Suspected Stroke Transcient Ischemic Attack TIA

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Section 5 -MEDICAL

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

Initial Medical Care – 2.01 OXYGEN only if SaO2 < 95%

  • 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 < 4.5 hours
  • Must have at least an 18 gauge IV access. Avoid multiple attempts and IO's

If greater than 5-hours, a “STROKE ALERT” is not indicated. Use normal radio protocol and transport to the nearest stroke-receiving facility.


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
  • 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)


EVALUATION FOR INTRA-ARTERIAL THERAPY Patients presenting with the following neurological findings shall be transported directly to FLORIDA HOSPITAL ORLANDO:

  • 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.


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)
  • 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.
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