Suspected Stroke Transcient Ischemic Attack TIA: Difference between revisions

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===5.04 SUSPECTED STROKE/TRANSCIENT ISCHEMIC ATTACK (T.I.A.)===
===5.04 SUSPECTED STROKE/TRANSCIENT ISCHEMIC ATTACK (T.I.A.)===


==== PRINCIPLES ====
*Rapidly identify patients with suspected stroke
*Minimize scene time & safe, expediate transport to the appropriate facility 
*Continuous review and improvement on the stroke management process 
*[[Initial Medical Assessment and Care|INITIAL MEDICAL CARE]] 2.01
*Differential Diagnosis
**[[Altered_Mental_Status_(AMS)|ALTERED MENTAL STATUS (AMS)]]  5.03
**[[Sepsis_Septic_Shock|SEPSIS]]  5.17
*Establish a definitive last known well (LKW) time
*Complete a Cincinnati Pre-Hospital Stroke Exam


====PRINCIPLES====
* Rapidly identify patients with suspected stroke
* Minimize scene time and safe expeditious transport to the appropriate facility 
* Continuous review and improvement of the stroke management process 


==== Cincinnati Pre-hospital Stroke Exam (amended) ====
 
*Cincinnati and VAN assessments can be performed simultaneously


{| class="wikitable"
|<span style="color: deeppink;">Face</span>
|Face numbness or weakness, especially one side
“Smile”
|-
|<span style="color: deeppink;">Arm</span>
|Arm numbness or weakness, especially on one side of the body
“Arms out like Superman”
|-
|colspan="2"|(<span style="color: red;">VAN </span> Positive or Negative?)
|-
|<span style="color: deeppink;">Speech </span>
|Slurred speech or difficulty speaking or understanding
“You can’t teach an old dog new tricks”
|-
|colspan="2"|(<span style="color: red;">VAN A</span>phasic? Consider <span style="color: red;">VAN V</span>isual Disturbance and <span style="color: red;">N</span>eglect!))
|-
|<span style="color: deeppink;">Time </span>
|Time since – Last seen normal/Last Known Well (LKW)
|}


'''[[Initial Medical Assessment and Care|Initial Medical Care]] – 2.01 [[Medical Gases|OXYGEN]] only if SaO2 < 95%'''


* Perform VAN Assessment:
**Have patient hold both arms up for 10 seconds palms up.
***Is arm weakness present?
****Yes, Continue VAN assessment
****No, Pt is VAN negative, perform Cinncinnati Pre-hospital Stroke Exam<BR>


'''VAN Assessment:'''<BR>
*Perform Blood Glucose 
*Complete Stroke Checklist
**Identify any t-PA exclusions and document all findings
**Leave copy at hospital
**Forward or Fax the duplicate Stroke Checklist to County EMS QA office
**A copy of the completed stroke checklist must also accompany the abbreviated report for the agency.
*Obtain IV Access
**An 18 gauge is preferable.
**Avoid multiple attempts and IO's
**Notify ER staff and document location of any missed IV’s.
**'''Be conscientious of numerous IV attempts due to possibility of Fibrinolytic therapy and subsequent bleeding from both successful and attempted IV sites.'''
*Perform blood draw of all tubes.
**The crew shall hold onto the tubes at the hospital until a staff member is ready to label the blood tubes.
**Document that blood was drawn.
*HYPERTENSION - Do not treat hypertension.
*Elevate the head of the stretcher 15-30 degrees  if systolic BP >100 mm Hg
*Do not allow aspiration
*Maintain head and neck in neutral alignment, without flexing the neck
*Protect paralyzed limbs from injury
*Obtain 12-lead EKG
*Nausea/vomiting - administer an antiemetic
*Have Patient hold both arms up for 10 seconds
**Is arm weakness present?
***<span style="color: deeppink;">YES - continue VAN assessment </span>
***NO - Patient is VAN negative.


