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CG20 | VERSION 1.0  1/16
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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
 Ambulance Care Assistant 
 Paramedic (non-SPUEC)
 Emergency Care Assistant 
 Nurse (non-NP)
Authorised Staff
 Student Paramedic 
 SP (EUC)
 Advanced Technician 
 Doctor
Clinical 
Guidance (Green) - Deviation permissible;  
Publication 
Apply clinical judgement
Category
1. 
Scope
1.1 
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 Definitions
2.1 
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
responsive 
2.2 
Strokes and transient ischaemic attacks (TIAs) are acute neurological events, 
committed 
presumed to be vascular in origin, that are caused by cerebral ischaemia, 
effective
cerebral infarction, or cerebral haemorrhage.2
© South Western Ambulance Service NHS Foundation Trust 2014

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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:
V  Thrombotic ischaemic stroke - A blood clot spontaneously forms in an artery 
in the brain. This is a common complication of atherosclerosis;
V  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:
V  Intracerebral haemorrhagic stroke - Bleeding from a blood vessel within the 
brain. High blood pressure is the main cause of intracerebral haemorrhagic 
stroke;
V  Subarachnoid haemorrhagic stroke - Bleeding from a blood vessel between 
the surface of the brain and the arachnoid tissues that cover the brain.
responsive 
2.3.5  Although subarachnoid haemorrhage (SAH) is classified as a type of stroke it is 
committed 
not included in this guideline. A sudden and violent headache is characteristic 
effective
of subarachnoid haemorrhage, which should be managed according to JRCALC 
guidelines.
© South Western Ambulance Service NHS Foundation Trust 2014

CG20 | VERSION 1.0  3/16
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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. 
Guidance
3.1. 
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:
V  Hypoglycaemia*;
V  Conditions which cause dizziness, faintness, or disturbed balance*;
V  Migraine*;
V  Neurological abnormalities;
V  Mass lesions such as subdural hematoma, cerebral abscess, primary central 
nervous system tumours, and metastatic tumours;
V  Postictal states, focal seizures, and generalized seizures*;
responsive 
V  Hyperglycaemia;
committed 
V  Factitious stroke;
effective
V  Psychological disorders, including anxiety*;
V  Physical trauma, including concussion*.
© South Western Ambulance Service NHS Foundation Trust 2014

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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.
V  Are the neurological symptoms focal?
V  Are the focal neurological symptoms negative?
V  Was the onset of the focal neurological symptoms sudden?
V  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
Stroke / Suspected TIA Care Pathway
YES
Acute stroke signs and 
NO
symptoms present?
Does the patient meet the 
Is the patient high risk (any of 
acute stroke pre-alert criteria?
the following are present)?
V FAST positive.
V ABCD2 4 or higher (Unless local 
V Blood sugar level greater than 
pathway states otherwise)
3.5mmol (following treatment if 
V Previous potential TIAs within the 
necessary)
past 7 days.
V Time between onset of 
V Atrial Fibrillation
symptoms and predicted arrival 
V Prescribed warfarin or other 
at thrombolysis centre within the 
anticoagulants (including 
time window set for the centre 
dabigatran, rivaroxaban, apixaban, 
(Appendix 1).
edoxaban).
V 18 years or older - no upper age 
V Diagnosed blood clotting disorder.
limit.
V Unable to be supplied aspirin due 
to PGD contraindication.
YES
NO
YES
NO
responsive 
committed 
effective
Minimise 
Normal 
Hospital 
Low Risk
on scene time, 
conveyance to 
assessment 
Refer to TIA 
rapid conveyance 
appropriate local 
within 24hrs
Clinic
to a stroke 
hospital
centre offering 
a thrombolysis 
service
‘STROKE 60’
© South Western Ambulance Service NHS Foundation Trust 2014

