Question: I have a question in regards to a specific situation with the Acute Stroke Protocol. We were called at 06:30 for an 85 year old female in a nursing home with slurred speech as witnessed by nursing staff. Upon our arrival she has a GCS of 15, blood glucose of 6.2 and obvious unilateral facial droop and pronounced associated slurred speech. The patient stated that she was up at 03:00 without concern which removed her from the Acute Stroke Protocol with all other criteria being met.

I understand that if the stoke symptoms resolve prior to our arrival the patient is not eligible for transport under the by-pass protocol. Additionally if their symptoms improve or resolve en route to a Stroke Centre transport should continue. However, en route her symptoms completely resolved and subsequently reoccurred €“ resolved again and while reporting to triage reoccurred in front of the staff at emerg.

After dialog with emerg staff I have the understanding that with completely resolved symptoms the "clock" would start (for them) with the onset of the recurrent (and witnessed) symptoms.

I would believe she would have the most appropriate care and best outcome being treated at a Stroke Centre. My question is twofold: first, is this a correct understanding of the possible in hospital treatment in way of assessing the initial onset of symptoms? Secondly, specifically for our transport decision could we use the recurrence onset of symptoms as the initial onset for meeting the Acute Stroke Protocol individually if it happened on scene or en route given we had equal distance to an ER or UH?

 Thanks for your great question. Fluctuating neurologic symptoms present a difficult clinical scenario. According to the MOHLTC Stroke Prompt Card and current clinical practice time of onset is always determined by "last seen normal". The clock "resets" so to speak every time the patient is truly in their normal state. For the second part of your question we would refer to "last seen normal". You are correct in that once en route you are to continue to the facility even if the patient's symptoms completely resolve. The receiving physician would take into account the entire picture to determine if the patient may benefit from thrombolytic therapy but ultimately "time" would be determined from last seen normal.

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