14.2 Stroke
Key Takeaways
- Last known well—not discovery time—starts the reperfusion clock; write the time, the last anticoagulant dose, and the glucose.
- Large-vessel-occlusion screens (RACE, LAMS, VAN conceptually) exist to send the right patient to a thrombectomy-capable center.
- Do not drop ischemic blood pressure indiscriminately; intracerebral hemorrhage often needs a lower systolic target—label both as American Heart Association-style teaching.
- Give oxygen only if the patient is hypoxic; raise the head of the bed for hemorrhage or high pressure; watch angioedema and bleeding after tenecteplase or alteplase.
- If large-vessel occlusion is suspected and time allows, fly to a comprehensive or thrombectomy-capable center; do not overfly the only thrombolysis-capable hospital without a reason.
A stroke in the aircraft is a clock you cannot rewind and a destination you can still get wrong. Domain 4.A of the August 2026 Board of Certification for Emergency Nursing (BCEN) Certified Flight Registered Nurse (CFRN) outline tests stroke because cabin hypoxia, an unnecessary blood-pressure crash, and the wrong pad erase the only hours that matter. Write last known well (LKW), sort ischemic from hemorrhagic pictures, and fly to the hospital that can open or secure the vessel.
Last known well, not last found down
The number that starts every clock
LKW is the last time the patient was seen at neurologic baseline—not the time a neighbor found them on the floor. Wake-up stroke uses bedtime or the last confirmed normal conversation as LKW. That number, not your lift time, starts the intravenous thrombolysis and endovascular thrombectomy clocks. Document LKW in clock time, who confirmed it, and whether onset was witnessed.
Ischemic, intracerebral, and subarachnoid pictures
You will not read the scanner at 3,000 feet. You will recognize the story.
Acute ischemic stroke is a sudden focal deficit—face, arm, speech, gaze, or neglect—often with atrial fibrillation, carotid disease, or a lacunar pattern.
Intracerebral hemorrhage (ICH) more often brings headache, vomiting, hypertension, and a declining level of consciousness. Anticoagulants and a known vascular malformation raise the prior. Subarachnoid hemorrhage (SAH) is the thunderclap: worst headache of life, neck stiffness, brief loss of consciousness, sometimes a sentinel headache days earlier. SAH can look “just a headache” until the aneurysm rebleeds in your litter.
Large-vessel occlusion (LVO) screens exist so you do not take a proximal-clot patient to a hospital that cannot pull it. Rapid Arterial oCclusion Evaluation (RACE), the Los Angeles Motor Scale (LAMS), and Vision, Aphasia, Neglect (VAN) are conceptual tools, not a BCEN point-total statute. What they share is cortical weight: gaze deviation, aphasia, neglect, and dense unilateral weakness. A positive screen plus a realistic time window is a comprehensive stroke center (CSC) or other thrombectomy-capable destination, not the closest clinic with a computed-tomography scanner and no interventionalist.
Blood pressure as American Heart Association-style teaching
Do not drop ischemic blood pressure indiscriminately. The ischemic penumbra is often hanging on that pressure. The following targets are American Heart Association / American Stroke Association (AHA/ASA)–style teaching, not BCEN law, and not a reason to freelance a drip the sending physician did not order.
| Picture | AHA-style pressure idea | Flight meaning |
|---|---|---|
| Ischemic, no reperfusion planned | Treat extreme hypertension, often discussed near greater than 220/120 mm Hg | Do not chase a “pretty” pressure of 140 and steal the penumbra |
| Ischemic, lytic or thrombectomy candidate | Often below 185/110 mm Hg before lytics and below 180/105 mm Hg after | Lower only enough to make reperfusion legal and safe |
| ICH | Presenting systolic often 150–220 mm Hg; lowering toward 140 mm Hg is commonly discussed as safe if you avoid a huge drop | Hemorrhage usually wants a lower systolic than untreated ischemia |
| SAH, unsecured aneurysm | Avoid spikes that encourage rebleeding; follow the sending neurosurgeon | Pain, vomiting, and a fighting patient are rebleed risks |
ICH often needs a lower systolic pressure than ischemic stroke. That does not mean you slam every stroke to 120 mm Hg. A 70-point drop in ten minutes is not “control.”
Cabin care, lytics already given, and the pad you must not overfly
Write the last dose and name of every anticoagulant and antiplatelet—warfarin, a direct oral anticoagulant (DOAC), heparin, aspirin. Reversal and operative decisions hang on that sentence. Check glucose: treat hypoglycemia as a stroke mimic; marked hyperglycemia is a secondary insult, not a reason to invent an insulin protocol in cruise. Raise the head of bed (HOB) about 30 degrees for ICH, SAH, or suspected high intracranial pressure (ICP). Some ischemic patients tolerate a flatter ride if pressure and airway allow. Give oxygen only if the patient is hypoxic. Unnecessary oxygen does not help an ischemic brain and is not a substitute for a lower cabin.
If alteplase (tPA) or tenecteplase (TNK) was already given:
- Watch the tongue, lips, and airway for angioedema, especially in patients on an angiotensin-converting enzyme (ACE) inhibitor.
- Watch for new headache, vomiting, or a crashing exam—post-lytic hemorrhage until proven otherwise.
- Keep the post-lytic pressure in the AHA-style range above; do not add a second unplanned antiplatelet or a needless stick.
Dalton's law drops inspired oxygen tension as cabin altitude rises. A stroke patient who is already saturating 91 percent on the ramp will be worse at altitude. Raise fraction of inspired oxygen (FiO2) or request a lower cabin; do not treat that hypoxia by dropping ischemic blood pressure. Vibration and noise will wreck a formal National Institutes of Health Stroke Scale (NIHSS). Reassess airway, gaze, and motor instead of performing theater.
- Document LKW, last anticoagulant dose, glucose, and whether the onset was witnessed.
- Use an LVO screen conceptually to choose CSC or thrombectomy capability over “closest CT.”
- Do not drop ischemic pressure without a reperfusion or extreme-hypertension reason; ICH often needs a lower systolic.
- Oxygen only if hypoxic; HOB up for bleed or high ICP.
- Do not fly a thrombolysis candidate past the only capable hospital without a reason.
A patient last seen normal ninety minutes ago now has gaze preference, aphasia, and dense right-arm weakness. The closest hospital has computed tomography but no thrombectomy. A comprehensive stroke center is twenty-five minutes farther and still inside a realistic window. What is the best destination decision?
An ischemic-stroke patient who is not a lytic candidate has a blood pressure of 198/104 mm Hg and a stable airway. The sending nurse asks you to drop the pressure to 130 mm Hg before lift so it 'looks better.' What is the correct response?
Tenecteplase was given twelve minutes before you arrive. The only hospital that can complete thrombolysis monitoring and rescue care is eight minutes away. The crew wants a forty-minute flight to the patient's 'home' hospital that cannot give or reverse lytics. The tongue is starting to swell. What is the priority plan?