Transferring Stroke Patients: Acls Facility Options And Protocols

Stroke patients require immediate attention and treatment to minimize brain injury and maximize recovery. The Advanced Cardiac Life Support (ACLS) algorithm provides a comprehensive set of guidelines for healthcare providers to identify, assess, and manage suspected stroke patients effectively. Early identification of stroke symptoms is critical, and healthcare providers should be well-versed in using assessment tools such as the Cincinnati Prehospital Stroke Scale (CPSS) to recognize the signs of a stroke, including facial drooping, arm weakness, and speech difficulties. Once a stroke is suspected, activating the emergency response system and ensuring prompt EMS assessments and interventions are crucial. This includes supporting the patient's airway, breathing, and circulation (ABCs) and performing a prehospital stroke assessment to determine the time of stroke onset. Triaging the patient to a stroke center and alerting the hospital in advance are also essential steps. When the patient arrives at the emergency department, timely interventions and assessments, such as neurological screening, head CT scans, and blood glucose checks, should be conducted within specified time frames to ensure rapid and effective treatment for the stroke patient.

Prehospital interventions

Firstly, focus on minimising the delay in transporting the patient to a suitable facility, ideally with EMS transport. The patient's airway should be supported, as they are at increased risk of airway compromise due to neurological impairment. Supplemental oxygen should be provided to maintain an oxygen saturation greater than 94%. If oxygen saturation monitoring is unavailable, supplemental oxygen should still be administered.

The Cincinnati Prehospital Stroke Assessment (CPSS) should be performed to evaluate the patient's condition. This includes checking for facial droop, arm drift, and abnormal speech, as these are key indicators of a probable stroke. Additionally, since hypoglycemia can mimic stroke symptoms, a blood glucose check is essential.

Establishing the "time zero", or the last known time the patient’s neurological status was normal, is crucial. This helps determine if the patient is eligible for fibrinolytic therapy, which must be administered within a specific time window. If possible, bring a witness, such as a family member, who can provide insights into the onset of stroke symptoms.

Triage and alert a stroke centre as early as possible. Contact the stroke centre, emergency department, or hospital to ensure they are prepared for the patient's arrival and can provide rapid treatment.

These prehospital interventions are vital for the timely and effective management of a stroke patient and can significantly impact their outcome and chances of recovery.

Triage and alert stroke centre

Triaging and alerting a stroke centre is a critical step in providing timely and effective care for stroke patients. Here are some key considerations for this process:

Triaging:

• Prompt Identification: It is essential to identify patients with suspected stroke symptoms as early as possible. This can be done using standardised assessment tools such as the Face, Arm, Speech, Time (FAST) test or the Cincinnati Prehospital Stroke Scale (CPSS). These tools help evaluate facial drooping, arm weakness, speech difficulties, and the time of stroke onset.
• Determining Transport Destination: When triaging a stroke patient, it is crucial to determine whether they should be transported directly to a stroke treatment centre or a hospital with acute stroke capabilities. This decision depends on various factors, including the medical stability of the patient, the time since the stroke occurred (or "time zero"), the severity of the stroke, and regional factors.
• Pre-notification: While en route to the hospital, it is essential to notify the receiving hospital's emergency department about the incoming stroke patient. This pre-notification allows the stroke team to prepare and ensures rapid treatment upon arrival.

Alerting the Stroke Centre:

• Rapid Assessment and Treatment: Once the stroke patient arrives at the stroke centre or hospital, a rapid general assessment should be conducted within the first 10 minutes. This includes vital sign checks, providing oxygen if needed, obtaining intravenous (IV) access, and performing laboratory assessments.
• Neurological Assessment: Within 20-to-25 minutes of arrival, a neurological assessment should be conducted by the stroke team or a designated professional. This includes reviewing the patient's history, establishing a timeline of symptom onset, and performing a neurological examination using standardised tools such as the NIH Stroke Scale or the Canadian Neurological Scale.
• Imaging and Further Evaluation: A computed tomography (CT) scan or magnetic resonance imaging (MRI) of the brain should be performed promptly to determine the presence of haemorrhage or ischemic stroke. If the CT scan shows haemorrhage, consult a neurologist or neurosurgeon and consider transferring to a more specialised facility if needed. If no haemorrhage is detected, consider fibrinolytic therapy, keeping in mind the onset of symptoms and any exclusions.

Remember, the key to successful stroke treatment is minimising delays and providing prompt assessment and treatment. Early notification of the stroke centre or hospital plays a vital role in ensuring the best possible outcome for the patient.

Prehospital stroke assessment

Face, Arms, Speech, Time (FAST) Test

The FAST test is the most commonly used prehospital stroke scale, especially in emergency settings. It focuses on evaluating the face, arms, and speech of the patient, along with the time since the onset of symptoms. While the FAST test is very useful for anterior circulation strokes, it may miss a significant proportion of patients with posterior circulation strokes.

Gaze, Face, Arms, Speech, Time (G-FAST) Test

The G-FAST test includes an additional evaluation of gaze, which makes it a useful tool for diagnosing posterior circulation strokes.

Balance, Eyes, Face, Arm, Speech, Time (BE-FAST)

BE-FAST is a modification of the FAST test that adds the assessment of balance and eye symptoms. This version aims to improve the diagnosis of posterior circulation strokes.

Field Assessment Stroke Triage for Emergency Destination (FAST-ED)

The FAST-ED scale includes evaluations of facial weakness, arm weakness, speech changes, eye deviation, and anosognosia/neglect. It has a higher predictive value for strokes related to large vessel occlusion and is used to identify candidates for mechanical revascularization (thrombectomy).

