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Iredell County EMS
Los Angeles Prehospital Stroke Screen 

Date: _________________

 

  CAD# ________________

 

 

 

1. Patient Name

____________________________
(Last Name)

___________________________
(First Name)

 

 

 

2. Information/History From:

[  ] Patient

[  ]Family Member

 

[  ] Other

 

 

 

 

_____________________________
(Name if other than patient)

__________________________
(Relationship)

 

 

 
3. Last time patient was deficit free and awake:

 

____________________
(Time in military time)

__________________
(Date)

 

 

 

 
           

 

SCREENING CRITERIA

 

 

 
 

YES

UNKNOWN

NO

4.  Age over 45 years        

{  }

{  }

{  }

5.  No Prior history of epilepsy or seizure     

{  }

{  }

{  }

6.  Symptom duration less than 24 hours 

{  }

{  }

{  }

7.  At baseline, patient is ambulatory 

{  }

{  }

{  }

8.  Blood glucose level between 60 and 400

{  }

{  }

{  }

9.  Exam:  Look for obvious asymmetry

 

 

 

 

NORMAL

RIGHT

LEFT

Facial: Smile / Grimace

{  }

{  }Droop

{  }Droop

 

 

 

 

Handgrip

{  }

{  }Weak

{  }Weak

 

{  }

  {  }No grip

  {  }No grip

 

 

 

 

Arm Strength

{  }

        {  }Drifts down

        {  }Drifts down

 

{  }

    {  }Falls fast

    {  }Falls fast

 

 

 

 

Based on exam, patient has only unilateral weakness:

{  }YES

{  }NO 

 

 

 

 

 

10.  Items 4,5,6,7,8,9 all YES’s (or unknown)-LAPSS screening criteria met:

{  }YES

{  }NO 

 

11.  If all of the LAPSS criteria are met, alert the receiving facility of a potential stroke patient and complete a Thrombolytic Screening Form (CVA).  If not, then return to the appropriate treatment protocol for the patient presentation.
(Note: a patient may still be experiencing a stroke even if the LAPSS criterion is not met).

12. Time LAPSS exam completed:

___________________________
(Military Time)

13. Form completed by:

_____________________________
(Signature)