Neurological Assessment of The Suspected Stroke Victim For the EMT-B Objectives • Discuss the importance of prehospital stroke assessment • Describe the importance of organized stroke management protocols • Discuss components of Cincinnati Prehospital Stroke Scale and the Los Angeles Prehospital Stroke Screen • Identify key components of prehospital stroke management Importance of Prehospital Stroke Assessment It is imperative for systems to utilize a consistent method to assess possible stroke victims. If a system is well organized and consistent then the results from these assessments will determine the best facility to care for the emergent stroke victim. Importance of Prehospital Stroke Assessment • If a system chooses one method of assessment it will promote consistency and continuity of care with receiving institutions. • This consistency will enhance communication with the hospital and physicians who will be caring for the patient. Organized Stroke Management Protocols A protocol, or Standing Order, provides a consistent format for the evaluation and treatment of patients. In the case of Stroke victims protocols will ensure that they are assessed and treated by EMS and then transported to the correct facility to meet their needs. Treatment may include medication administration, surgery or basic observation. Cincinnati Prehospital Stroke Scale Cincinnati Prehospital Stroke Scale • Developed in Cincinnati, Ohio. • Evaluates 3 major physical findings. • It is a brief and condensed exam. • Minimizes prehospital delays. • Enables prearrival notification of the receiving facility. Cincinnati Prehospital Stroke Scale • Evaluates: – Facial Droop – Motor Arm Weakness/Arm Drift – Speech Abnormalities Cincinnati Prehospital Stroke Scale • Brief exam. Can be accomplished in 60 seconds or less. • Does not require any special equipment to perform the exam. • Simple exam which is scored as either: – Normal – Abnormal Areas Assessed • Facial Droop: Have patient show teeth or smile. – Normal: Both sides of the face move equally well with no droop noted. – Abnormal: One side of face does not move as well as the other side. Areas Assessed • Arm Drift: Have patient close eyes and hold out both arms in front of them. – Normal: Both arms move the same or both arms do not move from their extended position. – Abnormal: One arm does not move or one arm drifts down compared with the other. Areas Assessed • Speech: Have the patient say “you can’t teach an old dog new tricks.” – Normal: Patient uses correct words with no slurring. – Abnormal: Patient slurs words, uses inappropriate words, or is unable to speak. Cincinnati Prehospital Stroke Scale Any abnormal score, in any of the three areas assessed are considered positive for Acute Stroke or TIA. Los Angeles Prehospital Stroke Screen (LAPSS) Los Angeles Prehospital Stroke Screen (LAPSS) • More detailed than the Cincinnati Prehospital Stroke Scale. • Statistically more likely to diagnose a stroke. • 3 to 7% likelihood that a patient may be suffering a Stroke/TIA even if ruled out by LAPSS. • Requires that blood glucose monitoring or dextrostix be performed as part of the assessment. Los Angeles Prehospital Stroke Screen (LAPSS) • Evaluates: – Age – History of Seizures/Epilepsy – Duration of Symptoms – Evaluation of Status before Symptom Onset – Glucose Level – Physical Assessment Los Angeles Prehospital Stroke Screen (LAPSS) • Age < 45 Years Old – Yes – No – Unknown Los Angeles Prehospital Stroke Screen (LAPSS) • History of Seizures or Epilepsy ABSENT – Yes – No – Unknown Los Angeles Prehospital Stroke Screen (LAPSS) • Symptom Duration < 24 Hours – Yes – No – Unknown Los Angeles Prehospital Stroke Screen (LAPSS) • At baseline, Patient is NOT wheelchair bound or bedridden. – Yes – No – Unknown Los Angeles Prehospital Stroke Screen (LAPSS) • Blood Glucose between 60 and 400mg%dL – Yes – No – Unknown Los Angeles Prehospital Stroke Screen (LAPSS) • Facial Smile/Grimace: – Equal or R/L sided facial droop • Grip – R/L sided weak grip or no grip • Arm Strength – R/L sided downward drift Los Angeles Prehospital Stroke Screen (LAPSS) Patients are considered positive for Stroke/TIA if they score a Yes or Unknown on the first 5 categories and have a deficit on any portion of the physical assessment. Key Components of Prehospital Treatment for Stroke/TIA Victims Prehospital Treatment • Airway Management – At risk for apnea – At risk for aspiration • Oxygen Therapy • Shock Management – Hypotension is very detrimental for victims of Stroke • Prevention of Injury – Patients are risk for injury since they may have decreased sensation and motor function in effected extremities Prehospital Treatment • Short Scene Times – With the exception of the previously mentioned treatments, Strokes are best cared for in a hospital. Decrease scene times when appropriate. – Care at the Appropriate Facility – Some patients who suffer Strokes may benefit from clot busting drugs. They must be given during a very short window of time following onset of symptoms. Other patients may benefit from surgical intervention. This requires that a patient be transported to a facility which can perform Neurological Surgery. One Very Important Factor Many of the therapies that are employed in the treatment of Stroke Victims are time sensitive. We as EMS personnel must try to isolate the time of onset of symptoms. If a patient awakens with symptoms or is found unresponsive Physicians will assume that the symptoms occurred when they first went to bed or when they were last seen. Stroke Treatment Stroke victims will benefit most by an organized system of assessment and treatment. EMS and Hospitals must work together for the patient to receive the best possible care.
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