Code Stroke Triage, Last Known Well, and Initial Assessment

Why the first minutes matter

A code stroke is a workflow emergency, not a diagnosis to be confirmed before acting. The classic teaching that "time is brain" is literal: an untreated large-vessel ischemic stroke destroys roughly 1.9 million neurons per minute, so every 15-minute reduction in treatment delay improves the odds of a good outcome by about 4 percent. The nurse's job is to recognize a possible stroke, protect immediate physiologic needs, and move the patient toward rapid imaging and expert decision-making.

The safest SCRN answer usually preserves two ideas at once: stabilize life threats and do not waste brain-saving time. If the patient has airway compromise, hypoxemia, seizure activity, or hemodynamic instability, address that immediately while calling for help. If the patient is stable but has sudden focal deficits, the priority is stroke-pathway activation, focused assessment, point-of-care glucose, last-known-well clarification, and transport to noncontrast CT. Do not wait for a complete history, bed assignment, or full provider evaluation before using the local activation pathway when the presentation is compatible with acute stroke.

Last known well is not symptom discovery

Last known well (LKW) means the last time the patient was known to be at neurologic baseline. If a patient wakes at 0700 with aphasia and was normal at 2230 before sleep, LKW is 2230, not 0700. The time symptoms were discovered (or the witnessed onset time) is also recorded, but it does not replace LKW for treatment-window decisions. Conflating the two is a frequent exam trap, because using discovery time would falsely shorten or lengthen the eligibility window.

Witnesses matter. EMS, family, caregivers, facility staff, telephone records, and medication lists may be the only reliable sources. Ask concrete questions: When was speech last normal? When did the patient last walk normally? Was the weakness present on awakening? Did symptoms fluctuate or resolve? Is there a history of seizure, fall, trauma, anticoagulant use, or recent surgery? Wake-up and unwitnessed strokes are no longer automatically excluded from treatment — advanced imaging (CT perfusion or MRI mismatch) can still identify candidates — so collecting a precise LKW keeps every option open.

Screening tools: BE-FAST and prehospital LVO scales

Use a validated stroke screen, then move into focused neurologic assessment. FAST captures Face droop, Arm drift, Speech change, and Time to call. BE-FAST adds Balance (sudden ataxia, gait instability) and Eyes (diplopia, sudden vision loss), capturing posterior-circulation strokes that plain FAST misses in roughly one of every seven cases. The Cincinnati Prehospital Stroke Scale (CPSS) is a sensitive three-item field screen (facial droop, arm drift, abnormal speech) but is not LVO-specific.

To flag a probable large-vessel occlusion (LVO) in the field, EMS use severity scales so the patient can be routed or prenotified to a thrombectomy-capable center. The Rapid Arterial oCclusion Evaluation (RACE) scale (0–9) uses a cutoff of ≥5 (about 66% sensitive, 72% specific for anterior LVO). The Los Angeles Motor Scale (LAMS) (0–5) uses a cutoff of ≥4. A negative or incomplete quick screen does not clear a patient when the story suggests isolated aphasia, severe neglect, hemianopia, or sudden decreased consciousness.

Initial assessment without delay

Keep the patient NPO until a swallowing-safety screen is performed; aspiration risk is high with facial weakness, dysarthria, or reduced consciousness. Do not give aspirin or other antithrombotics before hemorrhage is excluded and the reperfusion plan is clarified — antithrombotics can worsen an intracranial bleed and may close the thrombolytic door. Establish IV access (ideally two lines), draw protocol labs without delaying imaging, obtain or estimate weight for weight-based dosing, attach cardiac monitoring, and keep the patient calm and still for the scanner.

Handoff that helps the team act

A useful code-stroke handoff is short and decision-focused: age, LKW, discovery/witnessed-onset time, baseline function, presenting deficits, glucose, vital signs, anticoagulant use and last dose, allergies, recent procedures or bleeding, and family availability. Use closed-loop communication. If the patient is headed to CT, the nurse should know who is transporting, who is monitoring, and who is notifying neurology, radiology, pharmacy, and transfer resources.

For SCRN questions, avoid answers that treat a code stroke like routine triage; the correct priority keeps the system moving while the nurse collects the facts that make thrombolysis, thrombectomy, or hemorrhage management safer.