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3.2 
FAST Examination
3.2.1  Assess the patient using the Face, Arms, Speech Test (FAST):
V  Facial weakness:
O  Ask the person to smile or show their teeth;
O  The FAST test is positive if there is new facial asymmetry (e.g. the mouth 
or the area around their eye droops).
V  Arm weakness:
O  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;
O  The FAST test is positive if when you let go, one arm falls or drifts down.
V  Speech problems:
O  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;
O  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 
V  Level of consciousness (AVPU)
responsive 
V  Speech “You can’t teach an old dog new tricks”
committed 
Mental Status
effective
V  Questions (age and month)
V  Commands (close, keep shut then open eyes)
V  Facial Droop (show teeth or smile)
Cranial Nerves
V  Visual fields (four quadrants)
V  Horizontal gaze (side to side)
V  Motor - Arm drift (close eyes, hold out arms)
V  Leg drift (open eyes, left each leg separately.
Limbs
V  Sensory - Arms and legs
V  Coordination - Arms and legs - Finger-nose and heel-shin
© South Western Ambulance Service NHS Foundation Trust 2014

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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
Hypertension (Systolic >140 and/or 
Blood Pressure
1
diastolic >90mmHg)
Speech disturbance without weakness
1
Clinical Features
Focal weakness; clinical features of TIA
2
Duration of 
10-59 minutes
1
Symptoms
Over 60 minutes
2
Patient has diabetes, taking either oral 
Diabetes
1
or injectable medication
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 
responsive 
impacting on the extent of the patients future recovery. The priority is to convey 
committed 
the patient to a hospital providing acute stroke services for assessment for 
effective
thrombolysis.
© South Western Ambulance Service NHS Foundation Trust 2014

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3.5.2  At the earliest opportunity confirm whether the patient meets the acute stroke 
pre-alert criteria (Appendix 1):
V  FAST positive;
V  Blood sugar level greater than 3.5mmol (following treatment if necessary);
V  Time between onset of symptoms and predicted arrival at a stroke centre 
within the time window set for the centre (Appendix 1);
V  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):
V  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);
V  Provide oxygen therapy if SpO  <95%;
2
V  Gain IV access if time permits.
3.6.2  Double Crewed Ambulance (DCA):
V  If backing up a solo responder ensure that the moving and handling 
equipment requested is taken directly to scene;
V  Provide/continue oxygen therapy if SpO  <95%;
2
V  Minimise on-scene time.
V  If patient meets acute stroke pre-alert criteria:
O  Convey under emergency driving conditions; 
O  Provide an ATMIST pre-alert to the stroke centre;
O  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.
responsive 
committed 
3.6.4  Evidence shows that direct conveyance to a CT scanner can reduce the door to 
effective
scan and consequently door to thrombolysis time for acute stroke patients. The 
centres which offer this pathway are detailed in Appendix 2.
© South Western Ambulance Service NHS Foundation Trust 2014

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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:
responsive 
V  Previous potential TIAs within the past 7 days;
committed 
V  Atrial Fibrillation;
effective
V  Patients taking warfarin or other anticoagulants (including dabigatran, 
rivaroxaban, apixaban, edoxaban);
V  Patients with haemophilia or other coagulation defects; 
V  Unable to be supplied aspirin due to PGD contraindication.
© South Western Ambulance Service NHS Foundation Trust 2014

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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:
V  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.
V  The percentage of suspected stroke patients (assessed face to face) who 
receive an appropriate care bundle:
O  Recording FAST test; 
O  Recording blood pressure;
responsive 
O  Recording blood glucose.
committed 
effective
© South Western Ambulance Service NHS Foundation Trust 2014

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4. 
Incident Closure
4.1 
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.
responsive 
committed 
effective
© South Western Ambulance Service NHS Foundation Trust 2014

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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.
responsive 
committed 
effective
© South Western Ambulance Service NHS Foundation Trust 2014

