cg20 stroke transient ischaemic attacks
TRANSCRIPT
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1. Scope1.1 This clinical guideline covers the assessment and management of patients
presenting with acute onset stroke symptoms and suspected transient ischaemic
attack (TIA).
2. Background and Definitions2.1 Stroke is the third most common cause of death in the UK. Each year in England,
approximately 110,000 people have a first or recurrent stroke and a further
20,000 people have a transient ischaemic attack. More than 900,000 people in
England are living with the effects of stroke, with about half of these dependent
on other people for help with everyday activities. Most strokes occur in people
older than 65 years, but they can occur at any age.1
2.2 Strokes and transient ischaemic attacks (TIAs) are acute neurological events,
presumed to be vascular in origin, that are caused by cerebral ischaemia,
cerebral infarction, or cerebral haemorrhage.2
Guideline ID CG20
Version 1.2
Title Stroke and Transient Ischaemic Attacks
Approved by Clinical Effectiveness Group
Date Issued 01/11/2015
Review Date 31/10/2018
Directorate Medical
Authorised Staff
Ambulance Care Assistant Paramedic (non-SPUEC) Emergency Care Assistant Nurse (non-NP) Student Paramedic SP (EUC) Advanced Technician Doctor
Clinical Publication Category
Guidance (Green) - Deviation permissible; Apply clinical judgement
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2.3 Stroke
2.3.1 Stroke is defined by the World Health Organisation as a clinical syndrome
consisting of ‘rapidly developing clinical signs of focal (at times global)
disturbance of cerebral function, lasting more than 24 hours or leading to
death with no apparent cause other than that of vascular origin’.3 The signs
and symptoms of a non-disabling stroke last for more than 24 hours but resolve
later, leaving no permanent disability. In contrast, a disabling stroke results in
permanent deficit/s.
2.3.2 Strokes can be classified by their main causes as either ischaemic (85%) or
haemorrhagic (15%).2
2.3.3 Ischaemic strokes are caused when a blood vessel in the brain is blocked, for
example by a blood clot or by the fatty material from an atherosclerotic plaque.
The brain cells in the part of the brain served by the affected blood vessel die
due to a lack of oxygen and nutrients. There are two main types of ischaemic
stroke:
Thrombotic ischaemic stroke - A blood clot spontaneously forms in an artery
in the brain. This is a common complication of atherosclerosis;
Embolic ischaemic stroke - Part of the fatty material from an atherosclerotic
plaque or a clot in a larger artery or the heart breaks off and travels
downstream until it is trapped in a narrower artery in the brain. Embolic
strokes are common complications of atrial fibrillation and atherosclerosis of
the carotid arteries.
2.3.4 There are two main types of haemorrhagic stroke:
Intracerebral haemorrhagic stroke - Bleeding from a blood vessel within the
brain. High blood pressure is the main cause of intracerebral haemorrhagic
stroke;
Subarachnoid haemorrhagic stroke - Bleeding from a blood vessel between
the surface of the brain and the arachnoid tissues that cover the brain.
2.3.5 Although subarachnoid haemorrhage (SAH) is classified as a type of stroke it is
not included in this guideline. A sudden and violent headache is characteristic
of subarachnoid haemorrhage, which should be managed according to JRCALC
guidelines.
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2.4 Transient Ischaemic Attack (TIA)
2.4.1 Transient Ischemic Attacks (TIAs) are caused by a temporary reduction in the
blood supply to part of the brain, due to a thrombosis or embolism.2 Small blood
clots commonly form on an area of atheroma within the main vessels, or within
the atria in patients with atrial fibrillation. A TIA occurs when they break away,
traveling up the artery until it occludes a smaller cerebral artery.
2.4.2 The signs and symptoms of a TIA are identical to that of a stroke; the only factor
which distinguishes a TIA is the duration of the symptoms, which by definition
must fully resolve within 24 hours. The symptoms are transient, as small clots
break up rapidly. Any patient without fully resolved focal neurological signs and
symptoms must be assumed to have had a stroke.
