national-clinical-guidelines-for-stroke-fourth-edition

National clinical guideline for stroke
Prehospital clinicians are likely to assess people whose sudden onset neurological
symptoms have already resolved or resolve before reaching hospital, suggesting a
diagnosis of TIA rather than stroke. It is crucial these people are referred for further
investigation within a specialist TIA clinic, since the risk of subsequent stroke is greatest
in the first few days. It is possible that the prehospital clinicians will be the only witness
to transient symptoms. Before diagnosing TIA and making a direct referral, prehospital
clinicians need to be mindful that a person may have ongoing focal neurological deficits
of acute stroke despite a negative FAST. Patients in whom ongoing focal neurological
deficit(s) cannot be excluded should be managed along acute stroke pathways rather than
TIA pathways. There was insufficient evidence for the group to make recommendations
concerning the management of TIA and the use of risk tools (ie ABCD 2 ) by prehospital
clinicians. The working party suggests implementing more training around TIA and
non-FAST stroke symptoms with further research to validate safe and appropriate care
pathways.
Swallowing difficulties are common in stroke and this can lead to food and/or fluid
and/or saliva entering the airway (aspiration), which increases the risk of pneumonia.
Accepted prehospital practice is to keep all patients nil by mouth until the patient has
been formally evaluated by a clinician trained in swallow screening.
Evidence to recommendations
There is a paucity of research evidence on the management of the stroke patient before
arrival at the hospital. Use of screening tools for diagnosis has been shown to have a high
positive predictive value particularly for the recognition of anterior circulation events,
although less so for posterior circulation. The recognition of stroke in the emergency
room (ROSIER) is validated for use in the emergency department and is more detailed
than the FAST. It is of value particularly when screening of admissions is performed by
non-specialist staff. The remaining recommendations are based on consensus and widely
accepted practice for the acute management of patients who are acutely unwell.
4.1.1 Recommendations
A People seen by ambulance staff outside hospital, who have sudden onset of
neurological symptoms, should be screened using a validated tool (eg FAST) to
diagnose stroke or transient ischaemic attack (TIA). Those people with persisting
neurological symptoms who screen positive using a validated tool, in whom
hypoglycaemia has been excluded and who have a possible diagnosis of stroke, should
be transferred to a hospital with a specialist acute stroke unit within a maximum of
1 hour.
B If the patient is FAST negative, but stroke is still suspected, they should be treated as if
they have stroke until it has been excluded by a stroke specialist.
C People who are admitted to accident and emergency (A&E) with a suspected stroke or
TIA should have the diagnosis or provisional diagnosis established rapidly by a stroke
specialist or by using a validated tool.
D Prehospital pathways should be in place to minimise time from call to arrival at
hospital and should include a pre-alert to expedite specialist assessment and
treatment.
38 © Royal College of Physicians 2012