Suspected Stroke/Transient Ischemic Attack

Table of Contents

Aliases

Cerebrovascular accident (CVA), TIA

Patient Care Goals

  1. Detect neurological deficits
  2. Determine eligibility for transport to a stroke center

Patient Presentation

  1. Neurologic deficit such as facial droop, localized weakness, gait disturbance, slurred speech, altered mentation
  2. Hemiparesis or hemiplegia
  3. Dysconjugate gaze, forced or crossed gaze (if patient is unable to voluntarily respond to exam, makes no discernible effort to respond, or is unresponsive)
  4. Severe headache, neck pain/stiffness, difficulty seeing

Inclusion Criteria

  1. Patient has signs and symptoms consistent with stroke or transient ischemic attack (TIA)

Exclusion Criteria

  1. If glucose less than 60 mg/dL, treat per the Hypoglycemia guideline
  2. If trauma and GCS less than or equal to 13, treat per the Head Injury and General Trauma Management guidelines

Patient Management

Assessment

  1. Screen for anterior circulation strokes with Cincinnati Prehospital Stroke Scale (CPSS):
    1. Facial smile/grimace – ask patient to smile
    2. Arm drift – close eyes and hold out arms for count of 10 seconds
    3. Speech – “You can’t teach an old dog new tricks”
    4. Only 1 needs to be abnormal for CPSS to be positive
  2. If CPSS positive, proceed to LA Motor Scale (LAMS)
    1. Facial Droop
      1. Absent – 0 points
      2. Present – 1 point
    2. Arm Drift
      1. Absent after 10 secs – 0 points
      2. Drifts down – 1 point
      3. Falls rapidly – 2 points
    3. Grip Strength
      1. Normal – 0 points
      2. Weak grip – 1 point
      3. No grip – 2 points
    4. Calculate score
      1. 0 – 3: Mild to moderate
      2. 4 – 5: Severe
  3. Pertinent historical data includes:
    1. History – “last known well” and source of that information
    2. Neurologic status assessment [see Appendix VII]
    3. Patient is taking warfarin or any anticoagulant medication
  4. Evaluate for the presence of stroke mimics including:
    1. Hypoglycemia
    2. Seizure
    3. Sepsis
    4. Migraine
    5. Intoxication

Treatment and Interventions

  1. Determine “last known well” time
  2. Administer oxygen as appropriate with a target of achieving 94-98% saturation
  3. If seizure activity present, treat per Seizures guideline
  4. Check blood glucose level
    1. Treat only if glucose less than 60 mg/dL
  5. Emergent Group (Immediate Life Threats): transport to the closest appropriate facility for stabilization and manage life threats en-route to ED.
  6. Group 1: (Thrombectomy Candidates)
    1. LAMS ≥4 & Estimated hospital arrival from last known well (LKW) < 24 hours
    2. Transport to the closest Level 1 bypassing Level 2 stroke center if difference is less than 20 extra minutes of transportation time.
      1. Use of emergency lights and sirens is strongly recommended if safe.
    3. If more than 20 extra minutes of transportation time is predicted, transport to closest Level 2 stroke center
    4. Notify stroke center that patient is a “Group 1 – Thrombectomy Candidate”
  7. Group 2: (Thrombolysis Candidates)
    1. LAMS ≤3 & estimated hospital arrival from last known well (LKW) < 24 hours
    2. Transport to the closest Level 1 or Level 2 stroke center.
    3. Use of emergency lights and sirens is strongly recommended if safe.
    4. 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.
  8. Group 3: (Out of the therapeutic window)
    1. Suspected CVA > 24 hours from LKW
    2. Transport to stroke center (Level 1-4) in a non-emergent manner
  9. 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.
  10. If ground transport expected to be greater than 60 mins, consider use of helicopter EMS.
  11. Notify the Stroke Receiving Center ASAP of impending arrival with an acute stroke patient, Stroke screening scale, and time last known well.
    1. Emergency Group, Group 1, and Group 2.
  12. EMS will consider requests for transport to a specific hospital made by a patient.
  13. While transporting, consider:
    1. One attempt at IV access
      1. No external jugular attempts
    2. 12 lead ECG

Notes – Suspected Stroke/Transient Ischemic Attack