Stroke
Pathway
NWAS · ISDN Greater Manchester · CAL · CAM · North East & North Cumbria
⏱️ TIME IS BRAIN — Minimise on-scene time. Target <15 minutes on scene.
⚠️ New acute onset of symptoms — Take History, Complete AVPU/ABCD and FAST, Record Baseline Observations.
Check Pathway Exclusions First

Pathway Exclusions — If ANY present, transport to nearest appropriate ED

FAST Assessment
Assess each component. Any positive = FAST positive.
F
Face
Facial droop or asymmetry? Ask patient to smile.
POSITIVE
NEGATIVE
A
Arms
Arm weakness or drift? Ask patient to raise both arms.
POSITIVE
NEGATIVE
S
Speech
Slurred, confused or unable to speak? Ask patient to repeat a simple sentence.
POSITIVE
NEGATIVE
+
Other Features
Sudden: visual disturbance, severe headache, confusion, balance/coordination problems.
PRESENT
ABSENT
Symptom Status
Time Since Symptom Onset
Use last seen well time if onset is not known. Document last seen well time on PCR.
⚡ Under 9 Hours
→ Nearest Hyper-Acute Stroke Unit (HASU)
9 – 48 Hours
→ Nearest Hyper-Acute Stroke Unit (HASU)
Except Cheshire & Mersey area — suspected stroke patients attend nearest HASU per local pathway
Over 48 Hours
→ Local ED
Except Cheshire & Mersey — suspected stroke patients attend nearest HASU
Anticoagulation Check — Greater Manchester Only
⭐ GM ONLY — Is patient on anticoagulation medication listed below?

Anticoagulation Medications

Warfarin
Apixaban (Eliquis)
Rivaroxaban (Xarelto)
Dabigatran (Pradaxa)
Edoxaban (Lixiana)
Any other anticoagulant
Is patient on anticoagulation?
RED Stroke Standby
🚨 GM ONLY — Patient on anticoagulation. Use RED Stroke Standby pre-alert.

RED Stroke Standby — ASHICE Mnemonic

Include patient NAME and DATE OF BIRTH in pre-alert.
A
Age / Name / DOB
S
Sex
H
History / Chief Complaint
I
Injuries / Findings
C
Condition
E
ETA
No Pre-Alert Required
✓ Patient not on anticoagulation — no RED Stroke Standby pre-alert required for this pathway.
However — a standard pre-alert to the receiving HASU is still good practice and recommended locally.
HASU Destinations
All HASUs are 24 hours unless stated. Select your region.
CAL
Blackpool Victoria
Cumberland Infirmary
Furness General
Royal Blackburn
Royal Lancaster Infirmary
Royal Preston
CAM
Aintree
Arrowe Park
Countess of Chester
Leighton
Whiston [Facetime Triage]
GM
Fairfield 0645-2245
Salford Royal
Stepping Hill 0645-2245
⭐ GM: Patients in Wythenshawe ED catchment → Manchester Royal Infirmary ED. NMGH/Oldham ED catchment → Fairfield ED.
CAM: If clinician suspects stroke per JRCALC — consider HASU. Alternatively consider Complex Incident Hub for clinical advice.
📞 If in any doubt — Clinical Advice available from Clinical Incident Hub Advanced Paramedic CH183
Treatment Considerations
⏱️ Time is Brain — minimise scene time <15 minutes

On Scene / En-Route Checklist

Do NOT Delay For

  • 12-lead ECG — not required for stroke diagnosis
  • IV access — attempt en-route only
  • Repeat observations — record baseline and monitor en-route
FAST Negative — Query TIA / Stroke Not Suspected

Query TIA (FAST Negative, Clinician Suspects Stroke)

Follow NWAS clinical procedures:
  • General: Local ED
  • Cheshire & Mersey area: Suspected TIA patients attend nearest HASU
If clinician suspects stroke in line with JRCALC guidelines — consider HASU. Alternatively consider Complex Incident Hub for clinical advice.

Stroke Not Suspected / Symptoms Resolved

  • Manage as per presenting symptoms
  • Document assessment findings fully
  • Consider appropriate destination for underlying condition
⚠️ Symptoms that have resolved may represent a TIA — document thoroughly and convey for assessment.
Stroke
Summary
NWAS Stroke Pathway · Aide-memoire only — complete full PCR separately
⚠️ Aide-memoire only. Complete full PCR separately.
Plain Text Output — for PCR / Handover