STROKE

Inclusion Criteria: Patients suspected of having an acute stroke.  Refer also to the ALTERED LEVEL OF CONSCIOUSNESS, BRADYCARDIA, TACHYCARDIA (Stable Tachycardia or Unstable Tachycardia) and TRAUMA Guidelines for assistance, as needed.  Refer to the DESTINATION Policy for all patients.

NOTE: The most common type of stroke is ischemic stroke. Intracranial hemorrhage is less common. Be sure to obtain a thorough medical history, and inquire about the use of anti-coagulants or recent head injury. Significant hypertension is common in these patients.  Consider the diagnosis in pediatric patients (e.g. Sickle Cell Disease).

Basic Level

  1. Assess and support ABCs.
  2. Place the patient in a position of comfort, preferably with the head of the bed elevated at 30 degrees.  If there is evidence of shock, place the patient supine with the feet elevated and closely monitor airway status.  Treat shock according to the SHOCK Guidelines.
  3. Administer oxygen, as needed, to maintain a SpO2 of at least 92%.
  4. Perform POC blood glucose analysis and treat hypoglycemia, if present, according to the ALTERED LEVEL OF CONSCIOUSNESS Guidelines.
  5. ASCERTAIN THE TIME WHEN THE PATIENT WAS LAST KNOWN TO BE NORMAL, OR AT HIS/HER BASELINE. If the patient cannot communicate the time, or there is no witness present to report “Last Known Normal”, obtain a phone number for such a witness, if possible.
  6. Consider the presence of ANY of these signs to be evidence of an acute stroke:
    1. Facial droop (ask the patient to smile - asymmetry of facial expression is abnormal);
    2. Sudden asymmetry in neurological exam;
    3. Weak grip or loss of grip;
    4. Arm (pronator) drift (Hold the patient’s arms outstretched in front at shoulder level with the palms up.  Have patient close eyes and let go of the arms.  If one arm does not move or drifts downward, the result  is abnormal);
    5. Sudden abnormal speech not believed to be due to drug or alcohol intoxication (Ask the patient to repeat a sentence or nursery rhyme.  Slow or slurred speech or abnormal words or the inability to speak is abnormal);
    6. Sudden imbalance in walking;
    7. Acute arm or leg weakness;
    8. Sudden, non-traumatic, vision loss (vision loss may be unilateral and may be described as a “curtain”).

Advanced Level

  1. Apply ECG and monitor continuously until transfer of care to hospital staff.  Treat arrhythmias under the appropriate guideline.  Apply ETCO2 monitor, if respiratory distress or shock is present or develops.
  2. A 12-lead ECG should be obtained, but should NOT delay transport.
  3. Establish IV/IO access at a TKO rate or use a saline lock.
  4. Regardless of the symptom duration, for adult patients, you must contact either BioTel or the Stroke Center destination for pre-notification as soon as possible. For pediatric patients, you must contact BioTel as soon as possible for destination instructions and pre-notification.  Minimize on-scene time (less than 15 minutes).
  5. For additional patient care considerations not covered under standing orders, consult BioTel.

IMPORTANT: An appropriate report to the receiving facility staff should include the pertinent past medical history, the current vital signs & GCS, and the TIME of last normal or baseline for the patient (“Last Known Normal”).

 

PRE-HOSPITAL STROKE ASSESSMENT TOOLS

The assessment of a patient who may be having an acute stroke shall be based upon the signs listed in “Basic Level #6”  (above). Paramedics MAY utilize either of the following two methods to assist in determining if a patient is having an acute stroke. Paramedics shall contact BioTel with any questions regarding the assessment, management or destination decision-making for patients who might be having an acute stroke.

CINCINNATI PREHOSPITAL STROKE SCALE

FACIAL DROOP (Have patient show teeth or smile)

ARM DRIFT (Patient closes eyes and holds both arms straight out, with palms up, for 10 seconds)

ABNORMAL SPEECH (Have the patient say “You can’t teach an old dog new tricks”)

Jauch EC, et al. 2010 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science.
Part 11: Adult Stroke. Circulation. 2010; 122: S818-S828; Adapted from Kothari RU, et al. Cincinnati Prehospital Stroke Scale: reproducibility and validity.
Ann Emerg Med. 1999;33:373–378.




LOS ANGELES PREHOSPITAL STROKE SCREEN (LAPSS)

Kidwell CS, et al. Identifying Stroke in the Field: Prospective Validation of the Los Angeles Prehospital Stroke Screen (LAPSS). Stroke. 2000; 31(1):71-76.

 

StrokePatient Destination Decision-Making:

  1. Onset of symptoms less than 3.5 hours: Transport to the closest designated stroke center.  If the EMS provider is not certain that the desired destination hospital is a designated stroke center, contact BioTel for consultation.
  2. Onset of symptoms at least 3.5 hours, but less than 12 hours: Unless immediate intervention (e.g. ABCs, cardiac arrest, etc.) is required, these stroke patients should be preferentially transported to a comprehensive-capable stroke facility, if such a facility is available with less than 15 minutes of additional transport time.  If the EMS provider is not certain that the desired destination hospital is a comprehensive-capable stroke center, contact BioTel for consultation.
  3. Onset of symptoms at least 12 hours, or unknown last-known-normal time: Transport to the closest designated stroke center.