*'''V'''isual disturbance?
====VAN Assessment====
**Field cut (which side) (4 quadrants)
{| class="wikitable"
**Double vision
|<span style="color: deeppink;">Visual </span>
**Blind new onset
|'''IS VISION GAZED IN ONE DIRECTION? NEW ONSET BLINDNESS?'''
**NONE<BR>
Test: Ask the person to look up, then down then left, then right.  Or have them follow your finger in those directions.
Have patient look straight ahead and ask them to tell you number of fingers on left and right<BR>
Double vision meaning eyes semi crossed, one eye out or in<BR>
Have them track your hand to right and left<BR>


*'''A'''phasia?
Normal: No preferred gaze and eyes move past midline upon request.
**Expressive (inability to speak or errors)
**Receptive (not understanding or following commands)
**Mixed
**NONE<BR>


Ask the patient to repeat "today is a sunny day" & name 2 objects<BR>
Abnormal: Gaze is deviated to one side and does not pass the midline upon request or new onset blindness.
Ask them to close eyes and make fist. If they understand and follow commands and are making words '''DO NOT COUNT SLURRING of WORDS'''<BR>
|-
Paraphasic errors ("papple" for apple or "lelephone" for telephone)<BR>
|<span style="color: deeppink;">Aphasia </span>
|'''CAN THE PERSON SPEAK & UNDERSTAND LANGUAGE?'''
Test: Ask them to name an ordinary object such as a pen.  Or ask them to make a fist
Normal: The patient can understand language and name ordinary objects.


*'''N'''eglect?
Abnormal: Inability to understand or express speech or name ordinary objects, does not follow simple commands such as “close your eyes” or make a fist
**Forced gaze or inability to track to one side
**Unable to feel both sides at same time, or unable to indentify own arm
Slurred speech alone does not indicate a positive VAN test 
**Ignoring one side
**NONE<BR>


Neglect is the classic term and adding forced gaze from frontal eye fields to get more parts of the brain, includes frontal lobe in addition to parietal lobe<BR>
|-
Touch patient on right then left and then both. '''Can they feel right and left at same time?'''<BR>
|<span style="color: deeppink;">Neglect </span>
|'''IS THE PATIENT IGNORING ONE SIDEOF THE BODY (Usually the left side)?'''  
Test: Ask the patient to close their eyes and tell them that you will touch each arm individually and then both at the same time.  Ask them to acknowledge each touch.


Normal: Patient acknowledges both individual touches and simultaneous touch.


'''If the patient has arm weakness and is "positive" on any of the VAN assessment fields the patient is ''VAN POSITIVE''<BR>'''
Abnormal: Patient does not acknowledge simultaneous touch usually ignoring the left side
If the patient does not acknowledge individual touches this does not indicate a positive VAN test.


'''If the patient has arm weakness and is "negative" on all assessment fields the Patient is ''VAN NEGATIVE'', perform Cinncinnati Pre-hospital Stroke Exam'''<BR>
|}  


'''ALL ''VAN POSITIVE'' PATIENTS ARE TRANSPORTED TO A COMPREHENSIVE STROKE CENTER.''' '''Patients that are not able to respond but are likely to have had a stroke (sepsis negative) are to be transported to a Comprehensive Stroke Facility. Comprehensive Stroke Centers can provide treatment for up to 24 hours after last seen normal.'''<BR>


* Perform Cincinnati Pre-hospital Stroke Exam
<span style="color: deeppink;">'''ARM DRIFT PLUS ONE OF THE ABOVE IS VAN POSITIVE'''</span>
**Facial smile/grimace – Ask patient to show teeth or smile.
**Arm drift – close eyes and hold out arms for count of 5
**Speech – “You can’t teach an old dog new tricks.”
**Determine - LAST TIME SEEN NORMAL
**If altered sensorium, refer to [[Altered Mental Status (AMS)|ALTERED MENTAL STATUS PRACTICE PARAMETER]] (5.03).
*** Administer D50 with BGL ≤ 50,
*** Consider a half-dose of D50 if BGL < 100 AND > 50. Re-check BGL. If seizure activity present, refer to [[Seizure|SEIZURE PRACTICE PARAMETER]] (5.12).


