Question: I have a question regarding a call done recently; dispatched to a 73 year old female patient, healthy, independently and living with husband; takes no medications and has no allergies. In recent past however, has had NYD syncopal episodes lasting up to 30 minutes, no residual deficits from events suffered.

At 08:10, patient had sudden onset of weakness, called husband who held her before she fell and gently lowered her down to floor while family member called 911. They thought patient was having yet another familiar syncope. No seizure activity witnessed.

Patient was found unconscious on floor. While on scene patient regained consciousness to a GCS of 14, she had left sided facial droop, left sided paralysis and slurred speech which has never been the case in past events. All other vital signs where within limits including BS.

Although patient had initial GCS of 3 (normal for patient's events) Would it have been prudent to consider these two as different events and include her as a Stroke protocol candidate given the clear time of onset, her history and the marked CVA like symptoms. Thank you.

 This is a difficult and hopefully rare case! While CTAS 1 and uncorrected ABC problem would be contraindications to stroke bypass along with GCS < 10, it seems your patient improved to a GCS of 14 during your assessment.

The question really is (and we don't know the answer) were these "episodes of recurrent syncope lasting 30min" a form of seizure such as non convulsive status or atonic seizures: types of seizures which can lead to a profound LOC and loss of postural tone with a gradual regaining of consciousness during the post ictal phase. These would also be contraindications to stroke bypass. Neuro findings are possible during post ictal phases. Other possibilities would include arrhythmia with LOC from hypoperfusion.

Your specific question we believe relates the occurrence with the hemiplegia which the bypass criteria (hemiplegia, accurate time of onset determination, transport within time limit, GCS of 14, no clear evidence of seizure and normal BS). As such, you would have been correct to follow the prompt card in this case related to that specific situation and patient assessment at that moment.

Our advice however when considering all of the background information regarding the frequent losses of consciousness would be (when considering all of the SWORBHP region) if confronted with rare cases like this in the future is to not engage in stroke bypass in general with patients who have recurrent episodes of syncope with GCS of 3. Under the bypass protocol, paramedics may be transporting up to 2 hours to the stroke centre. Quite possibly the case above could force paramedics to be on long transports with a patient with a significant airway problem (if the loss of consciousness were to return on transport) and ultimately stroke may not be their underlying diagnosis.

Remember, ED physicians in the closest hospitals can always secondarily activate the stroke bypass protocol if required and consider your local destination protocols which may include patching for such cases.

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