Stroke Triage Protocol

Question 1

Inclusion Criteria for Pts who should be taken to a Stroke Center (Primary, Primary+ or Comprehensive)

Answer 1

1. Patients with suspected stroke
2. Positive prehospital stroke screen
3. New symptoms for <24 hours

Question 2

TX for Suspected Stroke Pt

Answer 2

1. Interview witnesses and obtain phone numbers
2. Document last known well time
3. Document patient weight
4. FSBG
5. 18-20g IV & Cardiac Monitor

Question 3

Prior to Transport

Answer 3

1. Provide STROKE ALERT for all patients included above
2. Provide accurate ETA and last known well (LKW) time
3. Provide direct communication w/ receiving facility for patients w/
   significantly AMS or concerns for airway compromise

Question 4

Where to transport Pts showing S/S (last known well)w/ in 4 hours

Answer 4

Nearest Stroke Center
- Primary
- Primary+
- Comprehensive

Question 5

Where to transport Pts showing S/S (last known well) over 4 hours

Answer 5

1. Assess for unilateral motor weakness for 10 seconds
   - If weakness present, perform screening for Large Vessel Occlusion (LVO);
   - if LVO screening positive, transport patient to nearest Primary+ or Comprehensive Stroke Center
2. If LVO screen is negative, transport to nearest stroke center (Primary,
   Comprehensive, or Primary Plus Stroke Center)

Question 6

How is LVO determined?

Answer 6

VAN Scale

1. Vision
2. Aphasia
3. Neglect

Question 7

Vision Test

Answer 7

1. Hold 2 fingers to the right and one to the left while the Pt stares at the providers nose/mouth (left and right visual fields):
   - Can patient correctly identify the number of fingers on both sides?
2. Ask the patient to look left and right one or more times (Double vision, equal eye movements):
   - Do both eyes move @ the same speed & direction?

Question 8

Aphasia Test

Answer 8

Show the Pt 2 common objects (pen, shirt) & ask patient to verbally identify:
- Can the Pt verbally correctly identify both objects?

Question 9

Neglect Test

Answer 9

1. Ask the Pt to follow your finger w/ only their eyes form left to right (forced gaze, inability to track):
   - Can Pt track your finger?
2. Ask the Pt to close their eyes with arms by their side. Begin brushing Pt’s forearms simultaneously & ask “which arm am I touching?” (equal arm sensation):
   - Can patient feel both arms at the same time?
3. Observe if the gaze turns to one side or does not react to stimuli on one side:
   - Can patient look, move, and react to stimuli on both sides?