CG20 | VERSION 1.0  12/16
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Appendix 1 - Stroke 60 Pathways:
Hospital
Contact 
Time 
Operating 
Tel
Window
Hours
Notes
Day & Evening
01
0 1
1 7
1 3 
If service not available, 

Bristol Royal Infirmary
6 hours
Seven day 
contact Southmead Hospital. 
422928
service
Direct to CT available.
Derriford Hospital 
01
0 7
1 52 
6 hours
24/7
Direct to CT available
Plymouth
24
2 5345
Dorset County 
01
0 3
1 05 
4.5 hours
24/7
Hospital Dorchester
25791
9 9
1
Gloucester Royal 
08454 
6 hours
24/7
Direct to CT available
Hospital
2251
5 2
1 6
2
Great Western 
01
0 7
1 93 
9
6 hours
24/7
Direct to CT available
Hospital Swindon
6041
4 0
1 0
North Devon District 
01
0 2
1 7
2 1 
Patients must be under 80 
71 
4.5 hours
24/7
years old and if known, an 
Hospital Barnstaple
33591
9 0
1
onset time must be provided
01
0 2
1 02 
Poole General Hospital
4.5 hours
24/7
661
6 0
1 21
2
Royal Bournemouth 
01
0 2
1 02 
4.5 hours
24/7
Direct to CT available
Hospital
70
7 41
4 6
1 5
Royal Cornwall 
01
0 8
1 72 
6 hours
24/7
Direct to CT available
Hospital Truro
2521
2 5
1 3
Royal Devon & Exeter 
07
0 825 
6 hours
24/7
Direct to CT available
Hospital Exeter
71
7 6
1 447
4
Royal United Hospital 
01
0 2
1 25 
6 hours
24/7
Direct to CT available
Bath
31
3 9
1 07
0 8
01
0 7
1 22
Salisbury District 
33626
2 2
6 hours
24/7
Hospital
Ext 41
4 5
1 6
01
0 1
1 7
1 9 
Southmead Hospital
4.5 hours
24/7
Direct to CT available
506862
01
0 8
1 23 
Taunton Hospital
4.5 hours
24/7
Direct to CT available
344920
01
0 8
1 03 
responsive 
Torbay Hospital
6 hours
24/7
Direct to CT available
committed 
65407
0 0
7
effective
Monday - Friday 
If service not available, 
Weston General 
01
0 9
1 3
9 4 
08:30-16:30 
convey to next nearest 
6 hours
Hospital
61
6 8
1 340
(excluding Bank 
appropriate hospital. 
Holidays)
Direct to CT available
01
0 9
1 3
9 5 
Yeovil District Hospital
4.5 hours
24/7
432894
© South Western Ambulance Service NHS Foundation Trust 2014

CG20 | VERSION 1.0  13/16
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Appendix 2 - Hospital Direct to CT Stroke 60 Pathways
Hospital
Procedure
V 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. 
V If patient confirmed as suitable, provide consultant with ETA and 
Bristol Royal Infirmary
patient’s name and DOB.
Southmead Hospital
V Minimise on-scene duration and convey patient under 
Royal United Hospital
emergency driving conditions in accordance with Stroke 60 Care 
Gloucester Royal Hospital
Pathway. 
V 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.
Direct to CT pathway is available for patients fulfilling the 
following criteria:
V  Onset time ≤ 6 hours or time uncertain
V FAST positive
V Blood sugar level greater than 3.5mmol (following treatment if 
necessary)
V 18 years or older (no upper age limit)
V Provide ATMIST pre-alert. Confirm that this is a stroke patient 
Derriford Hospital 
suitable for the direct to CT pathway, minimise on-scene 
(Plymouth)
duration and convey patient under emergency driving conditions. 
Operates 08.00–21.00  
The pre-alert will be used to activate the stroke team and 
(7 days a week)
generate a CT request.
V On arrival at the Emergency Department (ED), any stroke patient 
that meets the acute
V stroke Thrombolysis Criteria will be met in the corridor by an ED 
nurse or Stroke Coordinator nurse, where a handover will take 
place.
V 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.
V Provide pre alert, confirm stroke patient, minimise on-scene 
Royal Cornwall Hospital
duration and convey patient under emergency driving conditions.
V On arriving at the receiving hospital you will be met by the 
responsive 
Operates Monday 
committed 
- Friday 09:00-17:00 
stroke nurse co-ordinator. It the CT scanner is available you will 
effective
(excluding Bank Holidays)
be instructed to transfer the patient directly onto the scanner 
and complete your handover.
V 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.
Great Western Hospital 
V Upon arrival at the ED, you will be met by the Senior Medical 
(Swindon)
Doctor. Convey patient on the ambulance stretcher to the CT 
Operates 24/7
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.
© South Western Ambulance Service NHS Foundation Trust 2014

