Hillsborough County Fire Rescue

STANDING ORDERS AND PROTOCOL

Section: BLS Medical Care – Standing Orders Page 1 of 4
Subject: BLS STROKE, TIA, AND OTHER ACUTE NEUROLOGIC CHANGES
Section #: 320.12
Issue Date: March 21, 2011
Revision Date:
Approved By: Michael Lozano, Jr., M.D., HCFR Medical Director

1. Clinical intent
a. Inclusion criteria
i. Patients who have an acute episode of focal neurological deficit
ii. An acute episode of focal neurological deficit can include any combination of the
following signs and symptomsi: unilateral paralysis, focal numbness, language
disturbance (speaking and/or understanding), sudden severe unusual headache,
visual disturbance, monocular blindness, acute onset vertigo, acute onset double
vision, slurred speech, new onset of poor balance, or an acute change in the level
of consciousness.
b. Exclusion criteria
i. Significant preceding or accompanying head or spine trauma being the proximate
cause of the acute neurological emergency
ii. Overdose, intentional or accidental
iii. Seizure immediately and clearly preceding the onset of focal neurologic deficit(s)
iv. Symptomatic hypoglycemia clearly responding to treatment
c. Expected outcome
i. All patients who are experiencing an ischemic or hemorrhagic stroke are identified
in the pre-hospital setting, treated appropriately, and efficiently delivered to a
healthcare facility that is best suited to provide the patient with the best
opportunity for a successful treatment outcome

2. Diagnostics and evaluations:
a. Ensure that the patient’s airway is open, and that breathing and circulation are adequate.
b. Obtain and record the patient’s initial vital signs, repeat enroute as often as the situation
indicates.
c. Obtain and document the blood glucose level.
i. Avoid the administration of glucose-containing fluids unless the patient is
hypoglycemic less than 60 mg/dL.
d. Gather and document the following information:
i. The last date and time that the patient was known to be normal or at their
neurologic baseline (LKN). This shall be expressed in hours and minutes, and not
simply relative to EMS arrival. (i.e., 9/11/09 at 9 A.M., and not "30 minutes ago.").
All reasonable and expedient methods shall be used to ensure that this LKN time
is as accurate as possible given the circumstances.
ii. The name and all contact information for a witness who can communicate with the
destination facility regarding the patient’s baseline and acute medical condition
1. If possible, transport the reliable witness with the patient.
iii. Current medications
e. Perform a rapid structured stroke assessment using the FAST exam:1
i. Assessment
1. Facial movements: Ask the patient to smile or show teeth. If one side
does not move well, indicate on the form which is the affected side.
a. Normal: Both sides of the face appear symmetrical.

1
Harbison J; Hossain O; Jenkinson D; et. al. Diagnostic Accuracy of Stroke Referrals From Primary
Care, Emergency Room Physicians, and Ambulance Staff Using the Face Arm Speech Test. Stroke. 2003;34:71-76.
2709 E. Hanna Avenue • Tampa, FL 33610 • (813) 272-6600
www.hillsboroughcounty.org.firerescue/home.html
Hillsborough County Fire Rescue
STANDING ORDERS AND PROTOCOL

Section: BLS Medical Care – Standing Orders Page 2 of 4
Subject: BLS STROKE, TIA, AND OTHER ACUTE NEUROLOGIC CHANGES
Section #: 320.12
Issue Date: March 21, 2011
Revision Date:
Approved By: Michael Lozano, Jr., M.D., HCFR Medical Director

b. Abnormal: There is a new unequal smile, grimace, or obvious
facial asymmetry.
c. Questionable: It is unclear to the examiner if there is a new
unequal smile, grimace, or obvious facial asymmetry.
2. Arm movements: Lift the patient’s arms together to 90 degrees if sitting
or 45 degrees if supine, ask them to hold the position, and then let go. If
one arm drifts or falls, indicate on the form which is the affected side.
a. Normal: Neither arm drifts down or falls rapidly.
b. Abnormal: One arm drifts down, or falls rapidly.
c. Questionable: It is unclear to the examiner if one arm drifts
down or falls rapidly.
3. Speech: If the patient attempts to engage in a conversation, look for a
new disturbance in speech. The examiner may enlist the aid of a
companion to the patient. Look for slurred speech or word-finding
difficulties. The latter can be confirmed by asking the patient to name
commonplace objects that are nearby such as cup, chair, table, keys, or
pen. If there is a severe visual disturbance present, place an object in
the patient’s hand and ask them to name it.
a. Normal: There is no evidence for a new abnormality of
speech.
b. Abnormal: There appears to be a new abnormality of speech.
c. Questionable: It is unclear to the examiner if there is a new
abnormality in speech present.
ii. Interpretation:
1. A patient with an abnormal finding in all three areas of examination
should be considered to be having a stroke.
2. A patient with a questionable finding in one or more of the areas
examined may be having a stroke if the other areas are noted to be
abnormal.
f. If FAST criteria are met, call a Stroke Alert.
g. Once a potential stroke has been identified, perform an assessment of the severity of the
potential stroke using the Simple 3-Item (LAG) Scale:
i. Assess three aspects of neurological function
1. Level of consciousness (Use AVPU scoring)
a. Alert or Verbal only: 0 points
b. Pain only or Unresponsive: 2 points
2. Arm strength
a. Can lift arm and maintain in air for 5 seconds: 0 points
b. Can’t lift arm, or can’t maintain in air for 5 seconds: 2 points
3. Gaze
a. Patient can follow your finger across the midline: 0 points
b. Patient is not able to cross the midline when tracking a finger
or object: 2 points

2709 E. Hanna Avenue • Tampa, FL 33610 • (813) 272-6600
www.hillsboroughcounty.org.firerescue/home.html
Hillsborough County Fire Rescue
STANDING ORDERS AND PROTOCOL

Section: BLS Medical Care – Standing Orders Page 3 of 4
Subject: BLS STROKE, TIA, AND OTHER ACUTE NEUROLOGIC CHANGES
Section #: 320.12
Issue Date: March 21, 2011
Revision Date:
Approved By: Michael Lozano, Jr., M.D., HCFR Medical Director

ii. Interpretation: Add the points to determine the LAG score.

