Stroke: Assessment: Difference between revisions
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Emergency Medical Services (EMS) provide the first medical contact for upto 70% of all stroke patients, and are therefore in a unique position to reduce delays in presentation and treatment. Reliable identification of stroke patients in the field could decrease delays by permitting paramedics to notify receiving hospitals of the imminent arrival of a stroke case ensuring rapid rapid mobilisation of stroke teams and early access to required scanning on hospital arrival. Pre Hospital assessment and determination of stroke severity is a new concept, with the best scale yet to be determined. The Cincinnati and Los Angeles scales have been validated in hospital trials, but studies are mixed when applied by EMS <ref>Asimos AW, Ward S, Brice JH, Rosamond WD, Godstein LB, Studnek J. Out-of-hospital stroke screen accuracy in a state with an emergency medical services protocol for routing patients to acute stroke centers. Annals of Emergency Medicine, 2014; 64 (5) 509-515.</ref>. The RACE Scale has had some positive results when tested among paramedics in Spain with more studies underway <ref>Perez de la Ossa N, Carrera D, Gorchs M, Querol M, Millan M, Gomis M, et al. Design and validation of a prehospital stroke scale to predict large arterial occlusion: The rapid arterial occlusion evaluation scale. Stroke, 2014; 45:87–91</ref>, currently it is being adopted by many EMS Systems in the United States.<br> | Emergency Medical Services (EMS) provide the first medical contact for upto 70% of all stroke patients, and are therefore in a unique position to reduce delays in presentation and treatment. Reliable identification of stroke patients in the field could decrease delays by permitting paramedics to notify receiving hospitals of the imminent arrival of a stroke case ensuring rapid rapid mobilisation of stroke teams and early access to required scanning on hospital arrival. Pre Hospital assessment and determination of stroke severity is a new concept, with the best scale yet to be determined. The Cincinnati and Los Angeles scales have been validated in hospital trials, but studies are mixed when applied by EMS <ref>Asimos AW, Ward S, Brice JH, Rosamond WD, Godstein LB, Studnek J. Out-of-hospital stroke screen accuracy in a state with an emergency medical services protocol for routing patients to acute stroke centers. Annals of Emergency Medicine, 2014; 64 (5) 509-515.</ref>. The RACE Scale has had some positive results when tested among paramedics in Spain with more studies underway <ref>Perez de la Ossa N, Carrera D, Gorchs M, Querol M, Millan M, Gomis M, et al. Design and validation of a prehospital stroke scale to predict large arterial occlusion: The rapid arterial occlusion evaluation scale. Stroke, 2014; 45:87–91</ref>, currently it is being adopted by many EMS Systems in the United States.<br> | ||
==== Cincinnati Pre-Hospital Stroke Scale (CPSS) | ==== [http://www.strokecenter.org/wp-content/uploads/2011/08/LAPSS.pdf Cincinnati Pre-Hospital Stroke Scale (CPSS)] ==== | ||
Developed in 1997 at the University of Cincinnati Medical Center for pre-hospital use the Cincinnati Pre-Hospital Stroke Scale (CPSS) was derived from the National Institutes of Health Stroke Scale <ref name="Hurwitz">Hurwitz AS, Brice JH, Overby BA, Evenson KR. Directed use of the Cincinnati Prehospital Stroke Scale by laypersons. Prehospital Emergency Care. 2005 Jan 1;9(3):292-6.</ref><ref>Kothari, R.; Hall, K.; Brott, T.; Broderick, J. (1997-10-01). "Early stroke recognition: developing an out-of-hospital NIH Stroke Scale". Academic Emergency Medicine. 4 (10): 986–990. ISSN 1069-6563. PMID 9332632.</ref>. The CPSS is used to diagnose a potential stroke in a pre-hospital setting through testing the following three signs <ref name="Hurwitz" />. If any one of these tests show abnormal findings, the patient may be having a stroke and should be transported to a hospital as soon as possible. Patients with 1 of these 3 findings as a new event have a 72% probability of an ischemic stroke, while if all 3 findings are present the probability of an acute stroke is greater than 85% <ref>American Heart Association (2011). Advanced Cardiovascular Life Support Provider Manual. USA: First American Heart Association Printing. p. 137. ISBN 978-1-61669-010-6.