Suspected Stroke Transcient Ischemic Attack TIA

Section 5 -MEDICAL

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

Initial Medical Care – 2.01 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
        

VAN Assessment:

• Visual disturbance?
  • Field cut (which side) (4 quadrants)
  • Double vision
  • Blind new onset
  • NONE
    

Have patient look straight ahead and ask them to tell you number of fingers on left and right
Double vision meaning eyes semi crossed, one eye out or in
Have them track your hand to right and left

• Aphasia?
  • Expressive (inability to speak or errors)
  • Receptive (not understanding or following commands)
  • Mixed
  • NONE
    

Ask the patient to repeat "today is a sunny day" & name 2 objects
Ask them to close eyes and make fist. If they understand and follow commands and are making words DO NOT COUNT SLURRING of WORDS
Paraphasic errors ("papple" for apple or "lelephone" for telephone)

• Neglect?
  • Forced gaze or inability to track to one side
  • Unable to feel both sides at same time, or unable to indentify own arm
  • Ignoring one side
  • NONE
    

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
Touch patient on right then left and then both. Can they feel right and left at same time?

If the patient has arm weakness and is "positive" on any of the VAN assessment fields the patient is VAN POSITIVE

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

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.

• Perform Cincinnati Pre-hospital Stroke Exam
  • 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 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 PRACTICE PARAMETER (5.12).

STROKE-ALERT SCREENING PROCESS

• 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

STROKE-RECEIVING DESTINATIONS: 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 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)

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:

• Severe hemiparesis or hemiplegia, (inability to lift or hold arm up) AND
• 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
• 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.

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.

MANAGEMENT:

• Do NOT treat hypertension
• Do not allow aspiration - elevate head of stretcher 15 - 30 degrees if systolic BP >100 mm Hg
• Maintain head and neck in neutral alignment, without flexing the neck
• Protect paralyzed limbs from injury
• 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.
• Obtain BGL
• Obtain 12-lead EKG
• Nausea/vomiting - administer an antiemetic

DOCUMENTATION:

• Complete Stroke Checklist and 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.

Miami Emergency Neurologic Deficit

• Do not delay transport since definitive care for the restoration of neurologic function may be significantly improved with timely treatment at receiving facility.
• 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.