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 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
• 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.
• 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)
• 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.