</ref>. | Developed in 1997 at the University of Cincinnati Medical Center for pre-hospital use the Cincinnati Pre-Hospital Stroke Scale (CPSS) was derived from the National Institutes of Health Stroke Scale <ref name="Hurwitz">Hurwitz AS, Brice JH, Overby BA, Evenson KR. Directed use of the Cincinnati Prehospital Stroke Scale by laypersons. Prehospital Emergency Care. 2005 Jan 1;9(3):292-6.</ref><ref>Kothari, R.; Hall, K.; Brott, T.; Broderick, J. (1997-10-01). "Early stroke recognition: developing an out-of-hospital NIH Stroke Scale". Academic Emergency Medicine. 4 (10): 986–990. ISSN 1069-6563. PMID 9332632.</ref>. The CPSS is used to diagnose a potential stroke in a pre-hospital setting through testing the following three signs <ref name="Hurwitz" />. If any one of these tests show abnormal findings, the patient may be having a stroke and should be transported to a hospital as soon as possible. Patients with 1 of these 3 findings as a new event have a 72% probability of an ischemic stroke, while if all 3 findings are present the probability of an acute stroke is greater than 85% <ref>American Heart Association (2011). Advanced Cardiovascular Life Support Provider Manual. USA: First American Heart Association Printing. p. 137. ISBN 978-1-61669-010-6.</ref>. | ||
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Easy to Conduct - 3 Items, performed in < 1 Min<br> | Easy to Conduct - 3 Items, performed in < 1 Min<br> | ||
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Introduction[edit | edit source]
’Time is Brain’. Acute Stroke is a medical emergency. Stroke is a major cause of death and disability, and patient outcomes depend on how quickly the blood flow can be restored to the damaged area of the brain. Stroke scales are standardized assessment tools used to identify Stroke and clear a path to reperfusion. Treatment options for stroke include thrombolytic medications that aim to dissolve the clot, and interventional endovascular procedures (similar to a cardiac catheterization) to remove it. Successful stroke care requires early recognition, transporting the patient to a designated stroke center, and early activation of a stroke team at the hospital.
Stroke Assessment Scales[edit | edit source]
Pre Hospital[edit | edit source]
Emergency Medical Services (EMS) provide the first medical contact for upto 70% of all stroke patients, and are therefore in a unique position to reduce delays in presentation and treatment. Reliable identification of stroke patients in the field could decrease delays by permitting paramedics to notify receiving hospitals of the imminent arrival of a stroke case ensuring rapid rapid mobilisation of stroke teams and early access to required scanning on hospital arrival. Pre Hospital assessment and determination of stroke severity is a new concept, with the best scale yet to be determined. The Cincinnati and Los Angeles scales have been validated in hospital trials, but studies are mixed when applied by EMS [1]. The RACE Scale has had some positive results when tested among paramedics in Spain with more studies underway [2], currently it is being adopted by many EMS Systems in the United States.
Cincinnati Pre-Hospital Stroke Scale (CPSS)[edit | edit source]
Developed in 1997 at the University of Cincinnati Medical Center for pre-hospital use the Cincinnati Pre-Hospital Stroke Scale (CPSS) was derived from the National Institutes of Health Stroke Scale [3][4]. The CPSS is used to diagnose a potential stroke in a pre-hospital setting through testing the following three signs [3]. If any one of these tests show abnormal findings, the patient may be having a stroke and should be transported to a hospital as soon as possible. Patients with 1 of these 3 findings as a new event have a 72% probability of an ischemic stroke, while if all 3 findings are present the probability of an acute stroke is greater than 85% [5].
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Facial Droop Have the person smile or show their teeth
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Arm Drift Have the person close their eyes and hold their arms straight out in front for about 10 seconds
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Speech Have the person say, "You can't teach an old dog new tricks," or some other simple, familiar saying.
