Stroke Alert Criteria Form

PREHOSPITAL/HOSPITAL

ADVANCED STROKE TRIAGE FORM

Date Time Unit # Age Sex Male Female
Patient's Name Incident #
Event Witness Name Cell # Home #
Closest Relative
(if different from above)
Cell # Home #

Stroke/ Stroke Alert Determination Page

Rapid Arterial oCclusion Evaluation (RACE) scale Check the appropriate boxes
Assessment Item Instructions Evaluation Score
Facial Palsy Impaired understanding of speech Equal symmetrical smile 0
Mild weakness with crease still in nasolabial folds 1
Severe weakness with absent nasolabial folds and facial droop 2
Arm Motor Function Sitting extend arms out 90 degrees or lying down extend arms out 45 degrees, palms up, eye open, and hold for 10 seconds Limbs upheld for 10 seconds 0
Limb upheld for less than 10 seconds 1
Limb does not rise against gravity 2
Leg Motor Function Extend each leg out 30 degrees for 5 seconds Limbs upheld for 5 seconds 0
Limb upheld for less than 5 seconds 1
Limb does not rise against gravity 2
Head or Gaze Deviation Observe eyes or head deviated to one side after requesting patient to look forward Absent eye or head deviation 0
Eyes or head deviation 1
If Right Sided Weakness, Perform Aphasia Assessment Instruct patient to "close eyes" and "make fist" with left arm Performs both tasks correctly 0
Performs one task correctly 1
Performs neither task 2
If Left Sided Weakness, Perform Agnosia Assessment Ask patient while showing his/her left arm "Whose arm is this?" and "Do you feel weakness in this arm?" Identifies his/her arm and feels weakness 0
Does not recognize either arm or feeling of weakness in the arm 1
Does not recognize both arm and feeling of weakness in the arm 2
Total Score

Destination Determination Page

Transport to Comprehensive Stroke Center

If RACE scale score >= 5
or
IF ANY OF THE BELOW IN THIS COLUMN ARE CHECKED
Transport to Nearest Stroke Center

(Primary or Comprehensive Stroke Center)

IF ANY OF THE BELOW IN THIS COLUMN ARE CHECKED
Check all appropriate boxes
REGARDLESS OF RACE SCALE SCORE
Last Known Normal > 3.5 hours and < 8 hours
Pt awoke with symptoms
Estimated arrival at Emergency Department is greater than 3.5 hours since Last Known Normal
Seizure (at onset)
Patient is on any of the following blood thinners: Coumadin (warfarin), Pradaxa (dabigatran), Brilinta (ticagrelor), Xarelto (rivaroxaban), Lovenox (enoxaparin) or Fragmin (dalteparin)
Recent (within 14 days) or current bleeding, trauma, surgery, or invasive procedure
Bleeding / Clotting disorders (history of GI GU bleeding within last 21 days)
Pregnancy or Completion / Termination of pregnancy less than 30 days
Intracranial pathology (Tumor, Aneurysm, ArterioVenous Malformation (AVM), Intracranial hemorrhage)
Sudden onset of worst headache ever

(Call a Stroke Alert)

Transport to Comprehensive Stroke Center
RACE scale score < 5 AND Last Known Normal < 3.5 hours
Time Last Known Normal > 8 hours and did not wake up with symptoms
Patient Last Known Normal < 3.5 hours ago and is permanently bed or wheelchair confined, do they require constant care OR is assistance essential for activities of daily living prior to today’s event? If yes
Resolution of stroke symptoms prior to arrival in the ED (TIA)
Glucose less than 60 and symptoms improved with administration of D 50 (the above deemed NOT a STROKE ALERT)
(Call a Stroke Alert)

Transport to Nearest Primary Stroke Center