Hello! Question for you. If we have a patient who is complaining of unilateral weakness or numbness, but on exam has equal grip strength, no facial droop or slurred speech, and equal strength in both legs, what would be the appropriate destination? Should we still stroke bypass to the nearest stroke center? To clarify, the patient feels as though they have weakness or numbness on one side of their body, but we are unable to find any deficits on our physical stroke exam (LAMS score of zero).

If following a thorough physical exam, paying special attention to each of the Stroke Bypass conditions, is NOT met, the patient should be transported to the closest ED as directed by dispatch.

In many cases you may be speaking with your stroke neurologist depending in which system and service you are working, and it is important that you follow their direction in these matters. Another issue to consider is the TIA patient and improving patient who was worse before you arrived or gets better in your care. These patients may benefit from more advanced imaging, and may also be included in the stroke destination. Review these types of issues and your destination policies with your service as some of these transports could be long and may have ambulance coverage considerations for your region.

Make sure to fully assess motor function. Grip strength is one part of the motor exam, consider also assessing strength of the major muscle groupings (for example: Deltoid: Shoulder abduction, Biceps: Elbow flexion, Triceps: Elbow extension etc.)

The decision to transport to the Stroke Center is for assessment and consideration by a Stroke Neurologist for thrombolysis with tPA. In order to be considered for this therapy, a patient must meet a certain level of deficit, as measured by the National Institutes of Health Stroke Scale (NIHSS). Elements of the NIHSS scale are built into the Stroke Bypass in order to catch patients who have deficits severe enough to be considered for thrombolysis. Therefore, if a patient does not meet the Stroke Bypass criteria they will not be scored severely enough to meet the criteria for this time-dependent treatment.

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