Any person, 16 years and over, who is FAST positive or has suspected stroke or transient ischaemic attack.
Escalate immediately as per local CERS protocol.
This protocol is intended to be used by registered and enrolled nurses within their scope of practice and as outlined in The Use of Emergency Care Assessment and Treatment Protocols (PD2024_011). Sections marked triangle or diamond indicate the need for additional prerequisite education prior to use. Check the medication table for dose adjustments and links to relevant reference texts.
Remember FAST:
Facial weakness – can the person smile? Has their mouth or eye drooped?
Arm weakness – can they raise both arms?
Speech difficulty – can they speak clearly and understand what you say?
Time – time of onset of symptoms and duration.
Activate local stroke process
Early access to the advice of a clinician who manages hyperacute stroke is a priority.
NSW non-Telestroke site
Follow local pathway for escalation to stroke team and transfer if required.
NSW Telestroke site
Complete ASAP Tool.
Site with stroke team
Follow locally agreed process for activation of local stroke team.
History prompts, signs and symptoms
These are not exhaustive lists. Maintain an open mind and be aware of cognitive bias.
History prompts
- Presenting complaint
- Onset of symptoms
- Last seen well, including FAST
- Premorbid function
- Pain assessment – PQRST
- Pre-hospital treatment
- Past admissions
- Medical and surgical history, including neurosurgery, previous TIA or bleeding disorder
- Current medications
- Known allergies
- Risk factors, including diabetes, smoking, hypertension and atrial fibrillation
Signs and symptoms
- Altered level of consciousness
- Acute confusion
- Weakness or numbness to face or limbs
- Aphasia, difficulty speaking or following commands
- Dysphagia
- Agitation
- Dizziness
- Ataxia
- Headache
- Visual disturbances
Red flags
Recognise: identify indicators of actual or potential clinical severity and risk of deterioration.
Respond: carefully consider alternative ECAT protocol. Escalate as per clinical reasoning and local CERS protocol, and continue treatment.
Historical
- On anticoagulant or antiplatelet therapy
- Neurosurgery
- History of TIA or stroke
- Bleeding disorder
Clinical
- Altered speech
- Ataxia
- Acute onset confusion
- Facial asymmetry
- Visual disturbances
- Dizziness
- Limb weakness
- Headache
- Onset of symptoms less than 4.5 hours
- FAST positive
Remember adult at risk: patient or carer concern, frailty, multiple comorbidities or unplanned return.
Clinical assessment and specified intervention (A to G)
If the patient has any Yellow or Red Zone observations or additional criteria (as per the relevant NSW Standard Emergency Observation Chart), refer and escalate as per local CERS protocol and continue treatment.
Position
| Assessment | Intervention |
|---|---|
General appearance/first impressions | Position of comfort Position head up 30°, unless contraindicated |
Airway
| Assessment | Intervention |
|---|---|
Patency of airway | Maintain airway patency Consider airway opening manoeuvres and positioning |
Breathing
| Assessment | Intervention |
|---|---|
Respiratory rate and effort Auscultate chest (breath sounds) Oxygen saturation (SpO2) | Assist ventilation, as clinically indicated Consider oxygen if dyspnoeic, titrate oxygen to maintain SpO2 over 93% Patients at risk of hypercapnia, maintain SpO2 at 88–92% |
Circulation
| Assessment | Intervention |
|---|---|
Perfusion (capillary refill, skin warmth and colour) Pulse Blood pressure Cardiac rhythm | Assess circulation Monitor blood pressure regularly as per local stroke pathway Attach cardiac monitor and complete 12 lead ECG |
IVC and/or pathology | Insert IV cannula, if trained If unable to obtain IV access, consider intraosseous, if trained |
Signs of shock: tachycardia and CRT 3 seconds and over and/or abnormal skin perfusion and/or hypotension | If signs of shock present and/or SBP less than 90 mmHg, give 250 mL of sodium chloride 0.9% IV/intraosseous bolus Repeat every 10 minutes (up to 1000 mL) until SBP over 90 mmHg or signs of shock have resolved |
Disability
| Assessment | Intervention |
|---|---|
GCS, pupillary response and limb strength | Obtain baseline and repeat assessment, as clinically indicated |
| Pain | Assess pain. If indicated, give early analgesia as per analgesia section then resume A to G assessment |
Exposure
| Assessment | Intervention |
|---|---|
| Temperature | Measure temperature |
| Skin inspection, including posterior surfaces | Check and document any abnormalities |
Fluids
| Assessment | Intervention |
|---|---|
| Hydration status: last ate, drank, bowels opened, passed urine or vomited | Commence fluid balance chart, as required |
| NBM | NBM until ASSIST or swallow screen passed |
| Nausea and/or vomiting | If present, see nausea and/or vomiting section |
Glucose
| Assessment | Intervention |
|---|---|
| BGL |
Measure BGL If BGL less than 4 mmol/L:
If the patient is unconscious or peri-arrest:
Once stabilised, give patient long-acting carbohydrate and continue to check BGL hourly, or as clinically indicated |
Repeat and document assessment and observations to monitor responses to interventions, identify developing trends and clinical deterioration. Escalate care as required according to the local CERS protocol.