2.4.3 A TIA is an indicator that further clots may occur, with the risk of experiencing a
stroke increased by up to forty-five times the normal risk in the week following a
TIA, in the most high risk patients.4
2.4.4 Effective timely management of transient ischaemic attacks reduces mortality,
morbidity and the use of NHS resources.5
3. Guidance3.1. Assessment
3.1.1 Assess the patient using the CABCD approach and exclude hypoglycaemia and
other stroke mimics. Stroke mimics marked with an asterisk (*) have transient
symptoms that can also mimic those of a transient ischaemic attack:
Hypoglycaemia*;
Conditions which cause dizziness, faintness, or disturbed balance*;
Migraine*;
Neurological abnormalities;
Mass lesions such as subdural hematoma, cerebral abscess, primary central
nervous system tumours, and metastatic tumours;
Postictal states, focal seizures, and generalized seizures*;
Hyperglycaemia;
Factitious stroke;
Psychological disorders, including anxiety*;
Physical trauma, including concussion*.
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3.1.2 The clinician must establish whether the symptoms are typical of a cerebral
event. If the answer to all of the following questions is yes, the symptoms are
almost certainly due to cerebral ischaemia or haemorrhage.
Are the neurological symptoms focal?
Are the focal neurological symptoms negative?
Was the onset of the focal neurological symptoms sudden?
Were the neurological symptoms maximal at onset?
3.1.3 Follow the Stroke/Suspected TIA Care Pathway detailed in Figure 1.
3.1.4 Figure 1- Stroke/Suspected TIA Care Pathway
Does the patient meet the acute stroke pre-alert criteria?
FAST positive. Blood sugar level greater than 3.5mmol (following treatment if necessary) Time between onset of symptoms and predicted arrival at thrombolysis centre within the time window set for the centre (Appendix 1). 18 years or older - no upper age limit.
Is the patient high risk (any of the following are present)?
ABCD2 4 or higher (Unless local pathway states otherwise) Previous potential TIAs within the past 7 days. Atrial Fibrillation Prescribed warfarin or other anticoagulants (including dabigatran, rivaroxaban, apixaban, edoxaban). Diagnosed blood clotting disorder. Unable to be supplied aspirin due to PGD contraindication.
Minimise on scene time,
rapid conveyance to a stroke
centre offering a thrombolysis
service‘STROKE 60’
Normal conveyance to
appropriate local hospital
Hospital assessment
within 24hrs
Low RiskRefer to TIA
Clinic
Stroke / Suspected TIA Care Pathway
YES Acute stroke signs and symptoms present?
NO
YES NO YES NO
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3.2 FAST Examination
3.2.1 Assess the patient using the Face, Arms, Speech Test (FAST):
Facial weakness:
Ask the person to smile or show their teeth;
The FAST test is positive if there is new facial asymmetry (e.g. the mouth
or the area around their eye droops).
Arm weakness:
Raise the person’s arms to 90° if they are sitting or 45° if they are lying.
Ask the person to maintain their arms in that position, with their eyes
open when you let go and count aloud to 10. As you let go keep your
hands just below their arms, so that you can gently support a limb should
it suddenly flop downwards;
The FAST test is positive if when you let go, one arm falls or drifts down.
Speech problems:
During the conversation determine if their speech is slurred or the person
has difficulty finding the name for commonplace objects. Assess this by
asking them to repeat the sentence ‘you can’t teach an old dog new
tricks’, and asking them to identify common objects (e.g. cup, table, chair,
keys, pen). If they have difficulty seeing, place the objects in their hands;
The FAST test is positive if their speech is slurred/abnormal or they are
unable to state the names of common objects.
3.2.2 If unable to assess any element/s of the FAST test due to prior neurological
deficit, record this on the PCR.
3.2.3 If there was a witness present establish the time of onset and whether the
deficits detected are of new onset.
