Stroke Identification (CVA)

[jack10562 414]

It is the third leading cause of death and the leading cause of adult disability in the United States and Europe.

Sometimes symptoms of a stroke are difficult to identify. Unfortunately, the lack of awareness spells disaster. The stroke victim may suffer severe brain damage when people nearby fail to recognize the symptoms of a stroke .

Now doctors say a bystander can recognize a stroke by asking three simple questions:

S * Ask the individual to SMILE.

T * Ask the person to TALK and SPEAK A SIMPLE SENTENCE (Coherently)

(i.e. It is sunny out today)

R * Ask him or her to RAISE BOTH ARMS.

NOTE: Another 'sign' of a stroke is this: Ask the person to 'stick' out his/her tongue..

If the tongue is 'crooked', if it goes to one side or the other , that is also an indication of a stroke.

If he or she has trouble with ANY ONE of these tasks, call 911 immediately and describe the symptoms to the dispatcher.

A neurologist says that if he can get to a stroke victim within 3 hours he can totally reverse the effects of a stroke... totally . He said the trick was getting a stroke recognized, diagnosed, and then getting the patient medically cared for within 3 hours, which is tough.

Thrombosis

[firemoose827 324]

Great post Jack. I am an "Old School" EMT that used to be a EMT-CC about 9 years ago. Recently I was at work in my PT job and we had a call for possible stroke. My medic partner, just recently certified 8 months ago, starts talking about a scale for stroke PT's, I believe he called it the "Cincinati Scale". Does anyone else know of this? Its new to me. I was trained to check for hemiparesis by asking the pt to squeeze my hands, and apply pressure with the feet, than check for facial droop. It has changed a lot since I was first certified and I would like to stay current.

This brings up a great topic, and Im glad you discussed it. Thanks Jack!!

Moose

[JohnnyOV 2]

Great post Jack. I am an "Old School" EMT that used to be a EMT-CC about 9 years ago. Recently I was at work in my PT job and we had a call for possible stroke. My medic partner, just recently certified 8 months ago, starts talking about a scale for stroke PT's, I believe he called it the "Cincinati Scale". Does anyone else know of this? Its new to me. I was trained to check for hemiparesis by asking the pt to squeeze my hands, and apply pressure with the feet, than check for facial droop. It has changed a lot since I was first certified and I would like to stay current.

This brings up a great topic, and Im glad you discussed it. Thanks Jack!!

Moose

google solves it all...

http://en.wikipedia.org/wiki/Cincinnati_Stroke_Scale

[firemoose827 324]

google solves it all...

http://en.wikipedia.org/wiki/Cincinnati_Stroke_Scale

Yah, but without people like me asking the questions, none of the members who are scared to ask will ever learn. Right?

I was trying to spark further discusion brother, thanks for the link though!

[Guest alsfirefighter]

Most providers in my area use the Cincinnati Stroke Scale.

A couple of other points/symptoms:

Gaze. Some patients will stare to one side and only be able to bring their eyes back to the center line for a few seconds and then go right back to the side they stare at which tends to be the injured side as well.

Always rule out hypoglycemia!

Also providers need to understand that recognition of a possible stroke is the most critical field skill in these cases. Rapid transport with a good assessment of timeline is key. That closer you are to the end of the 3 hour window, the less that can be done. The diagnostic testing and evaluation that has to be completed at the hospital also has to fall into that 3 hour window. I've seen several cases over the years where because of the timeline, the patient arrived at the hospital to close to the 3 hour window to get it all done and if they were in the window thrombolytics would have been an option and probably reversed most of the symptoms.

Many EMS systems by protocol treat stroke similiarly to that of a trauma case. GET THEM TO THE HOSPITAL! Oxygen does nothing, saline does nothing. Attempt any IV access for later hospital use while enroute and get a min. of an 18 ga. if possible.

[NYMedic37 22]

I had learned of the Cincinatti pre hospital stroke scale as follows:

F - Assess Facial droop

A - Asess Arm drift

S - Assess Speech

T - Determine Time that symptoms first occurred

Follow your protocols but basics such as airway control (suction. A lot of CVA patients lose control to swallow saliva and drool), High concentration oxygen, IVSL (large bore), monitor EKG & V/S continously, rapid transport to a stroke center with a notification of your Cincinatti Pre Hospital Stroke Scale results ahead of your arrival to the ER.

