Airway/O₂; glucose; non-contrast CT; BP within limits; thrombolysis/thrombectomy clock.
Calculators:
First — before any anticoagulation:Head CT WITHOUT contrast (exclude hemorrhage) within 15 min; + CBC, PT/aPTT, ECG
Control BP:labetalol / nicardipine — BP must be <185/110 mm Hg before IV thrombolysis; maintain ≤180/105 for 24 h after IVT (AHA/ASA 2026)
If within window →IV thrombolysis for disabling deficits ≤4.5 h: alteplase 0.9 mg/kg (max 90 mg) OR tenecteplase 0.25 mg/kg IV single bolus (max 25 mg) — co-equal Class 1 (TNK 0.4 mg/kg NOT recommended — harm); minor non-disabling stroke within 4.5 h → DAPT ×21 days, NOT thrombolysis; extended-window IVT 4.5–9 h / wake-up with DWI-FLAIR or perfusion mismatch (Class 2a); LVO → thrombectomy ≤24 h (Class 1 large-core ASPECTS 3–5, 2a ASPECTS 0–2; basilar occlusion NIHSS ≥10 ≤24 h now Class 1)
If after 4.5 h / no tPA →Aspirin (give after 24 h if tPA given); statin; workup carotid US + echo
Decision tree
Haemorrhage on CT?
Yes
Haemorrhage pathway — reverse anticoagulation, BP control, neurosurgery referral
No
Within 4.5 h and no contraindication?
Yes
Thrombolysis; assess for thrombectomy if large-vessel occlusion (≤24 h)
No
Aspirin, admit to stroke unit; thrombectomy if LVO in window
Order set
Non-contrast CT head ≤15 min
Glucose
BP control (thresholds)
FBC, coags
ECG
Swallow screen
Suspected LVO → direct transport to EVT-capable center
DoseStroke: 0.9 mg/kg (max 90 mg) — 10% bolus, 90% over 1 h. Massive PE: 100 mg over 2 h (or 50 mg bolus in arrest)
PreparationReconstitute 50 mg vial with 50 mL sterile water (1 mg/mL); dedicate a line
MonitorBP <185/110 pre-lysis, ≤180/105 ×24 h post-lysis; neuro exam q15 min ×2 h; no antiplatelets ×24 h; adjuvant argatroban/eptifibatide with IVT not recommended
Tenecteplase (TNK)thrombolytic — co-equal Class 1
Dose0.25 mg/kg IV single bolus (max 25 mg) — no infusion needed; ≤4.5 h window; 0.4 mg/kg NOT recommended (harm)
PreparationReconstitute with sterile water; single IV bolus over 5–10 s
MonitorAs alteplase: BP <185/110 pre-lysis, ≤180/105 ×24 h; no antiplatelets ×24 h
Labetalol IVIV α+β-blocker
Dose20 mg IV over 2 min, repeat 20–80 mg q10 min (max 300 mg) or 0.5–2 mg/min infusion
Preparation200 mg in 160 mL (1.25 mg/mL) for infusion; boluses undiluted (5 mg/mL vial)
MonitorAvoid in asthma/decompensated HF; postural hypotension
Aspirinantiplatelet
DoseACS: 150–325 mg chewed once, then 75 mg OD. PV/stroke prevention: 75 mg OD
Preparation300 mg dispersible (chew/dissolve for loading); 75 mg enteric-coated maintenance
MonitorBleeding, dyspepsia; avoid in viral illness in children
Atorvastatinstatin
Dose20–80 mg OD (post-ACS 80 mg)
Preparation10/20/40/80 mg tablets, any time of day
ICU Decoded — original critical-care and internal-medicine pathways by
Dr Javed Akhtar, each cited to a current guideline. For education and quick
reference; verify every dose against local protocols before prescribing.