3.3 MEND Exam
3.3.1 FAST is an effective rapid screening tool, but it is less effective at identifying the
subtle signs of a stroke or TIA. If you have completed the Advanced Stroke Life
Mental Status
Level of consciousness (AVPU) Speech “You can’t teach an old dog new tricks” Questions (age and month) Commands (close, keep shut then open eyes)
Cranial Nerves Facial Droop (show teeth or smile) Visual fields (four quadrants) Horizontal gaze (side to side)
Limbs
Motor - Arm drift (close eyes, hold out arms) Leg drift (open eyes, left each leg separately. Sensory - Arms and legs Coordination - Arms and legs - Finger-nose and heel-shin
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Support course, the Miami Emergency Neurological Deficit (MEND) examination
should be completed (Figure 2), with each element recorded as free text on the
PCR. Where a stroke is conveyed this should not delay transport.
3.3.2 Figure 2 - Miami Emergency Neurological Deficit (MEND) Examination
3.4 ABCD2 Risk Assessment Score
3.4.1 Where the focal neurological signs and symptoms have completely resolved, the
ABCD2 score (Figure 3) should be applied as a simple way of predicting the risk
of stroke over the next seven days.6 The scoring of clinical features and duration
of symptoms is based on either examination or history. For example, a patient
who reported focal weakness which resolved 2 hours prior to assessment, would
still receive a score of 2 for the clinical features element.
3.4.2 Figure 3 - ABCD2 Scoring System
Area Criteria Points
Age Aged over 60 years 1
Blood PressureHypertension (Systolic >140 and/or diastolic >90mmHg)
1
Clinical FeaturesSpeech disturbance without weakness
Focal weakness; clinical features of TIA
1
2
Duration of Symptoms
10-59 minutes
Over 60 minutes
1
2
DiabetesPatient has diabetes, taking either oral or injectable medication
1
3.5 Management - Acute Stroke (On-going Signs and Symptoms)
3.5.1 Stroke is a medical emergency, with every minute that thrombolysis is delayed
impacting on the extent of the patients future recovery. The priority is to convey
the patient to a hospital providing acute stroke services for assessment for
thrombolysis.
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3.5.2 At the earliest opportunity confirm whether the patient meets the acute stroke
pre-alert criteria (Appendix 1):
FAST positive;
Blood sugar level greater than 3.5mmol (following treatment if necessary);
Time between onset of symptoms and predicted arrival at a stroke centre
within the time window set for the centre (Appendix 1);
18 years or older - no upper age limit.
3.6 Patients Meeting the Acute Stroke Pre-alert Criteria
3.6.1 Solo-responder (RRV, Officer):
Request/confirm priority 1 (P1) back-up as soon as it is established that the
patient meets the stroke pre-alert criteria. Ask the Clinical Hub to advise the
crew of the required moving and handling equipment (e.g. carry chair);
Provide oxygen therapy if SpO2 <95%;
Gain IV access if time permits.
3.6.2 Double Crewed Ambulance (DCA):
If backing up a solo responder ensure that the moving and handling
equipment requested is taken directly to scene;
Provide/continue oxygen therapy if SpO2 <95%;
Minimise on-scene time.
If patient meets acute stroke pre-alert criteria:
Convey under emergency driving conditions;
Provide an ATMIST pre-alert to the stroke centre;
Gain IV access en-route if time permits.
3.6.3 The specific pathways for each hospital are detailed in Appendix 1. If the nearest
hospital does not offer a stroke thrombolysis service (e.g. non 24/7 services),
bypass the patient to the next nearest hospital offering stroke thrombolysis,
provided that the receiving hospital agrees to accept the patient and they will
arrive within the centre’s thrombolysis time window. An incident report must be
completed if the hospital declines to accept the patient.
3.6.4 Evidence shows that direct conveyance to a CT scanner can reduce the door to
scan and consequently door to thrombolysis time for acute stroke patients. The
centres which offer this pathway are detailed in Appendix 2.
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3.6.5 A small number of people have severe comorbidity and might not benefit from
admission. If after discussion with the person and their family or carer a decision
is made not to admit, the reasons for this must be clearly documented. Access
support and guidance from a senior clinician (ECP, GP, Senior Clinical Advisor) to
support the decision making process.
3.7 Patients Not Meeting the Acute Stroke Pre-alert Criteria
3.7.1 If patient presents with acute stroke symptoms, but does not meet the pre-alert
criteria (e.g. no known onset time), convey to nearest appropriate hospital under
normal driving conditions. Place an ATMIST pre-alert where required by the
hospital.
