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IV Initiation on Stroke Codes

Question# 715

When on a stroke code, does the Base Hospital want medics placing more than one IV line?


The cornerstone prehospital treatment of stroke patients is a) rapid recognition of a potential stroke; and b) expeditious transport to an appropriate facility.

We should do everything possible to increase A, decrease B, and minimize unnecessary intervention(s); which naturally leads to the discussion on IV initiation. As with any prehospital intervention performed, we need to perform a risk analysis and consider and pros and cons of said intervention. The same can be said about initiating an IV in a stroke patient.

We have liaised with our regional stroke partners, who do feel that best practice is the prehospital initiation of 2 x IVs, albeit, they are adamant that the insertion is not to delay transport. If possible, they’d prefer:

1 x 18 gauge (alternatively 20 gauge) IV in the right antecubital fossa (ACF)
1 x 20 gauge (or bigger) IV in the left ACF, but must be above the hand
Keep in mind, this is their preference, and not an absolute. The skill of the provider, and anatomy of the patient will ultimately dictate site/size. A 22 gauge in the hand is better than a 18 gauge in the sharps container.

In the prehospital world, an IV is inserted for the “actual or potential need for intravenous medication OR fluid therapy”. Like ischemic chest pain, there is the potential for this patient cohort to deteriorate, and we don’t want to discourage you from inserting one if you have a clinical concern or index of suspicion. Preventative medicine should outweigh reactive medicine.

There is a vast body of literature that illustrates the insertion of IVs adds additional significant scene time and risk. If you’re considering initiating a 2nd IV, it should only be attempted on route and NOT on scene. Even then, unless there is an immediate need for emergent prehospital interventions, the 1st IV should be considered to be initiated on route.

The main principle is that we shouldn’t be delaying transport for IVs.

IVs inserted prehospitally carry an increased risk of infection, and are more likely to fail, compared to ones inserted in a more “stable” environment. Provider skill and vein availability is also an important confounder to consider, and if there are multiple “holes” in the patient from IV failures, this can lead to an increased bleeding risk for patients after they receive a thrombolytic.

Our hospital partners also approach this skill with a different lens than prehospital providers. Upon arrival, there are many capable hands to multi-task and insert IVs in a cleaner and well-lit environment, while handover is occurring, not to mention the IVs can serve a dual role as labs can be drawn at the same time. The hospitals are also concerned with “door to needle time”, as that’s an important metric when we look the efficiency of stroke care, and the IV will ultimately be used to give thrombolytic therapy (if patient is eligible).

The RPPEO would like paramedics to perform interventions that are patient-centered, and in the best interest of the patient. Period. The bottom line is that this is not an absolute, and we are not expecting paramedics to insert 2 x IVs in a stroke patient. Just to reiterate, the insertion of IV(s) in this patient cohort is not to delay transport ever.


BLS PCS - Cerebrovascular Accident (CVA, Stroke) Standard


17 July 2023

ALSPCS Version




Please reference the MOST RECENT ALS PCS for updates and changes to these directives.