<span style="color: deeppink;">Cincinnati and VAN assessments often are performed simultaneously</span>


'''STROKE-ALERT SCREENING PROCESS'''
====TRANSPORT DESTINATION  <span style="color: deeppink;">(Determined ONLY by VAN Assessment Results)</span>====
* Perform MEND* exam on scene, using the Stroke Alert Checklist
* Identify any t-PA exclusions and document all findings
* Begin immediate transport and initiate a “STROKE ALERT” if:  
**Patient has signs & symptoms consistent with stroke or T.I.A.
**LAST TIME SEEN NORMAL is < 3.5 hours and patient does not meet criteria for intra-arterial therapy
* If IV is obtained, it should be at least an 18 gauge.  Avoid multiple attempts and IO's


Symptoms 5 minutes to >5 days called in as <span style="color: red;">STROKE ALERT </span>


Stroke receiving center can determine acuity and level of aggressive action.


'''STROKE-RECEIVING DESTINATIONS:'''
Transporting <span style="color: red;">EMERGENCY</span> or <span style="color: deeppink;">NON-EMERGENCY</span> is determined by the crew but a LKW of <24 should receive <span style="color: red;">EMERGENCY</span> transportation.
All suspected stroke and T.I.A. patients must be transported to a stroke-receiving facility, unless the patient is UNSTABLE. The following hospitals have been approved by the Medical Director:
* Florida Hospital Altamonte – Primary Stroke Care
* Florida Hospital Apopka - Primary Stroke Care
* Florida Hospital East – Primary Stroke Care
* Central Florida Regional Hospital – Primary Stroke Care
* Orlando Regional Medical Center – Comprehensive Stroke Care and Neurosurgery
* Oviedo Medical Center - Primary Stroke Care
* South Seminole Community Hospital – Primary Stroke Care
* Florida Hospital Orlando – Comprehensive Stroke Care with 24/7 Interventional Radiology (IR) services and Neurosurgery. (revised 5.19.10)
* Winter Park Memorial Hospital - Primary Stroke Care (revised 1/25/2017)


Use of air medical resources is appropriate when the window for evaluation for Intra-arterial therapy is less than 1-hour and ground transport exceeds 30 minutes.


'''EVALUATION FOR INTRA-ARTERIAL THERAPY OR LARGE VESSEL OCCLUSION'''
Patients presenting with the following neurological findings shall be transported directly to FLORIDA HOSPITAL ORLANDO OR ORLANDO REGIONAL MEDICAL CENTER:
{| class="wikitable"
* Severe hemiparesis or hemiplegia, (inability to lift or hold arm up) '''AND'''
|+DESTINATION SELECTION
* Dysconjugate gaze, forced or crossed gaze, (if patient is unable to voluntarily respond to exam, perform Doll’s eye test) '''AND'''
|-
* Last seen normal greater than 3 ½ hours ago but less than approximately 12 hours '''OR'''
|colspan="2"|All suspected stroke and TIA patients must be transported to a stroke-receiving facility, unless the patient is UNSTABLE.
* Have contraindications for IV therapy such as Coumadin therapy, recent surgery, treatment of bleeding ulcer, etc.
|-
* If greater than 12-hours, a “STROKE ALERT” is not indicated. Use normal radio protocol and transport to the nearest stroke-receiving facility.
|VAN Negative
|PRIMARY STROKE CENTER
|-
|VAN Positive
|COMPREHENSIVE STROKE CENTER
|-
|VAN NEGATIVE or POSITIVE and tPA EXCLUSIONS   
|COMPREHENSIVE STROKE CENTER
|}
           


'''TRANSPORT CONSIDERATIONS:'''
* Use of air medical resources is appropriate when the window for evaluation for Intra-arterial therapy is less than 1-hour and ground transport exceeds 30 minutes.