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| Pros | Cons | |
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Easy to Conduct - 3 Items, performed in < 1 Min |
Does not measure Posterior Circulation Strokes | |
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Derived from NIHSS |
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Sensitivity 100% |
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Specificity 88% |
Los Angeles Prehospital Stroke Screen (LAPSS)[edit | edit source]
The Los Angeles Prehospital Stroke Screen (LAPSS) is a longer and widely used validated screening tool for early identification of stroke by Emergency Medical Technicians / Paramedics. The LAPSS showed a Sensitivity of 91%, Specificity of 97% with Positive Predictive Value of 86% and Negative Predictive Value of 97% following a Prospective Study In Field Validation Study with 19 UCLA Paramedic Crews, who following a 60-min Training Session [6][7].
| Criteria | Yes | No | Unknown |
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1. Age greater than 45 years |
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2. History of Seizures or Epilepsy |
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3. Onset of Neurological Symptoms is less than 24 hours |
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4. Patient was Ambulatory prior to onset of symptoms |
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5. Blood Glucose between 60 and 400 mg/dl |
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6. Motor Exam: Examine for Motor Asymmetry Based on Exam below, patient has only Unilateral 'Weakness: |
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| Equal | Right | Left | |
| Facial Smile / Grimace | Droop | Droop | |
| Grip Strength |
Weak Grip No Grip |
Weak Grip No Grip | |
| Arm Srength |
Drifts Down Falls Rapidly |
Drifts Down Falls Rapidly |
If Items 1 - 6 all Yes's or Items 5 - 7 Unknown then LAPSS Screening Criteria is met:
Note: the patient may still be experienceing a Stroke even if LAPSS Criteria are not met.
| Pros | Cons | |
| Takes < 3 mins to perform | Nine Items to Assess | |
| More Sensitive / Specific than CPSS |
Rapid Arterial oCclusion Evaluation (RACE)[edit | edit source]
Miami Emergency Neurological Deficit (MEND)[edit | edit source]
Melbourne Ambulance Stroke Screen (MASS)[edit | edit source]
Acute[edit | edit source]
Main role to measure deficits and stroke severity, which predicts patient discharge disposition. It provides a Standardized Neurological Exam, that can be utilised to monitor Neurological Status and can also be used to match patients to allow for comparison in clinical trials.
National Institutes of Health Stroke Scale (NIHSS)[edit | edit source]
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Canadian Neurological Scale - 1986[edit | edit source]
European Stroke Scale - 1994[edit | edit source]
Sub Heading 3[edit | edit source]
Recent Related Research (from Pubmed)[edit | edit source]
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References[edit | edit source]
References will automatically be added here, see adding references tutorial.
- ↑ Asimos AW, Ward S, Brice JH, Rosamond WD, Godstein LB, Studnek J. Out-of-hospital stroke screen accuracy in a state with an emergency medical services protocol for routing patients to acute stroke centers. Annals of Emergency Medicine, 2014; 64 (5) 509-515.
- ↑ Perez de la Ossa N, Carrera D, Gorchs M, Querol M, Millan M, Gomis M, et al. Design and validation of a prehospital stroke scale to predict large arterial occlusion: The rapid arterial occlusion evaluation scale. Stroke, 2014; 45:87–91
- ↑ 3.0 3.1 Hurwitz AS, Brice JH, Overby BA, Evenson KR. Directed use of the Cincinnati Prehospital Stroke Scale by laypersons. Prehospital Emergency Care. 2005 Jan 1;9(3):292-6.
- ↑ Kothari, R.; Hall, K.; Brott, T.; Broderick, J. (1997-10-01). "Early stroke recognition: developing an out-of-hospital NIH Stroke Scale". Academic Emergency Medicine. 4 (10): 986–990. ISSN 1069-6563. PMID 9332632.
- ↑ American Heart Association (2011). Advanced Cardiovascular Life Support Provider Manual. USA: First American Heart Association Printing. p. 137. ISBN 978-1-61669-010-6.
- ↑ Kidwell CS, Starkman S, Eckstein M, Weems K, Saver JL. Identifying stroke in the field: prospective validation of the Los Angeles Prehospital Stroke Screen (LAPSS) Stroke. 2000; 31 (1): 71–76. doi: 10.1161/01. STR.;31:71.
- ↑ Chen S, Sun H, Lei Y, Gao D, Wang Y, Wang Y, Zhou Y, Wang A, Wang W, Zhao X. Validation of the Los Angeles pre-hospital stroke screen (LAPSS) in a Chinese urban emergency medical service population. PLoS One. 2013 Aug 7;8(8):e70742.