VALUE
FINDING TEST SCORE
0 2
LOC Use AVPU
Arm Strength Lift arm for 5 seconds
Gaze Follow finger across midline
TOTAL SCORE

h. If the equipment is available, exclude the presence of a large acute myocardial infarction by
performing a 12-lead EKG.
3. Destination determination:
a. Once the potential for a stroke has been determined to exist and the severity of the
neurologic impact has been graded, the patient shall be transported to the closest
appropriate stroke center (primary or comprehensive) unless they are experiencing
cardiopulmonary arrest.
b. Potential destinations:
i. Primary Stoke Centers in Hillsborough County
1. Brandon Regional Hospital
2. South Bay Hospital South Florida Baptist Hospital
3. Town & Country Hospital
4. University Community Hospital (Fletcher)
ii. Comprehensive Stroke Centers in Hillsborough County
1. St Josephs Hospital
2. Tampa General Hospital
c. The destination of a potential stroke patient is dependent on both the LKN time and the
severity of the stroke symptoms
i. Severity screening is used because very severe strokes may be precluded from IV
thrombolytics and in fact may be only candidates fro the types of therapies
available at Comprehensive Stroke Centers.
1. If the LAG score is 4 or 6, transport to a Comprehensive Stroke facility
2. If the LAG score is 0 or 2, transport to the closest appropriate Stroke
Center (Primary or Comprehensive) depending on the LKN.
ii. Time Screening
1. If the LKN is less than 2 hours, transport to the closest Stroke Center
(Primary or Comprehensive).
2. If the LKN is greater than 2 hours, transport to a Comprehensive Stroke
facility.
3. If the LKN is greater than 8 hours, transport to the closest Stroke Center
(Primary or Comprehensive).
iii. Always ensure the receiving facility can handle the patient
iv. The use of an air ambulance should be considered when the benefits of rapid
transport outweigh the risks inherent in air-medical care. 2

2
Silliman SL, Quinn B, Huggett V, Merino JG. Use of a field-to-stroke center helicopter transport program to extend
thrombolytic therapy to rural residents. Stroke. 2003; 34: 729–733
2709 E. Hanna Avenue • Tampa, FL 33610 • (813) 272-6600
www.hillsboroughcounty.org.firerescue/home.html
Hillsborough County Fire Rescue
STANDING ORDERS AND PROTOCOL

Section: BLS Medical Care – Standing Orders Page 4 of 4
Subject: BLS STROKE, TIA, AND OTHER ACUTE NEUROLOGIC CHANGES
Section #: 320.12
Issue Date: March 21, 2011
Revision Date:
Approved By: Michael Lozano, Jr., M.D., HCFR Medical Director

1. Such cases would include situations when the transport time by ground
exceeds 60 minutes, or 3
2. where ground transport would pose an undue burden on HCFR's ability
to respond to other emergency calls
d. Include the following information in your report to the hospital:
i. Identify your unit and that you are bringing in a Stroke Alert patient
ii. Patient’s age and sex
iii. Fast Exam findings
iv. Simple 3-Item (LAG) Scale findings
v. Elapsed time since the patient was last seen normal (or at their baseline
neurologic status). If the information is not available or is unreliable say “unknown
time since last seen normal”.
vi. Relate if there was a seizure at symptom onset, or since your arrival.

4. Treatments:
a. Position
i. Protect any paralyzed or partially paralyzed extremities from undue compression or
injury due to malposition.
ii. Position of comfort with head of bed slightly elevated or flat, as tolerated.
b. Oxygen
i. If oxygen saturation <95%, then apply oxygen at 2 L/min via nasal cannula.
ii. If oxygen saturation <92%, begin respiratory support with BVM.
iii. If the patient is not able to handle their secretions, or has a level of consciousness
diminished to the point that their Glasgow Coma Scale (GCS) is 8 or less, call ALS for
intubation.
c. Blood pressure control
i. Monitor blood pressure every five minutes to establish a trend.
d. Record all patient care information, including the patient’s medical history and all treatment
provided, on the Patient Care Report (PCR). Particular care should be taken to document
accurate information as regards to the following:
i. Telephone numbers, including cellular telephone numbers, of witnesses or relatives
may help the ED to clarify the history or seek consent for treatment.
ii. A list of the patient’s medications, or the medication containers themselves, should be
sought, with particular attention paid to identifying anticoagulant (both oral and
injectable), antiplatelet, and antihypertensive medication use.

5. ALS evaluation and transport criteria
a. ALL patients with signs and symptoms of stroke, TIA, or other acute neurologic change are ALS

6. QA Points
a. The most important thing that you can do to help a patient who may be having a stroke is
correctly identify that the symptoms are present, and get them headed toward a stroke center.
b. Do not become distracted by the level of blood pressure, avoiding aspiration will help your patient
out much more than lowering blood pressure.

3
T. J. Crocco, J. C. Grotta, E. C. Jauch, et. al. EMS Management Of Acute Stroke– Prehospital Triage
(Resource Document to NAEMSP Position Statement). Prehospital Emergency Care 2007;11:313–317.
2709 E. Hanna Avenue • Tampa, FL 33610 • (813) 272-6600
www.hillsboroughcounty.org.firerescue/home.html