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Introduction
  • Stroke occurs when arterial blood supply to the brain is suddenly disrupted due to obstruction by a thrombus or plaque (Ischaemic stroke 85%), or because an artery ruptures (Haemorrhagic stroke 15%).
  • Transient ischaemic attack (T.I.A.) is also significant as it may precede a stroke.
  • Maintain a high index of suspicion of cerebrovascular accident in persons presenting with neurological symptoms over the past 24 hours, excluding obvious causes for these neurological symptoms such as hypoglycaemia.

Read the complete article; Stroke in the Medical Library >  Pathophysiology.

Clinical Presentation

Patients who present with any of the following should be assessed for a cerebrovascular accident:

  • Weakness, numbness or paralysis of the face, arm or leg (unilateral or bilateral)
  • Dysphasia, language difficulties
  • Dizziness, ataxia, loss of balance or an unexplained fall
  • Loss of vision, visual field disturbances, double vision, or sudden blurred or decreased vision in one or both eyes
  • Headache, usually severe and of abrupt onset
  • Dysphagia, difficulty in swallowing.
Exclusion Criteria
Exclusion Criteria
Risk Assessment
  • FAST (Face, Arm, Speech and Time) is a rapid diagnostic tool for the evaluation of stroke like symptoms.
    • If 1 or more abnormality exists (to Face, Arms or Speech), and symptom onset is ≤ 9 hours (Time), then the patient is considered FAST+.
    • Time is measured from symptom onset & must be ≤ 9 hours for patient to meet the FAST+ criteria.
    • If the patient has woken with stroke symptoms (but was asymptomatic prior to sleeping), time starts from waking up.
  • RACE (Rapid Arterial oCclusion Evaluation) is a quantifying tool used to assess the likelihood of a large vessel occlusion and identifies the patients’ that may require urgent neuroendovascular clot retrieval.
  • TIA (Transient Ischaemic Attack) symptoms may resolve completely within minutes to hours of onset, but are still indicative of an at-risk patient. These patients require assessment at a stroke centre.
  • Improved stroke patient outcomes rely on:
    • Rapid on-scene assessments
    • Early ED, ASC or ANU notification
    • Urgent transportation
    • Information gathering, inclusive of time of onset/last seen well and next of kin details
Management
Primary Care
Intermediate Care (EMT / Level 2)
  • Consider applying cardiac monitor if trained and authorised
  • Conduct FAST assessment; if FAST+, stroke is the likely diagnosis.
  • Conduct RACE assessment to identify Large Vessel Occlusion (LVO).
  • If stroke bypass criteria is met, transport to appropriate destination as indicated
  • If stroke bypass criteria is not met, transport to nearest ED
Advanced Care (AP)
  • Cardiac monitoring
  • Conduct FAST assessment;
    • If FAST- but history is suggestive of TIA, the patient is at risk and still meets stroke bypass criteria
    • If FAST+, stroke is the likely diagnosis; conduct a RACE assessment to identify Large Vessel Occlusion (LVO).
  • Obtain IV Access (ACF preferable)
  • Collect pre-hospital blood sample
  • Aim for on scene time < 15 minutes
  • If stroke bypass criteria is met, transport to appropriate destination as indicated
  • If stroke bypass criteria is not met, transport to ED as directed by ANC, or nearest ED if urgent intervention is required
Critical & Extended Care (CCP, PSO)
  • As per Advanced Care (AP) guidelines
Additional Information
Inclusion Criteria
  • Time of symptom onset < 9 hours
    • Note: If the patient has woken with stroke symptoms but was asymptomatic prior to sleeping, time starts from waking up.
  • Patient possesses full Activities of Daily Living
  • BGL between 4 - 22 mmol/L
Acute Stroke CentreAcute Stroke CentreAcute Neuroendovascular Unit

Transient Ichaemic Attack
(even if symptoms have resolved)

For patients FAST+
and with RACE ≤ 4

For patients FAST+ and with RACE ≥ 5

Transport via
normal road conditions
Transport Priority 1; pre-notify hospital via ED patch line
  • Sir Charles Gairdner Hospital
  • Fiona Stanley Hospital
  • Royal Perth Hospital
  • St. John of God - Midland
  • Joondalup Health Campus

Monday - Sunday, 24 hours a day

  • Sir Charles Gairdner Hospital:
    Monday - Sunday, 24 hours a day

  • Fiona Stanley Hospital:
    Monday - Friday, 08:00 - 16:00
    Arrival to ED must be within prescribed times
Regional Centres
  • If both FAST and RACE positive and within approximately 100km of the main regional hospital, consider calling that ED for potential bypass instructions if onset of symptoms is < 9 hours.
  • Early notification to hospital via patch line is essential for all FAST+ patients (with or without a RACE score).
Stroke bypass is not indicated where:
  • Specified inclusion criteria are not met.
  • An urgent intervention is required at closest ED.

Possible complications / outcomes of stroke:

  • Permanent Disability
  • Brain damage
  • Death

References
References
Key Terms & Links

FAST-STROKE-9

 

RACE Assessment

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