Stroke/TIA

Assessment

Pediatric Pearls: Signs & Symptoms: Differential: 
□ Pediatric hypotension is defined as SBP < 70 + (age in years x 2) mmHg □ Altered mental status 
□ Weak / Paralysis 
□ Blindness or other sensory loss 
□ Aphasia / Dysarthria 
□ Syncope 
□ Vertigo / Dizziness 
□ Vomiting 
□ Headache 
□ Seizures 
□ Respiratory pattern change 
□ Hyper/hypotension		□ Altered mental status 
□ Transient Ischemic Attack (TIA) 
□ Seizure 
□ Hypoglycemia 
□ Hypoxia / Hypercarbia 
□ Stroke Thrombotic / Embolic (85%) 
Hemorrhagic (15%) 
□ Tumor 
□ Trauma 
□ Atypical migraine 

Clinical Management Options

EMT-B
• Oxygen, target SpO2 92 – 96% 
• Blood Glucose Level
• Basic Airway Management
• Perform an extended Cincinnati Stroke Scale followed by a LAMS score to look for large vessel occlusion
• Transport immediately if stroke suspected and symptoms less than 24 hours old (scene time less than 15 minutes)
Paramedic
• Vascular access 
• Isotonic Crystalloid if hypotensive
• Consider push-dose epinephrine if hypotension continues after fluid bolus 
• Monitor ECG and ETCO2
Consult Online Medical Control as Needed

Pearls

  • Stroke patients are transported per Regional TCD Plan. 
  • Onset of symptoms is defined as the last time the patient was seen symptom free; example: Awakening with stroke symptoms would be defined as an onset time of the previous night when the patient went to bed symptom free. 
  • Whenever possible, a family member should accompany the patient to the hospital to provide a detailed history or provide the hospital with the name and contact information of someone who can. 
  • The differential list on the Altered Mental Status guideline should be considered. 
  • Be alert for airway problems (swallowing difficulty, vomiting). 
  • Hypoglycemia can present as a localized neurological deficit, especially in the elderly. 
  • Blood samples for performing glucose analysis should be obtained through a finger-stick (heel for infants). Venous blood samples may produce artificially high glucose values and should be avoided.

Expanded Cincinnati Pre-hospital Stroke Screen (eCPSS) 

Test Finding 
Balance: 
Have the patient walk in a line with eyes closed 
Normal – Coordinated walking
Abnormal – Uncoordinated/ ”Drunk”/ Stumbling gait
Abnormal – unable to do a finger-to-nose
Eyes: 
Assess for Partial/Total Vision loss in each eye as well as double vision 		Normal – No vision loss or double vision. Blurry vision is considered normal
Abnormal – Any amount of vision loss or double vision 
Facial Droop: 
Have the patient smile or show their teeth.		Normal – both sides of face move equally 
Abnormal – one side of the face does not move as well as the other side.
Arm Drift: 
Patient closes eyes and extends both arms straight out, palms up, and for 10 seconds.		Normal – both arms move the same or both arms and held steady.
Abnormal – one arm drifts downward or the palm turns towards the ground (pronator drift*) when compared with the other or unable to lift one arm. 
Abnormal Speech: 
Have the patient say: “You cannot teach an old dog new tricks.”		Normal – patient uses correct words with no slurring. 
Abnormal – patient slurs words, uses the wrong words, or is unable to speak. 
*Pronator drift is when the forearm will pronate, and arm will drift downwards. 

Large Vessel Occlusion (LVO) Stroke Screening 

LA Motor Scale (LAMS) 

Face 0Both sides move normally 
1One side is weak or flaccid 
Arm 0Both sides move normally 
1One side is weak 
2One side is flaccid/does not move
Grip 0Both hands grip normally 
1One hand is weak 
2One side is flaccid/does not move 
Total 0-5Score of 4 or 5 = LVO 

LVO suspected patient must be transported to a MO DHSS Level 1 Stroke Center 

Transport

  • Group 1: (Thrombectomy Candidates)
    • LAMS ≥4 & Estimated hospital arrival from last known well (LKW) < 24 hours
    • Transport to the closest Level 1 bypassing Level 2 stroke center if difference is less than 20 extra minutes of transportation time.
    • Use of emergency lights and sirens is strongly recommended if safe.
    • If more than 20 extra minutes of transportation time is predicted, transport to closest Level 2 stroke center
    • Notify stroke center that patient is a “Group 1 – Thrombectomy Candidate”
    • LevelIStrokeCenters.pdf (mo.gov)
  • Group 2: (Thrombolysis Candidates) 
    • LAMS ≤3 & estimated hospital arrival from last known well (LKW) < 24 hours
    • Transport to the closest Level 1 or Level 2 stroke center.
    • Use of emergency lights and sirens is strongly recommended if safe.
    • Process shall take into consideration time for transport, patient condition, and treatment window, with the goal to secure the appropriate treatment for the patient within the treatment window.
    • LevelIIStrokeCenters.pdf (mo.gov)
  • Group 3: (Out of the therapeutic window)
  • Patients presenting with worst headache of life, loss of consciousness associated with headache or neck stiffness, coma or evidence of very severe stroke (i.e.: mute and unable move arm and leg at all should be transported to Level 1 stroke center