2.6. SUSPECTED STROKE/TRANSIENT ISCHEMIC ATTACK

Related terms.

Cerebral vascular disease, Transient ischemic attack (TIA).

The purpose of care

1. Identification of neurological deficit.
2. Determination of the need to transport the patient to a neurological center.

Patient description

1. Neurological deficit manifested by facial expressions, localized weakness, gait disorders, speech disorders, and mental impairment.
2. Hypiparesis or hemiplegia.
3. Disconcerting gaze, forced or crossed gaze (if the patient is unable to respond voluntarily to the examination, does not make noticeable efforts to respond or does not respond).
4. Severe headache, neck pain/stiffness, difficulty seeing.

Inclusion criteria

Patient has signs and symptoms consistent with stroke or TIA.

Exclusion criteria

1. If the glucose level is below 3.5 mmol/L, provide care according to the Hypoglycemia guideline.
2. If trauma is present and the GCS score is 13 or lower, treat according to the Head Trauma and General Guidelines for Care guidelines.

Patient management

Assessment

1. Apply an approved stroke assessment scale for suspected stroke, which includes, but is not limited to, the following

a) change of facial expression – ask the patient to smile;
b) holding hands in the air – close your eyes, raise your hands and count to 10;
c) speech – ask the patient to say a sentence, such as “You can’t teach an old dog new tricks.”

2. Additional important information includes:

a) history – “the last time the patient was seen in a normal state” and the source of this information;
b) assessment of neurological status (see Appendix 3);
c) whether the patient is taking warfarin or any anticoagulant medication.

3. Assess for stroke-like symptoms:

a) hypoglycemia
b) seizures
c) sepsis
d) migraine;
e) intoxication.

Treatment and interventions

1. Determine the time of symptom onset.
2. Provide oxygen therapy to achieve a saturation of 94-98%.
3. If seizures persist, provide care according to the Seizures guideline.
4. Check the blood glucose level.
   Administer glucose if it is below 3.5 mmol/L.
5. Record a 12-lead ECG.
6. Notify the emergency department of the transportation of the stroke patient.

Patient safety

1. Prevent aspiration – raise the upper part of the stretcher by 15-30 degrees if the systolic blood pressure is above 100 mmHg.
   Support the head and neck in a neutral position, fix the cervical spine.
2. Protect paralyzed limbs from injury.
3. Avoid multiple attempts to gain IV access.

Useful information for training

Key points

1. The method of transportation and the destination should be chosen based on the local resources of the health care system.

The destination may be:

• • a neurology unit
  • neurological center;
  • a comprehensive stroke center.

2. Do not treat hypertension.

3. Use a heart rate monitor.

4. Children:

a) the principles of care remain the same;
b) despite the relative rarity of cases, children can have a stroke;
c) the stroke symptom assessment scale is not adapted for children;
d) EMS workers should check in advance with the emergency department to see if they can admit a patient.

Key elements of documentation

1. The time of symptom onset must be accurate.
   If the patient was healthy the evening before the incident and woke up with obvious symptoms, it should be documented that it was the evening of the previous day, not the morning when the patient woke up with symptoms.
2. Glucose level.
3. The scale used to assess the presence of stroke symptoms and the result of the assessment.
4. Time of notification of the emergency department.

Criteria for the effectiveness of care

1. Documentation of time to onset of symptoms.
2. Use of an approved stroke symptom assessment scale.
3. Determination of glucose level.
4. Minimum time for the EMS team to arrive at the scene (goal is less than 20 minutes).
5. Alerting the neurological team in the emergency department to the presence of a stroke patient as soon as possible after the symptoms are detected.