=====COMPREHENSIVE STROKE DESTINATIONS=====
*Evaluation of suspected Large Vessel Occlusion (LVO) -or-
*Have contraindications for IV therapy such as Coumadin therapy, recent surgery, treatment of bleeding ulcer, etc.
{| class="wikitable"
|Advent Health Orlando
|Comprehensive Stroke Care
|-
|Orlando Regional Medical Center
|Comprehensive Stroke Care
|}


'''MANAGEMENT:'''
=====PRIMARY STROKE DESTINATIONS=====
* Do NOT treat hypertension
The following hospitals have been approved by the Medical Director
* Do not allow aspiration - elevate head of stretcher 15 - 30 degrees if systolic BP >100 mm Hg
{| class="wikitable"
* Maintain head and neck in neutral alignment, without flexing the neck
|Advent Health Altamonte
* Protect paralyzed limbs from injury
|Primary Stroke Care
* IV Normal Saline (avoid multiple IV attempts)
|-
* Perform blood draw of all tubes.  The crew shall hold onto the tubes at the hospital until a staff member is ready to label the blood tubes.  Document that blood was drawn.
|Advent Health Apopka
* Obtain BGL
|Primary Stroke Care
* Obtain 12-lead EKG
|-
* Nausea/vomiting - administer an antiemetic
|Advent Health East
 
|Primary Stroke Care
 
|-
'''DOCUMENTATION:'''
|Advent Health Orlando
* Complete Stroke Checklist and leave copy at hospital.
|Comprehensive Stroke Care
* Forward or Fax the duplicate Stroke Checklist to County EMS QA office.
|-
* A copy of the completed stroke checklist must also accompany the abbreviated report for the agency.
|Central Florida Regional Hospital
 
|Primary Stroke Care
 
|-
'''Miami Emergency Neurologic Deficit'''
|Orlando Regional Medical Center
* Do not delay transport since definitive care for the restoration of neurologic function may be significantly improved with timely treatment at receiving facility.
|Comprehensive Stroke Care
* Be conscientious of numerous IV attempts due to possibility of Fibrinolytic therapy and subsequent bleeding from both successful and attempted IV sites. Notify staff and document location of any missed IV’s. **Do not use IO unless the patient needs immediate treatment.
|-
 
|Oviedo Medical Center
[[Category:Medical|0504]]
|Primary Stroke Care
|-
|South Seminole Community Hospital
|Primary Stroke Care
|-
|Winter Park Memorial Hospital
|Primary Stroke Care
|}

Revision as of 14:43, 24 May 2019

Section 5 -MEDICAL

5.04 SUSPECTED STROKE/TRANSCIENT ISCHEMIC ATTACK (T.I.A.)

PRINCIPLES

  • Rapidly identify patients with suspected stroke
  • Minimize scene time & safe, expediate transport to the appropriate facility
  • Continuous review and improvement on the stroke management process
  • INITIAL MEDICAL CARE 2.01
  • Differential Diagnosis
  • Establish a definitive last known well (LKW) time
  • Complete a Cincinnati Pre-Hospital Stroke Exam


Cincinnati Pre-hospital Stroke Exam (amended)

  • Cincinnati and VAN assessments can be performed simultaneously
Face Face numbness or weakness, especially one side

“Smile”

Arm Arm numbness or weakness, especially on one side of the body

“Arms out like Superman”

(VAN Positive or Negative?)
Speech Slurred speech or difficulty speaking or understanding

“You can’t teach an old dog new tricks”

(VAN Aphasic? Consider VAN Visual Disturbance and Neglect!))
Time Time since – Last seen normal/Last Known Well (LKW)