Focused assessment
Early assessment and management by a specialist stroke team is a priority.
Do not delay transfer to undertake focused assessments. Continue to reassess A to G and escalate as per local CERS protocol.
Precautions and notes
- Retrieval is time-critical, and delays to definitive treatment increases morbidity and mortality significantly.
- All patients with suspected stroke are candidates for thrombolysis and endovascular clot retrieval (ECR) until proven otherwise.
- Body temperature increases in up to 50% of patients during the first 48 hours after the onset of stroke. The presence of fever has been found to correlate with poorer outcomes in stroke. Therefore, antipyretics such as paracetamol or other fever-lowering strategies are recommended early in the management of acute stroke, until body temperature is lowered to 37.5°C
Interventions and diagnostics
Specific treatment
Aim for normothermia.
If 37.5°C and above, give paracetamol IV 15 mg/kg, maximum dose 1000 mg, once only, if not given already for pain relief.
Analgesia
If pain score 1–6 (mild to moderate): give paracetamol IV 15 mg/kg, maximum dose 1000 mg, once only, if not given already for fever.
Opioids are only given in consultation with stroke team.
Nausea and/or vomiting
If nausea and/or vomiting is present, give:
- ondansetron 4 mg IV/IM. If symptoms persist after 60 minutes, repeat once, maximum dose 8 mg.
Radiology
Radiology will depend on the working diagnosis. It needs to be requested by a medical or nurse practitioner. If there is concern for urgent radiology, escalate as per local CERS protocol.
Pathology
- FBC, UEC, glucose, LFT, coags, VBG
- Urinalysis: mid-stream (preferred), clean catch or catheter urine. If positive for nitrites and/or leucocytes send for MC&S. Keep sample refrigerated if transport delayed
- Temp less than 35°, or 38.5°C and over: take two sets of blood cultures from two separate sites
Medications
The shaded sections in this protocol are only to be used by registered nurses who have completed the required education.
Drag the table right to view more columns or turn your phone to landscape
| Drug | Dose | Route | Frequency |
|---|---|---|---|
1 mg | IM | Once only | |
200 mL | IV infusion over 15 minutes | Once only | |
50 mL | Slow IV injection | Once only | |
4 mg Maximum dose 8 mg | IV/IM | Repeat once if required after 60 minutes | |
Oxygen | 2–15 L/min, device dependent | Inhalation | Continuous |
15 mg/kg Maximum dose 1000 mg | IV | Pain score 1–10 Once only | |
250 mL Maximum dose 1000 mL | IV/intraosseous | Bolus Repeat every 10 minutes (up to 1000 mL) until SBP over 90 mmHg or signs of shock have resolved |
Medications with contraindications or requiring dose adjustment are marked:
- H for patients with known hepatic impairment
- R for patients with known renal impairment.
Escalate to medical or nurse practitioner.
