Suspected Stroke Transcient Ischemic Attack TIA

Section 5 -MEDICAL

5.04 SUSPECTED STROKE/TRANSIENT 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
  • ALTERED MENTAL STATUS (AMS) 5.03
  • SEPSIS 5.17
• Establish a definitive last known well (LKW) time
• Complete a BE-FAST Pre-Hospital Stroke Exam

BE FAST Exam

• BE FAST and VAN assessments can be performed simultaneously

Balance	Is the person suddenly having trouble with balance or coordination?
Eyes	Is the person experiencing suddenly blurred or double vision or a sudden loss of vision in one or both eyes without pain?
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

BE-FAST and VAN assessments often are performed simultaneously

TRANSPORT DESTINATION (Determined ONLY by VAN Assessment Results)

If patient exhibits symptoms, regardless of time frame, call 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
Suspected Cerebellar infarct with posterior circulation LVO symptoms	COMPREHENSIVE STROKE CENTER
VAN NEGATIVE or POSITIVE and tPA EXCLUSIONS	COMPREHENSIVE STROKE CENTER

COMPREHENSIVE STROKE DESTINATIONS

• Evaluation of suspected Large Vessel Occlusion (LVO) -or-
• Suspected Cerebellar infarct with posterior circulation LVO symptoms, including acute dizziness/balance findings or acute visual changes (blurred, limited or double vision)
• 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

Hospitals meeting Comprehensive Stroke Care Capability and able to manage Large Vessel Occlusion (LVO) and Suspected Cerebellar infarct care:

HCA Lake Monroe

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
HCA Lake Monroe	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