Stroke (CVA)

This protocol is intended to reduce the time to thrombolysis in the acute stroke patient. Patient with symptoms of less than 4 hours duration are considered “time-critical.” Other patients with symptom onset less than 24 hours should be considered urgent but not “time-critical”.
Patients may present as having fallen, unable to walk, have new balance problems or with acute altered level of consciousness. 

 

BLS

 

  1. Administer oxygen as indicated. See Oxygen Administration protocol.
  2.  

  3. Perform blood glucose analysis. If blood glucose < 70 mg/dL, refer to hypoglycemia protocol in “Altered Level of Consciousness”
  4.  

  5. Evaluate any patient with suspected stroke using the Cincinnati Stroke Scale. If positive/abnormal, perform RACE Stroke Scale and determine, to the best of your ability, the time last known normal (neurologically).
  6.  

  7. Contact the receiving emergency department and include the following information: time of onset of signs/symptoms, RACE Stroke Scale findings, and blood glucose results. Document all results.
  8.  

  9. Identify a close family member or friend to accompany the patient to the hospital to provide information on baseline function, onset of symptoms, and possible consent for tPA. Include this information in your handover report. If a family member is unable to accompany the patient, obtain a phone number for a family member to provide the hospital with this same information.
  10.  

  11. If level of consciousness is decreased or vital signs abnormal, transportation by advanced life support is preferred.

 

ALS

 

  1. Obtain a 12-lead EKG
  2.  

  3. Ensure blood glucose analysis has been performed. If blood glucose < 70 mg/dL, refer to hypoglycemia protocol in “Altered Level of Consciousness”
  4. Do not treat hypertension
Cincinnati Prehospital Stroke Scale

    Facial Droop (have patient show teeth or smile):

      Normal – both sides of face move equally well
      Abnormal – one side of face does not move as well as the other side

     

    Arm Drift (have patient close eyes and hold both arms out, palms up):

      Normal – both arms move the same or both arms do not move at all
      Abnormal – one arm does not move or one arm drifts down compared with the other

     

    Speech (have the patient say “you can’t teach old dog new tricks”):

      Normal – patient uses correct words with no slurring
      Abnormal – patient slurs words, uses inappropriate words, or is unable to speak

 

RACE Stroke Scale

Facial Palsy Absent
  0  
Mild
+1
Moderate/Severe
+2
Arm Motor Impairment Normal/Minimal
0
Moderate
+1
Severe
+2
Leg Motor Impairment Normal/Minimal
0
Moderate
+1
Severe
+2
Head and Gaze Deviation Absent
0
Present
+1
Left Hemiparesis

Ask the patient:
(1) While showing patient the paretic arm, “Whose arm is this?”
(2) “Can you lift both arms and clap?”
Patient recognizes his/her arm and the impairment
0
Does not recognize his/her arm or the impairment
+1
Does not recognize his/her arm AND the impairment
+2
Right Hemiparesis

Instruct the patient:
(1) Close your eyes”
(2) “Make a fist.”
Performs both tasks correctly
0
Performs one task correctly
+1
Performs neither task correctly
+2