References
- Beasley R, Chien J, Douglas J, et al. Thoracic Society of Australia and New Zealand oxygen guidelines for acute oxygen use in adults: 'Swimming between the flags'. Respirology. 2015 Nov;20(8):1182-91. DOI: 10.1111/resp.12620
- Bracard S, Ducrocq X, Mas JL, et al. Mechanical thrombectomy after intravenous alteplase versus alteplase alone after stroke (THRACE): a randomised controlled trial. Lancet Neurol. 2016 Oct;15(11):1138-47. DOI: 10.1016/s1474-4422(16)30177-6
- Drury P, Levi C, D'Este C, et al. Quality in Acute Stroke Care (QASC): process evaluation of an intervention to improve the management of fever, hyperglycemia, and swallowing dysfunction following acute stroke. Int J Stroke. 2014 Aug;9(6):766-76. DOI: 10.1111/ijs.12202
- National Stroke Foundation. Clinical guidelines for stroke management. Australia: Stroke Foundation; 2022 [cited 17 Feb 2023]. Available from: https://informme.org.au/guidelines/living-clinical-guidelines-for-stroke-management
- Middleton S, McElduff P, Ward J, et al. Implementation of evidence-based treatment protocols to manage fever, hyperglycaemia, and swallowing dysfunction in acute stroke (QASC): a cluster randomised controlled study. Lancet. 2011;378(9804). Available from: https://pubmed.ncbi.nlm.nih.gov/21996470/
- MIMS Australia. Clinical Resources. Australia: MIMS Australia Pty Ltd; 2022 [cited 2 Feb 2023]. Available from: https://www.mimsonline.com.au.acs.hcn.com.au/Search/Search.aspx
- Nogueira RG, Jadhav AP, Haussen DC, et al. Thrombectomy 6 to 24 hours after stroke with a mismatch between deficit and infarct. N Engl J Med 2017;378(1):11-21. Available from: https://www.nejm.org/doi/full/10.1056/NEJMoa1706442
- NSW Agency for Clinical Innovation. Eligibility for endovascular clot retrieval: NSW Referral Guide. Sydney: NSW Health; 2019 [cited 17 Feb 2023]. Available from: https://aci.health.nsw.gov.au/__data/assets/pdf_file/0007/506617/ACI-Stroke-network-NSW-referral-guide-eligibility-ECR.pdf
- NSW Agency for Clinical Innovation. Statewide programs: Telestroke service NSW Health; 2021 [cited 17 Feb 2023]. Available from: https://aci.health.nsw.gov.au/statewide-programs/telestroke/about
- NSW Health. Infection prevention and control policy. Sydney: NSW Government; 2017 [cited 17 Feb 2023]. Available from: https://www1.health.nsw.gov.au/pds/Pages/doc.aspx?dn=PD2017_013
- NSW Health. Australian Medicines Handbook. Australia: Australian Government, NSW; 2022 [cited 17 Feb 2023]. Available from: https://amhonline.amh.net.au.acs.hcn.com.au/
- Powers WJ, Rabinstein AA, Ackerson T, et al. 2018 Guidelines for the Early Management of Patients With Acute Ischemic Stroke: A Guideline for Healthcare Professionals From the American Heart Association/American Stroke Association. Stroke. 2018 Mar;49(3):e46-e110. DOI: 10.1161/str.0000000000000158
- Therapeutic Guidelines. Antiemetic drugs in adults. Australia: Therapeutic Guidelines Limited; 2022 [cited 15 Feb 2023]. Available from: https://tgldcdp.tg.org.au.acs.hcn.com.au/topicTeaser?guidelinePage=Gastrointestinal&etgAccess=true#
| Evidence informed |
Information was drawn from evidence-based guidelines and a review of latest available research. For more information, see the development process. |
| Collaboration |
This protocol was developed by the ECAT Working Group, led by the Agency for Clinical Innovation. The group involved expert medical, nursing and allied health representatives from local health districts across NSW. Consensus was reached on all recommendations included within this protocol. |
| Currency | Due for review: Jan 2026. Based on a regular review cycle. |
| Feedback | Email ACI-ECIs@health.nsw.gov.au |
Accessed from the Emergency Care Institute website at https://aci.health.nsw.gov.au/ecat/adult/stroke-and-transient-ischaemic-attack