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
ISCHEMIC STROKE SUSPECTED:
- 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
INTRACEREBRAL HEMORRHAGE SUSPECTED:
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)
COMMENTS:
- 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.
DOCUMENT:
- 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.
***IMPORTANT***
Document last time seen normal with witness name and phone number, if possible.