3.8 Management of Suspected Transient Ischaemic Attack (TIA)
3.8.1 The diagnosis of TIA relies on the recognition of clinical features associated with
focal cerebral dysfunction. As stroke symptoms will have resolved by the time of
assessment, accurate diagnosis is challenging, requiring the process to be based
on the patient or witness recollection of events. The role of the ambulance
clinician is to identify patients who are suspected of experiencing a TIA, rather
than making a definitive diagnosis.
3.8.2 The FAST test must be conducted and confirm that the patient has no new focal
neurological symptoms at the time of assessment. A thorough history to identify
any previous focal neurological symptoms must also be obtained. Where trained,
assess the patient using the MEND exam; all the elements must be negative.
3.8.3 If you are confident that all focal neurological deficits have resolved, treat the
patient as a potential TIA; if not follow the stroke pathway. Apply the ABCD2
score. Research indicates that patients with a score of three or below have a 0%
seven day risk of stroke, compared to a 11.7% risk in those with a score above
five.6 Patients with a total ABCD2 score of three or less are considered low risk,
and can therefore be left at home and referred directly to a TIA clinic provided
that none of the following exclusion criteria are present:
Previous potential TIAs within the past 7 days;
Atrial Fibrillation;
Patients taking warfarin or other anticoagulants (including dabigatran,
rivaroxaban, apixaban, edoxaban);
Patients with haemophilia or other coagulation defects;
Unable to be supplied aspirin due to PGD contraindication.
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3.8.4 In the absence of any of the exclusion criteria detailed in Para 3.8.3, patients
are considered low risk and may be left on scene with a referral to a TIA clinic.
Supply the patient with a pack containing a 7 day course of 300mg aspirin
under the Trust’s PGD. If the patient is already prescribed 75mg aspirin, advise
them to cease taking the 75mg tablets until review at the TIA clinic and replace
with the 300mg aspirin. The patient should be advised to take one 300mg
aspirin from the pack prior to the ambulance clinician leaving scene. Refer the
patient to a TIA clinic according to local pathways (Appendix 3), and inform the
patient’s GP via local mechanisms. If aspirin is unable to be supplied due to the
presence of contraindications to the PGD, the patient must be referred to their
GP or hospital for assessment within 24 hours. Where no local care pathways
exist consider discussing the case with a senior clinician (ECP, GP, Senior Clinical
Advisor) and the need for same day hospital admission.
3.8.5 Patients who have an ABCD2 score of 4 or above (the ABCD2 limit my vary
depending on local pathways, please check you TIA pack), or any of the
exclusion criteria detailed in Para 3.8.3 are considered high risk and must be
referred to an Emergency Department for assessment. A single dose of oral
aspirin 300mg must be administered if the patient meets the administration
guidance detailed in Appendix 4.
3.9 National Ambulance Clinical Quality Indicator
3.9.1 Ambulance clinicians must ensure that the high quality of care that they deliver
is reflected through the achievement of the National ACQIs for the management
of stroke, which is divided into two indicators:
The percentage of Face Arm Speech Test (FAST) positive stroke patients
(assessed face to face) potentially eligible for stroke thrombolysis, who arrive
at a hyperacute stroke centre within 60 minutes of call.
The percentage of suspected stroke patients (assessed face to face) who
receive an appropriate care bundle:
Recording FAST test;
Recording blood pressure;
Recording blood glucose.
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4. Incident Closure4.1 Patients who have experienced a suspected TIA and are not conveyed to hospital
must be provided with a copy of the PCR, a 7 days course of aspirin 300mg
tablets and a TIA patient information leaflet. The requirement not to drive until
after their TIA clinic must be emphasised.
5. Documentation 5.1 In line with Trust Policy, a Patient Clinical Record must be completed and
annotated appropriately. It is particularly important that each element of the
stroke care bundle is recorded, with the rationale for any patient not arriving at
hospital within 60 minutes of the call being recorded on the PCR (e.g. distance
to hospital). In the case of TIA, the signs and symptoms which have resolved
must be clearly recorded to assist the TIA clinic.