CG20 | VERSION 1.0  14/16
t r u s t   c l i n i c a l   g u i d e l i n e
V Provide pre alert, confirm stroke patient, minimise on-scene 
duration and convey patient under emergency driving conditions.
Musgrove Park Hospital
V On arriving at the receiving hospital you will be met by a 
Operates 24/7
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.
V Provide pre alert, confirm stroke patient, minimise on-scene 
Torbay Hospital 
duration and convey patient under emergency driving conditions.
Royal Devon and Exeter 
V On arriving at the receiving emergency department of the 
Hospital 
chosen hospital you will be met by the stroke nurse co-ordinator. 
Operates Monday 
Following handover you will be instructed to transfer the patient 
- Friday 09:00-17:00 
onto a hospital trolley, they will then be taken to the CT scanner 
(excluding Bank Holidays)
by the stroke nurse co-ordinator.
V Patient may be conveyed directly to CT if they have a deficit 
Royal Bournemouth 
on either the MEND or ROSIER score. If CT indicated pre-alert 
Hospital 
Emergency Department stating ‘Stroke Code 1 - Acute stroke 
Operates Monday 
meeting thrombolysis criteria. Patient being transported directly 
- Friday 09:00-17:00 
to CT scanner. Please alert crash call to meet patient at scanner’.
(excluding Bank Holidays)
V Transfer the patient directly to the scanner, which is located 
immediately left once inside the main hospital entrance.
V All FAST positive patients to be conveyed to the the ED. Fast 
Weston General Hospital 
positive patients within 6 hours of symptom onset will be 
Operates Monday 
considered for direct to CT during the operating hours.
- Friday 08:30-16:30 
V Provide pre-alert, confirm stroke patient, minimise on-scene 
(excluding Bank Holidays)
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.
responsive 
committed 
effective
© South Western Ambulance Service NHS Foundation Trust 2014

