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Meanwhile, the nurse recorded a blood pressure of 205/110. James recalled the 2024 EMJ guidelines: BP >185/110 is a relative contraindication to IV alteplase unless rapidly controlled. He ordered IV labetalol 10 mg push. As the labetalol took effect (BP 168/94), Mr. Patel suddenly became agitated. His left arm began jerking rhythmically. The monitor showed tachycardia to 120. Junior doctor Sarah shouted, “Seizure?” James shook his head – the movements were focal, but the patient’s eyes were deviated to the left, and he was unresponsive.

James calculated: Door-to-needle time would be 82 minutes if they gave alteplase now. But giving thrombolysis before transfer to thrombectomy carries bleeding risk if the clot doesn’t move. emergency medicine journal

The stroke consultant, Dr. Khan, arrived. “This is a large vessel occlusion. Thrombolysis alone may not recanalise. We need mechanical thrombectomy, but our nearest centre is 45 minutes away by ambulance.” Meanwhile, the nurse recorded a blood pressure of 205/110