STROKE Name: PID: DOB: Consultant: Heart of England Foundation Trust ACUTE STROKE PATHWAY EMERGENCY DEPARTMENT ATTACHMENTS November 2010 TIME IS BRAIN SUSPECTED STROKE Onset Within 6 Hours? (FAST TEST +VE / ROSIER 1-5) COMMENCE THROMBOLYSIS PATHWAY IMMEDIATELY CONFIRM THE FOLLOWING HAVE TAKEN PLACE IN THE ED: A: Aspirin 300mg PR / PO stat dose given (if not for lysis) B: Blood glucose corrected to normal (especially > 3.5 mmol/l) C: CT scan either done or requested already on IMPAX If not why not?... D: Bloods: E: Bed on ASU Peter Carr Lead Nurse for Stroke Dr David Sandler Consultant Lead for Stroke 1
WITHIN 4 HOURS: ED ASU STROKE DURATION FAST POSITIVE ALERT ALERT SELF PRESENTATION AMBULANCE STROKE ONSET: Time: : Date: / / TIME PRESENTED: Time: : Date: / / DURATION OF SYMPTOMS IN: hours days Recognition Of Stroke In Emergency Room ROSIER assessment tool. 1. Has there been loss of Yes (-1pt) [ ] No (0pts)[ ] consciousness or syncope? 2. Has there been seizure Yes (-1pt) [ ] No (0pts)[ ] activity? 3. Is there NEW ACUTE ONSET (or on waking) in the following? * Asymmetrical facial weakness. * Asymmetrical arm weakness. Yes (+1pt) [ ] No (0pts) [ ] Yes (+1pt) [ ] No (0pts) [ ] * Asymmetrical leg weakness. Yes (+1pt) [ ] No (0pts) [ ] * Speech disturbance. Yes (+1pt) [ ] No (0pts) [ ] * visual field defect / Yes (+1pt)[ ] No (0pts)[ ] opthalmoplegia Total score NB. Stroke is unlikely but not excluded if total score = or < Zero Provisional diagnosis: Score 1 to 5) STROKE [ ] (score 0 to -2) Non-stroke [ ] Specify STROKE - less than 6hours since onset. May be suitable for THROMBOLYSIS. IMMEDIATE ACTION REQUIRED. [ ] Contact Stroke Team / Consultant. If agreement to start Thrombolysis pathway then complete the following immediately. [ ] Organise next slot CT scan. STROKE more than 6 hours since onset. Urgent investigation required. [ ] CT [ ] ECG [ ] Bloods (as per urgent). [ ] Swallow screen or NBM with IVI. [ ] Vital signs within normal ranges. [ ] Take blood for urgent FBC, U&E, GLUCOSE, CLOTTING. Also [ ] Referral to RMO for admission. send LFTs, cholesterol, CPK. [ ] Check drug availability. [ ] Admit to ASU if possible. [ ] Referral to stroke team. 2
If patient not for thrombolysis indicate reason below; (Tick all that applies) Haemorrhagic stroke Patient a suitable candidate but unable to scan quickly enough Thrombolysis not available at all at the centre Patient arrived outside thrombolysis time window Patient arrived outside normal thrombolysis service hours Patient/carer refused Patient contra-indicated for thrombolysis due to comorbidity, age or medication Other Does the patient require urgent (within 1 hour) imaging? YES NO CT HEAD in STROKE (NICE / RCP) INDICATIONS FOR IMMEDIATE CT HEAD (CONTACT RADIOLOGY ON-CALL OUT OF HOURS) Thrombolysis candidate (first call stroke team) On anticoagulant treatment or needs early anticoagulation Known bleeding tendency Depressed conscious level (GCS < 13) Unexplained progressive or fluctuant symptoms Papilloedema, neck stiffness or fever Severe headache at onset of symptoms ALL OTHER PATIENTS SHOULD BE SCANNED AS SOON AS POSSIBLE AND CERTAINLY IN 24 HOURS PLEASE REQUEST THIS SCAN WITH A TIME OF ONSET CLEARLY MARKED TO FACILITATE THIS Date and time of first imaging? Date: / /20 Time: : (hh:mm) What was the initial imaging modality? CT MRI NOT IMAGED If imaging not requested, why not? 3
NEUROLOGY RIGHT LEFT CRANIAL NERVES POWER Face: Face: I: Arm: / 5 Arm: / 5 II: Leg: / 5 Leg: / 5 III, IV, VI: TONE Arm: Arm: V: Leg: Leg: VII: REFLEXES Arm: Arm: VIII: Leg: Leg: IX: PLANTARS Up / Down / Equiv Up / Down / Equiv X: SENSATION Face: Face: XI: Arm: Arm: XII: Leg: Leg: CEREBELLAR: DYSARTHRIA: YES / NO DYSPHASIA: EXPRESSIVE / RECEPTIVE / BOTH / NEITHER NEGLECT: VISUAL / SENSORY / BOTH / NEITHER HANDED: RIGHT / LEFT / AMBIDEXTROUS OTHER RELEVANT FINDNGS VISUAL FIELDS RIGHT LEFT NIHSS SCORE 4
GUIDANCE FOR THE ACUTE STROKE PATHWAY 5