Stroke including Transient Ischaemic Attack (TIA)

Question 1

Clinical Severity Prompts (4)

Answer 1

Facial weakness - can person smile? is there mouth or eye droop?

Arm weakness - can the person raise both arms?

Speech difficulty - can the person speak clearly and understand what you say?

Time - of onset of symptoms and duration

Question 2

Treat as a …

Answer 2

Medical Emergency.

Question 3

History Prompts (5)

Answer 3

Onset

Associated symptoms:

• Altered LOC, dizziness or loss of balance, loss of vision, blurred vision or decreased vision in one or both eyes, headache, difficulty swallowing, altered or garbled speech, weakness or numbness in face or limbs, acute onset of confusion.

Relevant past history - confirmed previous TIAs, diabetes, smoker, hypertension, age > 60 years

Medication history - especially diabetic medication and anticoagulants such as warfarin, aspirin, clopidogrel. Seizure medication. Alternative therapies.

Allergies.

Question 4

Airway - Assessment

Answer 4

Assess patency

Question 5

Airway - Intervention

Answer 5

Maintain airway patency

Question 6

Breathing - Assessment

Answer 6

Respiratory rate and effort

SpO2

(Auscultation)

Question 7

Breathing - Intervention

Answer 7

Assist ventilation if required

Apply O2 to maintain SpO2 > 95%

Question 8

Circulation - Assessment

Answer 8

Skin temperature (touch)

Pulse - rate/rhythm

Capillary refill

Blood pressure

Cardiac monitor

Electrocardiograph

Question 9

Circulation - Intervention

Answer 9

IV cannulation / pathology

If SBP < 90mmHg give IV 0.9% NaCl 500ml bolus

Monitor vital signs frequently

12 - lead ECG

Question 10

Disability

Answer 10

AVPU/GCS + pupils ⇒ Monitor LOC frquently

Finger prick BGL if < 3.5mmol/L

⇒ If unconscious or confused administer IV 50% Glucose 50ml or if IV access unavailable, administer IM Glucagon 1mg

Question 11

Measure and Test

Answer 11

Pathology - Collect blood for FBE, UEC, ESR, BGL, coags, venous blood gases)

Temperature - if > 37.5^oC give Paracetamol 500mg - 1g IV or PR

Neurological Obs - Monitor frequently

Headache pain - If score 4-10 give IV Morphine 2.5mg increments every 5 minutes to a total of 10mg or IM Morphine 5 - 10mg (if IV access unavailable)

U/A - full urinalysis

Fluid input/output - FBC, nil by mouth, consider NGT

Chest x-ray (if available)

Question 12

Specific Treatment

Answer 12

Nausea/vomiting - give IV or IM Metoclopramide 10mg

Hydration - IV 0.9% NaCl 1000ml (125ml/hour maintenance)

• Rapid initial stroke screen (ROSIER Scale) if > 0 transfer for urgent CT/MRI
• ABCD² if TIA suspected ⇒ if > 4 transfer for urgent CT/MRI

Bedside swallow screen (within 24hours) - nil by mouth in the meantime

Possible alcohol abuse? ⇒ give IM Thiamine 100mg