Protocol 2-880-48 - Suspected Stroke - EMS Information Form

CMH EMS & MIH Protocols

This form is a communication tool from EMS to ER with the goal of expidited patient care of stroke patients.

Patient Demographics

Patient name:
Patient DOB:
Family/caregiver/witness name:
Family/caregiver/witness phone number:

Assessment Results

Abnormal Balance: Yes No
Abnormal Eyes/Vision: Yes No
Abnormal Face: Yes No
Abnormal Arm: Yes No
Abnormal Speech: Yes No
Time (Last Known Well):
Blood glucose reading:
Blood pressure: /
Taking blood thinner: Yes, list: No
RACE score:
NIH score:
Patient weight: lb / kg

tPA exclusion checklist

Hemorrhage: Yes, hemorrhage No
Intracranial or intraspinal surgery within three (3) months: Yes, recent neuro surgery No
Serious head trauma within three (3) months: Yes, recent head trauma No
Other intercranial conditions (i.e. neoplasms, aneurysms): Yes, IC conditions No
Current, severe, uncontrolled hypertension: Current BP: Yes, hypertensive No
Age greater than 80 years: Current age: Yes, over 80 No
NIHSS greater than 25: Yes, NIHSS > 25, see page 1 No
History of diabetes: Yes, diabetic No
History of prior stroke: Yes, prior stroke No
Taking an oral anticoagulant: Yes, see list on page 1 No

NEMSIS Protocol: 9914145 - Medical-Stroke/TIA

Citations:

Change Log:

DateLink to
previous
version		Description of change
02/18/21Added first draft of this document to be used as a communication tool from EMS to ER with stroke patients.
02/18/21pdfAdded patient weight and other minor corrections as suggested by Jenna Hicks.
06/06/21pdfMoved to emsprotocols.online
09/29/21pdfAt the request of the TCD coordinator, added blood pressure to this form.
10/15/21pdfAfter feedback from stroke competency, the option to mark NO on this form has been added in appropriate locations.

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