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Stroke/Intracranial hemorrhage

New Updated 4/2019

Stroke Triage Criteria

Base Contact for all Stroke Triage Designation Patients

- No Oral fluids or solids

- Monitor rhythm and document

- Monitor SPO2, Administer O2 for SPO2 < 95%

- Treat for low blood sugar for glucose < 60

- Administer Zofran for Nausea / Vomiting


- Last seen at usual neurological baseline within the past 24 hours, AND

- Responds in an appropriate manner to verbal or visual stimuli or has spontaneous eye opening, AND


Demonstrates one or more of the following as new onset neurologic signs:

- Arm (pronator) drift or paralysis, asymmetric to right or left arm, OR

- Facial paresis or droop (new onset), OR

- Decreased grip strength, asymmetric to right or left hand



Sudden, severe headache w/ onset in past 24 hrs. with any of the following:

- Vomiting (repeated), OR

- Neuro deficit (hemi-paresis or weakness, gaze to one side, or asymmetric pupils w/o prior eye surgery, OR

- Altered mental status, OR

- Marked blood pressure elevation (diastolic > 100 mm Hg) 



- No oral fluids of solids (OK to give Zofran for nausea/vomiting).

- Monitor/document cardiac rhythm and O2 saturation.

- Monitor/document blood glucose reading.

- Establish IV access (NO IO or ext jug) and complete blood glucose analysis. 

- Glucagon may be ineffective in reversing hypoglycemic stroke-like symptoms.

- Avoid IO or External Jugular.



- Presence/absence of weakness in arm/leg.

- If patient has history of stroke in past.

- Exact time of onset of stroke symptoms, if known.

- If patient has used any of their own meds immediately prior to or during arrival.



Document last time seen normal with witness name and phone number, if possible.

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