-bore IVs, isotonic saline without dextrose.
• Direct-to-CT with CTA; the scanner is free, so nothing nonessential should precede it.
• Weight, medication history, and contact information for family so consent for transfer is not delayed later.
• Keep him NPO, head midline, neck neutral, SpO2 in the mid-90s, normothermic, and treat agitation with the least sedating option so you can track the exam.

Avoid or delay

• No aspirin, heparin, or anticoagulant before CT excludes hemorrhage. This is the classic error.
• Do not aggressively lower the blood pressure. At 186/102 he is above the threshold for reperfusion therapy (generally keep below 185/110 if thrombolysis or thrombectomy is planned), but a reflexive labetalol push to 140 can infarct the penumbra. Lower it modestly and deliberately if a reperfusion pathway is active.
• No nasogastric tube, no indwelling catheter, no unnecessary lines or labs that delay imaging or transport; a dysphagia screen is required before anything by mouth, but the screen comes later.
• Do not wait for coagulation studies in a patient on no anticoagulant to move him to CT.
• Do not let his aphasia be mistaken for confusion or noncompliance; assume comprehension is intact and speak to him directly.

Differential - think in systems, not just 'the stroke got worse'

• Infarct extension or edema from an unrelocated large vessel occlusion, which is the most likely and most time-critical.
• Hemorrhagic transformation (less likely without thrombolysis or anticoagulation, but not impossible).
• Hypoglycemia or hyperglycemia, hypoxia, hypercapnia, fever, or a new arrhythmia - all reversible, all checked in 60 seconds.
• Seizure, postictal state, or nonconvulsive status.
• Aspiration with hypoxemia, very plausible at NIHSS 14 with a drooling face.
• Drug effect if any sedating agent was given for agitation.

Immediate actions

1. Airway, breathing, circulation, repeat glucose, SpO2, cardiac monitor, and a repeat NIHSS with the exact time documented.
2. Escalate to the provider and stroke team immediately; this is a change in exam, not a routine reassessment.
3. Repeat CT (and CTA if not already done), draw CBC and coags, and prepare for transfer or a neurosurgical conversation.
4. Support BP to maintain cerebral perfusion rather than simply lowering it; keep the head of bed flat to 30 degrees as tolerated if perfusion is a concern.
5. Anticipate deterioration in airway protection: suction at the bedside, NPO, and intubation equipment nearby.

The framing to write in the chart is the delta: what changed, when, and what the new number is.