5.2 Any deviation from this clinical guideline must be recorded, with any potential or
actual adverse event reported through the incident reporting system.
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6. References 1. Nice Institute for Health and Clinical Excellence (2008) Stroke: Diagnosis and
initial management of acute stroke and transient ischaemic attack (TIA). NICE.
2. Clinical Knowledge Summaries http://www.cks.nhs.uk/stroke_and_tia
[accessed 18th September, 2012].
3. World Health Organisation (1978) Cerebrovascular disorders: a clinical and
research classification. Geneva. World Health Organization.
4. National Audit Office (2005) Reducing Brain Damage: Faster access to better
stroke care. London. NAO.
5. Intercollegiate Stroke Working Party (2004) National clinical guidelines for
stroke. 2nd ed. London. Royal College of Physicians.
6. Johnston S.C, Rothwell P, Nyuyen-Huynh M.N, Giles M, Elkins J.S, Bernstein
A.L. and Sidney S. (2007) Validation and refinement of scores to predict very
early stroke risk after transient ischaemic attack. The Lancet. 369: 283-292.
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Appendix 1 - Stroke 60 Pathways:
Hospital Contact Tel
Time Window
Operating Hours Notes
Bristol Royal Infirmary01173 422928
6 hoursDay & EveningSeven day service
If service not available, contact Southmead Hospital. Direct to CT available.
Derriford Hospital Plymouth
01752 245345
6 hours 24/7 Direct to CT available
Dorset County Hospital Dorchester
01305 257919
4.5 hours 24/7
Gloucester Royal Hospital
08454 225126
6 hours 24/7 Direct to CT available
Great Western Hospital Swindon
01793 604100
6 hours 24/7 Direct to CT available
North Devon District Hospital Barnstaple
01271 335910
4.5 hours 24/7Patients must be under 80 years old and if known, an onset time must be provided
Poole General Hospital01202 661021
4.5 hours 24/7
Royal Bournemouth Hospital
01202 704165
4.5 hours 24/7 Direct to CT available
Royal Cornwall Hospital Truro
01872 252153
6 hours 24/7 Direct to CT available
Royal Devon & Exeter Hospital Exeter
07825 716447
6 hours 24/7 Direct to CT available
Royal United Hospital Bath
01225 319078
6 hours 24/7 Direct to CT available
Salisbury District Hospital
01722336262Ext 4156
6 hours 24/7
Southmead Hospital01179 506862
4.5 hours 24/7 Direct to CT available
Taunton Hospital01823 344920
4.5 hours 24/7 Direct to CT available
Torbay Hospital01803 654070
6 hours 24/7 Direct to CT available
Weston General Hospital
01934 618340
6 hours
Monday - Friday 08:30-16:30 (excluding Bank Holidays)
If service not available, convey to next nearest appropriate hospital. Direct to CT available
Yeovil District Hospital01935 432894
4.5 hours 24/7
01173 422928
01752 245345
01305 257919
08454 225126
01793 604100
01271 335910
01202 661021
01202 704165
01872 252153
07825 716447
01225 319078
01722336262Ext 4156
01179 506862
01823 344920
01803 654070
01934 618340
01935 432894
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Appendix 2 - Hospital Direct to CT Stroke 60 Pathways
Hospital Procedure
Bristol Royal InfirmarySouthmead HospitalRoyal United HospitalGloucester Royal Hospital
During pre-alert state that you are attending a patient who meets the AGWS Network acute stroke pre-alert criteria and request to speak to the ED consultant. The ED consultant will discuss further details, such as co-morbidities, to confirm patient is suitable for direct access to CT scan. If patient confirmed as suitable, provide consultant with ETA and patient’s name and DOB. Minimise on-scene duration and convey patient under emergency driving conditions in accordance with Stroke 60 Care Pathway. On arrival at emergency department, one member of the crew priority registers the patient. The other crew member to accompany ED consultant and nurse to CT scanner. Once the patient is in the CT scanner, crew member to return to ED with ambulance stretcher and complete any remaining documentation and clear.
