WHO GETS WHATBy time from LKW
Suspected stroke. Check glucose · straight to CT (+ CTA same trip) · NIHSS · set LKW
Blood on CT?
YES ▶ ICH pathway (back)
No bleed: time from last known well
0–4.5 hLytic window
Disabling deficit and no contraindication?
YesNo
TNK 0.25 mg/kg
(max 25)
(max 25)
NIHSS ≤3, non-disabling: DAPT × 21 d
LVO on CTA?
EVT. Don't wait to see lytic response
4.5–24 hImaging selects
CTA + perfusion (or MRI)
LVO and meets DAWN / DEFUSE-3?
EVT
4.5–9 h or wake-up with salvageable tissue: consider lytic
>24 hLate
No lytic, no routine EVT
Aspirin within 48 h, stroke workup
All ischemic strokes: aspirin 160–325 mg within 24–48 h. After a lytic, wait 24 h and repeat imaging first.
DEFUSE-3: 6–16 h, NIHSS ≥6, core <70 mL, mismatch ≥1.8. DAWN: 6–24 h, NIHSS ≥10 with small core (clinical–core mismatch). Adapted from NEJM 2020 algorithm.
Verify against institutional protocol.Lincoln EM · Oct 2026
THE CLOCKDoor-to-treatment goals
Run it in parallel, not in series
PREEMS
Prenotify. Activate code, page team, CT on hold, pharmacy mixes on weight.
0min
Door. Glucose, weight, straight to CT on the EMS stretcher.
≤10
ED MD at bedside. LKW, NIHSS, anticoagulants.
≤15
Stroke team / neuro at bedside or on telestroke.
≤20
CT start, CTA on the same trip.
≤40
EVT team activated if LVO suspected (NIHSS ≥6).
≤45
CT read. BP <185/110 before lytic.
≤60
Needle. Goal ≤45, best ≤30. Give in CT.
≤75
Groin puncture. Transfers: door-in–door-out ≤60.
ICH pathway
Blood on CT. Stop antithrombotics. No lytic.
SBP ~140 (130–150) within 1 h. Avoid <130 and big swings. Nicardipine or clevidipine drip.
Reverse now
- Warfarin
- 4F-PCC (INR-based) + vitamin K 10 mg IV
- Xa inhibitor
- Andexanet alfa, or 4F-PCC 50 units/kg
- Dabigatran
- Idarucizumab 5 g IV
- Heparin
- Protamine 1 mg per 100 units (last 2–3 h)
Neurosurgery consult · HOB 30° · neuro ICU
Verify against institutional protocol.Scan the badge card QR for the tracker.