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Pre-Hospital Assessment of Stroke

Pre-Hospital Assessment of Stroke

A lot of time and effort has gone into educating the public over the last number of years in relation to cerebrovascular accident's (CVA's) or strokes, as they are more commonly known. From inclusion of a stroke module in the Pre-Hospital Emergency Care Council Cardiac First Response Programme and consequently the FETAC occupational first aid course. To the Irish Heart Foundation National Stroke Week [] (16th - 20th April 2012) which includes public awareness campaigns, tv and radio information,  to direct marketing of stroke awareness material to GP surgeries and primary health centres. As a result of a lot of hard work by lots of different organisations, people are becoming more aware of the sign and symptoms of stroke. 

Here are some facts in relation to stroke in Ireland:

Around 10,000 people will have a stroke in Ireland this year. Over 2,000 will die and thousands more will be left disabled. But a significant proportion of this death and disability is avoidable. By creating awareness about stroke we hope to lower these rates.

At least 15% of strokes are misdiagnosed – that’s over 1,500 cases a year.

Less than one in three acute hospitals has a stroke unit – if all hospitals admitting patients with acute stroke had a stroke unit we could save up to 500 lives a year.

Almost half of our acute hospitals cannot provide the life-saving clot buster treatment, also known as thrombolysis. Many hospitals that provide thrombolysis can only do so during office hours or on an intermittent basis.

Acute rehabilitation is recorded as being available to just one in four patients. Tens of thousands of people who return home or enter nursing homes after a stroke have to endure inadequate rehabilitation and support services.

But, did you know that there is more than one assessment available for the diagnosis of stroke? One source that we read listed 35 different methods of assessment for the diagnosis of stroke. The indicators for the different assessments were wide and varied. There are 3 different methods used "Pre-Hospital" for the diagnosis of stroke. 

The Cincinnati Prehospital Stroke Scale (FAST Assessment)

This is essentially the same FAST assessment that people have seen publicised over the last number of years. It involves carrying out 3 simple tests with the casualty. 

Face - Ask the casualty to give you a big smile or to show you their teeth. In normal conditions both sides of the face should move equally. In abnormal situations one side of their face not not rise as well as the other. One side of face of the casualty could also look like it has "drooped" or "fallen". Where you see this you should immediately consider that the person is having a stroke. 

Arms - Ask the casualty to straighten their arms and while doing that raise them to shoulder level. You can also do this for the casualty. Ask them to hold their arms in that position for a number of seconds. In a normal case the person will be able to hold their arms there without any movement or drift. In an abnormal case, one arm may move slower than the other. Or where you have brought their arms to that position one arm might immediately drift away from the position you left it in. Again, you should consider this a sign that the casualty is having a stroke. 

Speech - You should give the casualty a phrase to repeat. The phrase you give them should make them enunciate, i.e. movement of the face, tongue and lips. Such phrases could include; "You can't teach an old dog new tricks." or "The quick brown fox, jumps over the lazy dogs". in normal conditions the person should be able to repeat these without any mumbling or slurring. If they cannot you should consider that they are having a stroke. 

If any 1 of these 3 signs is abnormal, the probability of a stroke is 72%

Los Angeles Prehospital Stroke Scale (LAPSS)

 This assessment method involves a number of questions and a small physical examination. All the question had yes / no answers. 

The questions involved are:

  • Age over 45 years
  • No prior history of seizure disorder
  • New onset of neurologic symptoms in last 24 hours
  • Patient was ambulatory at baseline (prior to event)
  • Blood glucose between 60 and 400

The physical examination would involve looking at a casualtys facial smile, grip and arms. In all aspects the casualty could score normal, or if it was abnormal is could be attributed to an a particular side. e.g Facial Smile / grimace - droop (left), Grip - Normal, Arm Weakness - Falls Rapidly (right)

Facial smile / grimace:  droop

Grip: Weak Grip / No Grip

Arm weakness: Drifts Down / Falls Rapidly

The assessment would then ask "Based on exam, patient has only unilateral (and not bilateral) weakness" this was a yes or no question. 

If Yes (or unknown) to all items above LAPSS screening criteria met: Yes / No

If LAPSS criteria for stroke met, call receiving hospital with “CODE STROKE”, if not then return to the appropriate treatment protocol. (Note: the patient may still be experiencing a stroke if even if LAPSS criteria are not met.)

ABCD Score

Used to predict the risk of stroke during the first seven days after a TIA. Researchers found there to be over 30% risk of stroke in TIA patients with an 'ABCD score' of six, as compared to no strokes in those with a low ABCD score. Can be used in routine clinical practice to identify high-risk individuals who require emergency investigation and treatment.

ABCD Score
  Risk Factor Category Score
A Age of Patient Age >/= 60 1
Age < 60 0
B Blood pressure at assessment SBP > 140 or DBP >/= 90 1
Other 0
C Clinical Features presented with Unilateral weakness 2
Speech disturbance (no weakness) 1
Other 0
D Duration of TIA symptoms >/= 60 minutes 2
10-59 minutes 1
10 minutes 0
    TOTAL 6
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