Derriford Hospital (Plymouth)Operates 08.00–21.00 (7 days a week)
Direct to CT pathway is available for patients fulfilling the following criteria:
Onset time ≤ 6 hours or time uncertain FAST positive Blood sugar level greater than 3.5mmol (following treatment if necessary) 18 years or older (no upper age limit) Provide ATMIST pre-alert. Confirm that this is a stroke patient suitable for the direct to CT pathway, minimise on-scene duration and convey patient under emergency driving conditions. The pre-alert will be used to activate the stroke team and generate a CT request. On arrival at the Emergency Department (ED), any stroke patient that meets the acute stroke Thrombolysis Criteria will be met in the corridor by an ED nurse or Stroke Coordinator nurse, where a handover will take place. The nurse will then accompany the crew direct to the CT scanner. The crew will transfer the patient onto the scanner; they will then be available to book clear in the normal way.
Royal Cornwall HospitalOperates Monday - Friday 09:00-17:00 (excluding Bank Holidays)
Provide pre alert, confirm stroke patient, minimise on-scene duration and convey patient under emergency driving conditions. On arriving at the receiving hospital you will be met by the stroke nurse co-ordinator. It the CT scanner is available you will be instructed to transfer the patient directly onto the scanner and complete your handover.
Great Western Hospital (Swindon)Operates 24/7
Provide stroke pre-alert on 01793 604100, including (where known) time of onset, name, date of birth, first line of address and estimated time of arrival. Upon arrival at the ED, you will be met by the Senior Medical Doctor. Convey patient on the ambulance stretcher to the CT scanner with the Senior Doctor. Once the patient is in the CT scanner, the crew will return to the ED with the ambulance stretcher and complete any remaining documentation.
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Musgrove Park HospitalOperates 24/7
Provide pre alert, confirm stroke patient, minimise on-scene duration and convey patient under emergency driving conditions. On arriving at the receiving hospital you will be met by a member of the stroke team. It the CT scanner is available you will be instructed to transfer the patient directly onto the scanner and complete your handover.
Torbay Hospital Royal Devon and Exeter Hospital Operates Monday - Friday 09:00-17:00 (excluding Bank Holidays)
Provide pre alert, confirm stroke patient, minimise on-scene duration and convey patient under emergency driving conditions. On arriving at the receiving emergency department of the chosen hospital you will be met by the stroke nurse co-ordinator. Following handover you will be instructed to transfer the patient onto a hospital trolley, they will then be taken to the CT scanner by the stroke nurse co-ordinator.
Royal Bournemouth Hospital Operates Monday - Friday 09:00-17:00 (excluding Bank Holidays)
Patient may be conveyed directly to CT if they have a deficit on either the MEND or ROSIER score. If CT indicated pre-alert Emergency Department stating ‘Stroke Code 1 - Acute stroke meeting thrombolysis criteria. Patient being transported directly to CT scanner. Please alert crash call to meet patient at scanner’. Transfer the patient directly to the scanner, which is located immediately left once inside the main hospital entrance.
Weston General Hospital Operates Monday - Friday 08:30-16:30 (excluding Bank Holidays)
All FAST positive patients to be conveyed to the the ED. Fast positive patients within 6 hours of symptom onset will be considered for direct to CT during the operating hours. Provide pre-alert, confirm stroke patient, minimise on-scene duration and convey patient under emergency driving conditions.
Important Additional Information
If direct to CT is not available, acute stroke patients who meet the acute stroke
pre-alert criteria must still be conveyed to an Emergency Department offer a stroke
thrombolysis service as an emergency in accordance with the Stroke 60 Care
Pathway.