Remember - "Time is brain function" so don't delay transport.

Also consider, hypoglycemia, head trauma, cardiac insuffiency (poor perfusion to the brain), hypoxia, etc.

[firemoose827 324]

Great points. Also, remember to transport pt on their unaffected side, so they can maintain their airway on their own. Laying them on their backs could make their saliva pool in the paralysed side and therefore make them drown. Position them on the unaffected side, secure the bad arm with the strap, and make sure you have suction ready.

Make sure you position their faces aimed at your partner so if they vomit they get covered and not you!! (Kidding)

[Guest]

Speaking of F.A.ST. here's a link to a Public Service Announcement about stroke done by the MAssachusetts Department of Public Health- It's pretty good and educational too!

http://www.maclearinghouse.com/animations/Stroke.wmv

[irishfire2491 24]

Is Every Hosptial In Westchester County A Stroke Center Now??? and Is Puntam A Stroke Center??

[Guest]

Is Every Hosptial In Westchester County A Stroke Center Now??? and Is Puntam A Stroke Center??

Every 911 receiving hospital in Westchester except Dobbs Ferry are Stroke Centers. I don't know about Putnam.

[ny10570 745]

Just to add to what ALS said, most ER's need 30 min to an hour to complete their assessment. This includes the neurologist assessing the pt, which depending on how far away the Doc, is usually the big hang-up with the 3hr window. Also remember the clock begins when that pt was last seen as being normal. Wake up in the morning with signs and symptoms and the clock starts when the pt went to sleep.

[NWFDMedic 58]

Just to add to what ALS said, most ER's need 30 min to an hour to complete their assessment. This includes the neurologist assessing the pt, which depending on how far away the Doc, is usually the big hang-up with the 3hr window. Also remember the clock begins when that pt was last seen as being normal. Wake up in the morning with signs and symptoms and the clock starts when the pt went to sleep.

I believe at stroke centers, the ER doc is qualified to do the assessment for stroke thrombolytics. The only thing that needs to be done by a neurologist is confirmation of the CT scan, which is generally done by computer with a service that has 24 hour docs to read the scans.

The one interesting thing I've noticed from the Westchester medics here is that their protocol seems to include large bore IV access. We still have some doctors up here that say that they don't want IV catheters bigger than a 20 ga. in patients that are candidates for thromoblytics. We all understand it is relatively inconsequential, but I have had a couple of doctors give me an attitude about starting 18's.

Finally, I went to a CME last year and apparently a study was done that the CCS criteria will correctly identify a neurological insult (CVA or TIA) in 72% of the cases, assuming you rule out hypoglycemia (and I'd assume drug/alcohol influence). The Hudson Valley Region has a prehospital suspected stroke form that was supposed to be in all ALS rigs quite some time ago.

[NWFDMedic 58]

Every 911 receiving hospital in Westchester except Dobbs Ferry are Stroke Centers. I don't know about Putnam.

Putnam Hospital is a stroke center as of June 01, 2007 per the HVREMAC website.

[firemoose827 324]

For all of you up-staters like me, the only Stroke Facilities here are Albany Medical Center, Ellis Hospital, and Cooperstown Hospital....I believe. Could be more.

Anyone know of others up here?

[louis 1]

Great topic! all the information is perfect, but one problem. Some Volunteer organizations that have paramedic services sometimes delay transport until ALS arrives. As an EMT once we walk into the household and take baseline vitals, and make a determination. It's Load and go! Due the rest of the testing in the rig and notify the Hospital you have a possible CVA. Some EMTs go to the home due Vitals and wait for AlS. I don't know if it's lack of training or because their affrad to make a judgment so severe. EMT's have to be better trained and not wait for ALS to arrive

[Guest mediconpatrol]

DOH standard is door to ct result is 45 minutes so optimally they are looking at ER arrival to be within 2 hours of stroke symptom onset.

ALS is correct..if there is a deviation in gaze it will go toward the side of injury and weakness will be on the opposite side of injury.

Also....Hudson Valley Hospital is going to have a Stroke CME Conference on March 26..It is going to have 3 speakers...Paramedic educator, ER physcian and Neurologist....

It technically is a two part series...911 to discharge...

This is part one and it deals with prehopsital and ED care....