Stroke Triage

Question 1

Possible causes of acute neurological deficit or altered level of consciousness include:

Answer 1

• Hemorrhagic stroke
• Ischemic stroke
• Craniocerebral / cervical trauma
• Meningitis / encephalitis
• Hypertensive encephalopathy
• Intracranial mass
  ‐ Tumor
  ‐ Subdural / epidural hematoma
• Seizure with persistent neurological signs (Todd’s paralysis)
• Migraine with persistent neurological signs
• Metabolic
  ‐ Hyperglycemia (nonketotic hyperosmolar coma)
  ‐ Hypoglycemia
  ‐ Post cardiac arrest ischemia
  ‐ Drug overdose

Question 2

Draw out LAMS table

Answer 2

LAMS Score the Affected Side Description

Facial Droop
0 Absent No facial asymmetry - Normal

1 Present Partial or complete - lower facial droop

Arm Drift
0 Absent No drift - Normal

1 Drifts down - Drifts down but does not hit the bed within 10 seconds

2 Falls rapidly Arm cannot be held up against gravity and falls to the bed within 10 seconds

Grip Strength
0 Normal

1 Weak grip - Weak but some movement

2 No grip No movement - Muscle contraction can be seen but without movement

Final Score 0-5

Question 3

What does LAMS indicate?

Answer 3

A Brief Prehospital Stroke Severity Scale Identifies Ischemic Stroke Patients Harboring Persisting Large Arterial Occlusions

score of 4 or greater higher indication

Question 4

Describe the speech aspect in the Stroke Triage

Answer 4

Speech (have the patient say a statement such as “you can’t teach an old dog new tricks”):
* Normal ‐ patient uses correct words with no slurring
* Abnormal‐ patient slurs words, uses inappropriate words, or is unable to speak

Question 5

If symptoms have completely resolved prior to EMS arrival?

Where do we transport to?

Answer 5

Transport to appropriate Emergency Department as per Destination Advisory

Patients transported to an Emergency department will benefit from appropriate diagnostic evaluation and timely stroke prevention treatment. Evidence suggests that immediate intervention can reduce the risk of recurrent stroke and that the incidence of a recurrent stroke is highest in the 48 hours following a TIA.

Question 6

Do the following apply:
¤ LAMS Score > 0 and/or new speech deficit (slurred/abnormal/aphasic)?

AND

¤ Is estimated time from symptom onset to arrival at hospital ≤ 6 hours?

Next step is?

Answer 6

Complete Thrombolytic Checklist if estimated time from symptom onset to arrival at hospital is under 3.5 hours.

Select stroke patients may be candidates for thrombolytic therapy. This therapy, if applicable, must be started within 4½ hours (270 minutes) of the onset of stroke symptoms. For the purpose of pre‐hospital triage and to be eligible for thrombolysis, the patient must arrive at hospital within 3½ hours from symptom onset.

Question 7

If we contact the neurologist, what do we say?

Answer 7

The crew will call HSC paging at (204)787‐2071:
‐ Identify themselves as a Winnipeg EMS Unit
‐ Ask to speak to the on‐call neurologist
Once on the line with the neurologist, the crew should
‐ Identify themselves as a Winnipeg EMS unit
‐ Be prepared to discuss HPI and the patient’s condition including the thrombolytic checklist.
‐ If requested by paging, crews must leave a call back number as the neurologist may not be readily
available.
‐ In the event the crew is unable to speak with the neurologist, crews should not delay transport.

In the event the neurologist is unable to be reached after two attempts, the crew should transport to HSC. For all acute stroke patients being transported to HSC, it is still the responsibility of the paramedic crew to activate the entire Stroke Team via an appropriate radio patch to the
Emergency department as soon as possible after the transport to HSC has been initiated.

Question 8

Draw out the Paramedic Thrombolytic Therapy Checklist for Ischemic Stroke

Answer 8

Only minor or rapidly improving stroke symptoms

Blood glucose less than 2.7 or greater than 22.2 mmol/L

Within 3 months of intracranial/intraspinal surgery, serious head trauma, or previous stroke

Recent arterial puncture at noncompressible site within 7 days

Lumbar puncture within 7 days

Within 14 days of major surgery of serious trauma

Active internal bleeding (e.g., gastrointestinal bleeding or urinary bleeding within last 21 days)

History of intracranial/CNS hemorrhage, arteriovenous malformation, or aneurysm

Witnessed seizure at stroke onset

Pregnancy

Recent myocardial infarction (discuss timing with on-call neurologist)