Los Angeles Prehospital Stroke Screen (LAPSS)

The LAPSS is designed to confirm a stroke diagnosis. It includes criteria such as the absence of a seizure/epilepsy history, symptom duration of less than 24 hours, normal blood glucose levels, and the presence of a unilateral deficit in one of three items (arm drift, hand grip, or face).

Cincinnati Prehospital Stroke Scale (CPSS)

The CPSS, derived from the National Institutes of Health Stroke Scale, tests for three abnormal findings: facial droop, arm drift, and speech abnormalities. If any one of these tests shows abnormal findings, the patient is likely experiencing a stroke and should be transported to a hospital immediately.

Other Prehospital Stroke Scales

Other prehospital stroke scales include the 3-item Stroke Scale (3I-SS), Austrian Prehospital Stroke Scale (APSS), Rapid Arterial Occlusion Evaluation (RACE) scale, and the shortened National Institutes of Health Stroke Scale for Emergency Medical Service (sNIHSS-EMS). These scales vary in their sensitivity and specificity for stroke diagnosis and the prediction of large vessel occlusion strokes.

Neurological screening assessment

A neurological screening assessment is a vital part of stroke patient care. The assessment tools help identify the likelihood of a stroke and estimate its severity. Here is a detailed overview of the process:

Pre-Hospital Interventions and Assessments:

• Airway Support: Stroke patients are at an increased risk of airway compromise due to neurological impairment. Thus, ensuring a clear airway and providing supplemental oxygen to maintain oxygen saturation is crucial.
• Cincinnati Prehospital Stroke Scale (CPSS): This scale is used to diagnose a potential stroke in a pre-hospital setting. It evaluates three signs: facial droop, arm drift, and speech abnormality. If one of these signs is abnormal, there is a >70% chance of stroke, and if all three are present, the probability exceeds 85%.
• FAST (Face, Arm, Speech Test): FAST is a simple and quick test developed in the UK. It includes evaluating facial weakness, arm weakness, and speech disturbance by asking the patient to show their teeth, lift their arms, and speak a sentence. If any of these tests show abnormal findings, there is a 72% probability of stroke.
• Blood Glucose Check: Hypoglycemia can mimic stroke symptoms, so checking blood glucose levels is essential to rule out other potential causes.
• Establish "Time Zero": Determining the last known time the patient's neurological status was normal, or "time zero," is crucial for deciding if the patient is a candidate for fibrinolytic therapy.
• Triage and Alert Stroke Center: Early notification to the stroke center or hospital ensures they are prepared for the patient's arrival and rapid treatment.

Hospital Interventions and Assessments:

• General Assessment and Stabilization: Upon arrival at the emergency department, vitals are assessed, oxygen is provided if needed, IV access is obtained, labs are run, and glucose levels are checked.
• Neurological Screening: A neurological assessment by the stroke team should be done within 20-25 minutes of patient arrival. This includes reviewing the patient's history, establishing a timeline of symptom onset, and performing a neurological examination using standardized tools such as the NIH Stroke Scale or Canadian Neurological Scale.
• CT Scan: A CT scan without contrast should be obtained within 20 minutes of patient arrival to check for hemorrhage. If hemorrhage is present, a neurologist or neurosurgeon should be consulted, and the patient may require transfer to a specialized unit or intensive care.
• Fibrinolytic Therapy Considerations: If the CT scan shows no hemorrhage, the patient may be eligible for fibrinolytic therapy. Exclusions include significant head trauma, previous stroke, intracranial hemorrhage, elevated blood pressure, active internal bleeding, or low blood glucose.
• Post-Treatment Monitoring: After initiating fibrinolytic therapy, close monitoring of blood pressure and neurological symptoms is necessary, along with watching for adverse reactions.

The neurological screening assessment is a critical component of stroke patient care, helping to identify the likelihood and severity of a stroke and guiding treatment decisions.

Post-rtPA stroke pathway

The post-rtPA stroke pathway should be initiated within 3 hours of the patient's arrival at the emergency department. Here is a step-by-step outline of the process:

• Admit the patient to the stroke unit or intensive care unit: Once the patient has been assessed and is deemed a suitable candidate for fibrinolytic therapy (specifically, rtPA), they should be admitted to the stroke unit or intensive care unit for further monitoring and treatment.
• Aggressively monitor blood pressure and neurologic deterioration: It is crucial to closely monitor the patient's blood pressure and neurological status to detect any signs of deterioration or complications.
• Administer rtPA: If the patient and their family consent to the treatment, administer rtPA. It is important to note that anticoagulants and antiplatelets should be avoided for 24 hours before and after rtPA administration.
• Provide supportive care: Ensure that the patient's vital signs are stable and provide any necessary interventions to maintain their physiological stability.
• Perform regular neurologic assessments: Repeat neurological examinations at regular intervals to evaluate the patient's response to treatment and detect any signs of improvement or deterioration.
• Manage complications: Stroke patients may experience various complications, such as intracranial hemorrhage or neurologic deficits. It is essential to closely monitor for these complications and manage them promptly to improve patient outcomes.
• Initiate rehabilitation: Early rehabilitation, including physical therapy and occupational therapy, can play a crucial role in the patient's recovery. It helps improve functional outcomes, reduce disability, and enhance the patient's overall quality of life.
• Provide ongoing patient education and support: Educate the patient and their family about stroke prevention, risk factors, and lifestyle modifications to reduce the risk of recurrent strokes. Offer psychological support and ensure a smooth transition to any necessary long-term care facilities.

The post-rtPA stroke pathway aims to optimize patient outcomes, minimize complications, and facilitate the patient's recovery following fibrinolytic therapy for acute ischemic stroke.

Frequently asked questions