1. Chiara Franchini, Anne Bruton , Cathy Limby Stroke Specialist Nurses
Stroke and TIA Pathway
Chiara Franchini, Anne Bruton , Cathy Limby
Stroke Specialist Nurses

2. Time to treat Target 2hrs Max 3 hours Recognise React Respond Refer
Time to recognise stroke what does the pt do first, who do they call, how long for paramedics to respond and load and go, travel to hospitals, call stroke team, scan & treat
Target 2hrs

3. Time is Brain

5. Work up Max 30-45 mins Assessment (GCS, vital signs,ABC, ECG)
PMH & event history
Drug History
NIHSS
Bloods & Glucose
Imaging CT/MRI
Decision
Treat
Max mins
These are the key points in ED

6. ROSIER Score YES NO Has there been loss of consciousness or syncope?-1
Has there been seizure activity?
Is there a NEW ACUTE onset (or on awakening from sleep)?
Asymmetric facial weakness +1
Asymmetric arm weakness
Asymmetric leg weakness
Speech disturbance
Visual field defect
If Score = 1 or more then treat as possible stroke and do assessment
TOTAL
Recognition of stroke in the emergency room
To quickly rule out stroke mimics

7. Exclude stroke mimics Sudden onset Maximal at onset
Fits within vascular territory
Stroke is: sudden in onset, maximal at onset, fits with vascular territory – history tells you the story keep this in mind

8. Mimics Seizure Migraine Sub /extra dural Tumour MS Hyperglycaemia
Non organic
Cerebral abscess /infection
Felt funny & shaking
Visual disturbance
Pins & needles
Fluctuating symptoms
What are the mimics discuss each one and how they differ from stroke

9. CT requests should be correctly filled.

10. Inclusion criteria Clinical S&S of definite acute stroke
Clear time of onset
Presentation within 4 hrs of acute onset
Haemorrhage excluded by CT scan
Age over 18
NIHSS < 25, >3
Consent to treat (every effort must be made to contact next of kin)
Inclusion

11. Exclusion Criteria Rapidly improving or minor stroke symptoms
Stroke or serious head injury 3 months
Major surgery, obstetrical delivery, external heart massage last 14 days,
Seizure at onset of stroke
Prior stroke and concomitant diabetes
Severe haemorrhage last 21/7
Increased bleeding risk
History of central nervous damage (neoplasm, haemorrhage, aneurysm, spinal or intracranial surgery or haemorrhagic retinopathy)
Symptoms suggestive of SAH (even if CT is normal)
*Blood pressure above 185 mmHg systolic or 110 mmHg diastolic

12. Exclusion criteria cont.
Known clotting disorder
Patient on heparin or warfarin
Suspected iron deficient anaemia or thrombocytopenia
Suspected hypo or hyper glycaemia >3 mmol/l > 22 mmol/l
Bacterial endocarditis, pericarditis
Acute pancreatitis
Premorbid dependency
Ulcerative GI disease last 3 months, oesophageal varices, arterial-aneurysm, arterial/venous malformation.
Severe liver disease including cirrhosis, acute hepatitis
Large hypodensity on CT scan (use ASPECTS* scoring if time permits; otherwise use the 1/3 of MCA territory rule)

13. Consent Do not need formal written consent
Informed choice - Need to give full explanation of risks and benefits to patient.
Treat in patients best interest if consent can not be gained.

14. How do we do?

16. Telemedicine protocol
Instructions are on the cart

17. Before leaving ED
ED to do full clerking on stroke proforma, write drug chart and start treatment.
All stroke patients should have Proforma A
Thrombolysed patients should also have Proforma B
All stroke patients must be transferred directly to stroke unit within 4 hours.
All patients to have swallow screen within 4 hours

18. TIA Pathway
Don’t forget to put onset time and contact time. This is how our performance against targets are measured.
High Risk only to be faxed to Luton at weekends, low risk can be sent to TIA clinic here as usual.
It is helpful if a copy of the cascard and the ECG could be faxed with referral.
Within working hours, bleep stroke nurses if you have very frail, elderly patients for TIA clinic. We may be able to get them seen without the need to come back to clinic.