CG20 | VERSION 1.0  15/16
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Appendix 3 - TIA Clinics
Telephone 
Hospital
Contact Fax
Referral 
Method
Number to be 
Left with Patient
Bristol Royal Infirmary
01
0 1
1 7
1  91
9 7
1 0
7 1
0 5
1 9
FAX
01
0 3
1 05 25
2 5
5 1
5 8
1 5
Dorset County Hospital 
01
0 3
1 05 255
5 26
2 3
FAX
01
0 3
1 05 255
5 484
Dorchester
Gloucester Royal Hospital
0300 4226
2 326
2
FAX
0300 4226
2 321
2
Great Western Hospital 
01
0 7
1 93
9  60407
0 5
FAX
01
0 7
1 93
9  6051
5 6
1 6
Swindon 
Te
T l
Dorset 
Poole General Hospital
03000 334000
03000 334000
SPoA
Te
T l 
Dorset 
Royal Bournemouth Hospital
03000 334000
03000 334000
SPoA
Te
T l 
Dorset 
Royal Cornwall Hospital Truro
03000 334000
03000 334000
SPoA
Royal Devon & Exeter 
01
0 3
1 92 402595
FAX
01
0 3
1 92 40255
25 2
Hospital Exeter
Royal United Hospital Bath
01
0 2
1 25 821
2 2
1 87
FAX
01
0 2
1 25 821
2 1
1 8
1 6
01
0 7
1 22 33626
2 2
Salisbury District Hospital
01
0 7
1 22 4291
9 4
1 6
FAX
Ext 47
4 6
7 0
Southmead Hospital
01
0 1
1 7
1 3 40351
5 5
1
FAX
01
0 1
1 7
1 3 405452
Taunton Hospital
01
0 8
1 23 3447
4 4
7 7
4
FAX
01
0 8
1 23 343438
Torbay Hospital
01
0 8
1 03 655
5 07
0 7
FAX
01
0 8
1 03 654847
4
Weston General Hospital
01
0 9
1 3
9 4 647
4 297
FAX
01
0 9
1 3
9 4 647
4 1
7 8
1 3
Yeovil District Hospital
01
0 9
1 3
9 5 384690
FAX
01
0 9
1 3
9 5 384875
responsive 
committed 
Appendix 4 - Aspirin Administration Guidance
effective
When 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.
© South Western Ambulance Service NHS Foundation Trust 2014

CG20 | VERSION 1.0  16/16
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Clinical Situation
V Adults 16 years and over presenting with a possible Transient 
Inclusion criteria
Ischaemic Attack who are being conveyed to hospital.
V Patients who do not fulfil the TIA pathway criteria:
 
O
Patients with an ABCD2 score higher than the limit agreed by the 
Trust with local TIA services
 
O
Previous potential TIAs within the past 7 days
 
O
Atrial Fibrillation
 
O
Patients taking warfarin or other anticoagulants (including 
dabigatran, rivaroxaban, apixaban, edoxaban)
 
O
Patients with haemophilia or other coagulation defects (decreases 
platelet aggregation and increases bleeding time).
V Previous or active peptic ulceration;
Exclusion criteria
V Children <16yrs;
V Evidence of hypersensitivity to aspirin or other NSAIDS (those in 
whom attacks of asthma, angioedema, urticaria or rhinitis have been 
precipitated);
V Pregnancy;
V Breastfeeding;
V Severe hepatic impairment (increased risk of GI bleeding);
V Severe renal impairment (increased risk of GI bleeding, sodium and 
water retention, deterioration in renal function);
V Patients already taking anti-platelet drugs e.g 300mg aspirin or 
clopidogrel (See advice below under action if excluded).
V Patients already taking
 
O NSAIDs (check OTC use) 
 
O Lithium
 
O Corticosteroids
 
O Ciclosporin 
 
O Methotrexate
 
O Tacrolimus
Cautions
 
O SSRIs (citalopram, sertraline, escitalopram, venlafaxine)
V Uncontrolled hypertension;
V G6PD deficiency (an inherited condition in which the body doesn’t 
have enough of the enzyme G6PD, which helps red blood cells function 
normally;
V Asthma (patient may be sensitive to NSAIDS);
V Excessive alcohol consumption.
Appendix 4 - Aspirin Administration Guidance (cont.)
Clinical Situation (cont.)
V Hypersensitivity reactions including skin rashes (common), angioedema 
and bronchospasm.
V Gastro-intestinal discomfort, nausea, diarrhoea and occasionally 
responsive 
Side effects
committed 
bleeding and ulceration. (NB Systemic as well as local effects contribute 
effective
to GI damage)
V Haemorrhage
V Aspirin antagonises the diuretic effect of spironolactone. 
V 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, 
Interactions
SSRI, methotrexate or corticosteroids.
V Aspirin reduces excretion of methotrexate increasing the risk of toxicity.
V Metoclopramide increases the rate of absorption of aspirin and increases 
its effect.
© South Western Ambulance Service NHS Foundation Trust 2014