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(Created page with "==Section 5 -MEDICAL== ===5.04 SUSPECTED STROKE/TRANSCIENT ISCHEMIC ATTACK (T.I.A.)=== ==== PRINCIPLES ==== *Rapidly identify patients with suspected stroke *Minimize scen...")
 
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*Cincinnati and VAN assessments can be performed simultaneously
*Cincinnati and VAN assessments can be performed simultaneously


Face
{| 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)
(<span style="color: deeppink;">Only Needed for ER</span>)
|}




Arm


*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 15-30degrees  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.


(VAN Positive or Negative?)
====VAN Assessment====
{| class="wikitable"
|<span style="color: deeppink;">Visual </span>
|'''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.


Speech
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.
|-
|<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.


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 


(VAN Aphasic? Consider VAN Visual Disturbance and Neglect!)
|-
 
|<span style="color: deeppink;">Neglect </span>
Time
|'''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.


Differential Diagnosis 5.03 ALTERED MENTAL STATUS (AMS)
Normal: Patient acknowledges both individual touches and simultaneous touch.
5.17 SEPSIS
BLOOD GLUCOSE 
STROKE CHECKLIST 
Identify any t-PA exclusions and document all findings
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.


IV  ACCESS: an 18 gauge is preferable. Avoid multiple attempts and IO's
Abnormal: Patient does not acknowledge simultaneous touch usually ignoring the left side
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.
Notify ER staff and document location of any missed IV’s. **
If the patient does not acknowledge individual touches this does not indicate a positive VAN test.
Be conscientious of numerous IV attempts due to possibility of Fibrinolytic therapy and subsequent bleeding from both successful and attempted IV sites.  
HYPERTENSION Do not treat hypertension


ELEVATE THE HEAD OF THE STRETCHER  15-30degrees  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.
 
Visual


<span style="color: deeppink;">'''ARM DRIFT PLUS ONE OF THE ABOVE IS VAN POSITIVE'''</span>


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


====TRANSPORT DESTINATION  <span style="color: deeppink;">(Determined ONLY by VAN Assessment Results)</span>====


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


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


Transporting EMERGENCY or NON-EMERGENCY is determined by the crew but <24 hours of LKW is recommended EMERGENCY transportation.
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.


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.
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.
Line 94: Line 122:




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


PRIMARY STROKE DESTINATIONS:
=====PRIMARY STROKE DESTINATIONS=====
All suspected stroke and TIA patients must be transported to a stroke-receiving facility, unless the patient is UNSTABLE. The following hospitals have been approved by the Medical Director:
All suspected stroke and TIA patients must be transported to a stroke-receiving facility, unless the patient is UNSTABLE. The following hospitals have been approved by the Medical Director
Advent Health Altamonte - Primary Stroke Care
{| class="wikitable"
Advent Health Apopka - Primary Stroke Care
|Advent Health Altamonte  
Advent Health East - Primary Stroke Care
|Primary Stroke Care
Central Florida Regional Hospital - Primary Stroke Care
|-
Orlando Regional Medical Center - Comprehensive Stroke Care
|Advent Health Apopka
Oviedo Medical Center - Primary Stroke Care
|Primary Stroke Care
South Seminole Community Hospital - Primary Stroke Care
|-
Advent Health Orlando - Comprehensive Stroke Care
|Advent Health East
Winter Park Memorial Hospital - Primary Stroke Care
|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
|}

Revision as of 21:04, 16 March 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)

(Only Needed for ER)


  • 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 15-30degrees 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.




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

All suspected stroke and TIA patients must be transported to a stroke-receiving facility, unless the patient is UNSTABLE. 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