  • Perform Blood Glucose
  • Complete Stroke Checklist
    • Identify any t-PA exclusions and document all findings
    • Leave copy at hospital
    • Forward or Fax the duplicate Stroke Checklist to County EMS QA office
    • A copy of the completed stroke checklist must also accompany the abbreviated report for the agency.
  • Obtain IV Access
    • An 18 gauge is preferable.
    • Avoid multiple attempts and IO's
    • Notify ER staff and document location of any missed IV’s.
    • Be conscientious of numerous IV attempts due to possibility of Fibrinolytic therapy and subsequent bleeding from both successful and attempted IV sites.
  • Perform blood draw of all tubes.
    • The crew shall hold onto the tubes at the hospital until a staff member is ready to label the blood tubes.
    • Document that blood was drawn.
  • HYPERTENSION - Do not treat hypertension.
  • Elevate the head of the stretcher 15-30 degrees if systolic BP >100 mm Hg
  • Do not allow aspiration
  • Maintain head and neck in neutral alignment, without flexing the neck
  • Protect paralyzed limbs from injury
  • Obtain 12-lead EKG
  • Nausea/vomiting - administer an antiemetic
  • Have Patient hold both arms up for 10 seconds
    • Is arm weakness present?
      • YES - continue VAN assessment
      • NO - Patient is VAN negative.

VAN Assessment

Visual IS VISION GAZED IN ONE DIRECTION? NEW ONSET BLINDNESS?

Test: Ask the person to look up, then down then left, then right. Or have them follow your finger in those directions.

Normal: No preferred gaze and eyes move past midline upon request.

Abnormal: Gaze is deviated to one side and does not pass the midline upon request or new onset blindness.

Aphasia CAN THE PERSON SPEAK & UNDERSTAND LANGUAGE?

Test: Ask them to name an ordinary object such as a pen. Or ask them to make a fist

Normal: The patient can understand language and name ordinary objects.

Abnormal: Inability to understand or express speech or name ordinary objects, does not follow simple commands such as “close your eyes” or make a fist

Slurred speech alone does not indicate a positive VAN test

Neglect IS THE PATIENT IGNORING ONE SIDEOF THE BODY (Usually the left side)?

Test: Ask the patient to close their eyes and tell them that you will touch each arm individually and then both at the same time. Ask them to acknowledge each touch.

Normal: Patient acknowledges both individual touches and simultaneous touch.

Abnormal: Patient does not acknowledge simultaneous touch usually ignoring the left side

If the patient does not acknowledge individual touches this does not indicate a positive VAN test.


ARM DRIFT PLUS ONE OF THE ABOVE IS VAN POSITIVE

Cincinnati and VAN assessments often are performed simultaneously

TRANSPORT DESTINATION (Determined ONLY by VAN Assessment Results)

Symptoms 5 minutes to >5 days called in as STROKE ALERT

Stroke receiving center can determine acuity and level of aggressive action.

Transporting EMERGENCY or NON-EMERGENCY is determined by the crew but a LKW of <24 should receive EMERGENCY transportation.

Use of air medical resources is appropriate when the window for evaluation for Intra-arterial therapy is less than 1-hour and ground transport exceeds 30 minutes.


DESTINATION SELECTION
All suspected stroke and TIA patients must be transported to a stroke-receiving facility, unless the patient is UNSTABLE.
VAN Negative PRIMARY STROKE CENTER
VAN Positive COMPREHENSIVE STROKE CENTER
VAN NEGATIVE or POSITIVE and tPA EXCLUSIONS COMPREHENSIVE STROKE CENTER


COMPREHENSIVE STROKE DESTINATIONS
  • Evaluation of suspected Large Vessel Occlusion (LVO) -or-
  • Have contraindications for IV therapy such as Coumadin therapy, recent surgery, treatment of bleeding ulcer, etc.
Advent Health Orlando Comprehensive Stroke Care
Orlando Regional Medical Center Comprehensive Stroke Care
PRIMARY STROKE DESTINATIONS

The following hospitals have been approved by the Medical Director

Advent Health Altamonte Primary Stroke Care
Advent Health Apopka Primary Stroke Care
Advent Health East Primary Stroke Care
Advent Health Orlando Comprehensive Stroke Care
Central Florida Regional Hospital Primary Stroke Care
Orlando Regional Medical Center Comprehensive Stroke Care
Oviedo Medical Center Primary Stroke Care
South Seminole Community Hospital Primary Stroke Care
Winter Park Memorial Hospital Primary Stroke Care
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