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Appendix 3 - TIA Clinics
Hospital Contact Fax Referral Method
Telephone Number to be Left with Patient
Bristol Royal Infirmary 0117 9170159 FAX 01305 255185
Dorset County Hospital Dorchester
01305 255263 FAX 01305 255484
Gloucester Royal Hospital 0300 4226326 FAX 0300 4226321
Great Western Hospital Swindon
01793 604075 FAX 01793 605166
Poole General HospitalTel03000 334000
Dorset SPoA
03000 334000
Royal Bournemouth HospitalTel 03000 334000
Dorset SPoA
03000 334000
Royal Cornwall Hospital TruroTel 03000 334000
Dorset SPoA
03000 334000
Royal Devon & Exeter Hospital Exeter
01392 402595 FAX 01392 402552
Royal United Hospital Bath 01225 821287 FAX 01225 821186
Salisbury District Hospital 01722 429146 FAX01722 336262Ext 4760
Southmead Hospital 01173 403515 FAX 01173 405452
Taunton Hospital 01823 344747 FAX 01823 343438
Torbay Hospital 01803 655077 FAX 01803 654847
Weston General Hospital 01934 647297 FAX 01934 647183
Yeovil District Hospital 01935 384690 FAX 01935 384875
Appendix 4 - Aspirin Administration GuidanceWhen a 7 day course of aspirin is supplied to a patient, this occurs under the Patient
Group Direction (PGD), as this is required to enable Nurses and Paramedics to legally
supply the medicine. Nurses and Paramedics are however able to administer a single
300mg dose to patients who are admitted to hospital outside of the PGD, as the
legislation for administering a medicine is different to that covering the supply. The
guidance below, which mirrors the PGD, must be used for administration.
0117 9170159
01305 255263
0300 4226326
01793 604075
Tel03000 334000
Tel 03000 334000
Tel 03000 334000
01392 402595
01225 821287
01722 429146
01173 403515
01823 344747
01803 655077
01934 647297
01935 384690
01305 255185
01305 255484
0300 4226321
01793 605166
03000 334000
03000 334000
03000 334000
01392 402552
01225 821186
01722 336262Ext 4760
01173 405452
01823 343438
01803 654847
01934 647183
01935 384875
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Clinical Situation
Inclusion criteria Adults 16 years and over presenting with a possible Transient Ischaemic Attack who are being conveyed to hospital.
Exclusion criteria
Patients who do not fulfil the TIA pathway criteria: Patients with an ABCD2 score higher than the limit agreed by the
Trust with local TIA services Previous potential TIAs within the past 7 days Atrial Fibrillation Patients taking warfarin or other anticoagulants (including
dabigatran, rivaroxaban, apixaban, edoxaban) Patients with haemophilia or other coagulation defects (decreases
platelet aggregation and increases bleeding time). Previous or active peptic ulceration; Children <16yrs; Evidence of hypersensitivity to aspirin or other NSAIDS (those in whom attacks of asthma, angioedema, urticaria or rhinitis have been precipitated); Pregnancy; Breastfeeding; Severe hepatic impairment (increased risk of GI bleeding); Severe renal impairment (increased risk of GI bleeding, sodium and water retention, deterioration in renal function); Patients already taking anti-platelet drugs e.g 300mg aspirin or clopidogrel (See advice below under action if excluded).
Cautions
Patients already taking NSAIDs (check OTC use) Lithium Corticosteroids Ciclosporin Methotrexate Tacrolimus SSRIs (citalopram, sertraline, escitalopram, venlafaxine)
Uncontrolled hypertension; G6PD deficiency (an inherited condition in which the body doesn’t have enough of the enzyme G6PD, which helps red blood cells function normally; Asthma (patient may be sensitive to NSAIDS); Excessive alcohol consumption.
Appendix 4 - Aspirin Administration Guidance (cont.)
Clinical Situation (cont.)
Side effects
Hypersensitivity reactions including skin rashes (common), angioedema and bronchospasm. Gastro-intestinal discomfort, nausea, diarrhoea and occasionally bleeding and ulceration. (NB Systemic as well as local effects contribute to GI damage) Haemorrhage
Interactions
Aspirin antagonises the diuretic effect of spironolactone. Ensure history includes other medication taken as risk of a GI event is increased if patient taking another drug that can cause an increased GI risk in their own right i.e. anticoagulants, clopidogrel, low dose aspirin, SSRI, methotrexate or corticosteroids. Aspirin reduces excretion of methotrexate increasing the risk of toxicity. Metoclopramide increases the rate of absorption of aspirin and increases its effect.