Question: I recently did a call in which the patient was found by nursing home staff to be agitated and non-verbal with left sided arm paralysis. On EMS arrival the patient was moving all limbs but was still non-verbal and agitated. I also noted LT side neglect and some LT side facial drooping. The patient was last seen in a normal state at 04:30 and the time of our arrival was 08:30. The patient also had a valid DNR and I confirmed again with the POA on scene that it was still the wishes. By the time we loaded and transported the patient was outside the 4 hour mark for any CVA treatment. I returned to patient CTAS 3 as they were outside the time line and for the valid DNR. I am wondering if the patient had been within the 4 hour mark for treatment should this patient be returned CTAS 2 or would they still be CTAS due to the DNR? Thanks.

 Great question. As per your Paramedic Prompt Care for Acute Stroke, the indications for transport include patients that can be transported to arrive at a Designated Stroke Centre within 3.5 hours of a clearly determined time of symptom onset or the time the patient was "last seen in a usual state of health".

These patients should then be transported CTAS 2 Code 4.

It should be noted that the presence of a valid DNR should not influence this decision. Rather (as detailed in our Webinar presentation on acute stroke which can be found on our website) terminally ill or palliative care patients are the contraindications determined by the Ontario Stroke Network, not a valid DNR.

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