Part 9: Adult Stroke / V-113 Facial D 1. The Cincinnati Prehospital Stroke Scale providers should support cardiopulmonary function, monitor Droop(have patient show teeth or smile): neurologic status, and if authorized by medical control, check Normahboth sides of face move equally Abnormak-one side of face does not move as well as the other side Patients with acute stroke are at risk for respiratory ompromise from aspiration, upper airway obstruction, hy Left: normal. Right: stroke patient with facial droop(right side of face Kothari R, et al. Acad Emerg Med. 1997; 4: 986-990 poventilation, and (rarely) neurogenic pulmonary edema. The combination of poor perfusion and hypoxemia will exacer bate and extend ischemic brain injury and it has been associated with worse outcome from stroke. 38 Although one small randomized clinical trial (LoE 2)39 of selected stroke patients suggested a transient improvement in clinical deficit and mri abnormalities following 8 hours of high-flow (by face mask ), a laI randomized trial (oe 3) 0 did not show any clinical benefit from routine administration of low-flow (3 L/min)oxygen for 24 hours to all patients with ischemic stroke. In contrast, the administration of supplementary oxygen to the subset of stroke patients who are hypoxemic is indirectly supported by several studies showing improved functional outcomes and survival of stroke patients treated in dedicated stroke units in which higher supplementary oxygen concentrations were Arm Drift(patient closes eyes and holds both arms straight out for 10 used(LOE7).38.394142 Both out-of-hospital and in-hospital medical Normakboth arms move the same or both arms do not move at all should administer supplementary oxygen to hypoxemic (ie, (other findings, such as pronator drift, may be helpful oxygen saturation <92%0) stroke patients( Class I)or those e Abnormakone arm does not move or one arm drifts down compared with unknown oxygen saturation. Clinicians may consider th the other giving oxygen to patients who are not hypoxemic(Class llb) Abnormal Speech(have the patient say"you can't teach an old dog The role of stroke centers and stroke units continues to be new tricks") debated.43 Initial evidence44-50 indicated a favorable benefit from triage of stroke patients directly to designated stroke Abnormal-patient slurs words, uses the wrong words, or is unable to centers(Class IIb), but the concept of routine out-of-hospital speak triage of stroke patients requires more rigorous evaluation. Interpretation: If any 1 of these 3 signs is abnormal, the probability of a Each receiving hospital should define its capability for stroke is 72%% treating patients with acute stroke and should communica this information to the EMS system and the community. With standard training in stroke recognition, paramedics Although not every hospital is capable of organizing the ing patients with stroke. 31,34,35 After training in using a stroke evel ry hospital with an ED should have a written plan assessment tool, paramedic sensitivity for identifying patients describing how patients with acute stroke are to be managed with stroke increased to 86% to 97%(Loe 3 to 5).33.36,37 in that institution. The plan should detail the roles of Therefore, all paramedics and emergency medical healthcare professionals in the care of patients with acute technicians-basic (EMT-basic) should be trained in the rec- stroke and define which patients will be treated with fibrino- ognition of stroke using a validated, abbreviated out-of- lytic therapy at that facility and when transfer to another hospital screening tool, such as the CPSS or the LAPSS hospital with a dedicated stroke unit is appropriate( Class lla) (Class Ila) Multiple randomized clinical trials and meta-analyses Transport and Care year survival rate, functional outcomes, and quality of life Once EMS providers suspect the diagnosis of stroke, they when patients hospitalized with acute stroke are cared for in should establish the time of onset of symptoms. This time a dedicated stroke unit by a multidisciplinary team experi- represents time zero for the patient. If the patient wakes from enced in managing stroke. Although the studies reported were sleep or is found with symptoms of a stroke, time zero is the conducted outside the United States in in-hospital units that last time the patient was observed to be normal. EMs provided both acute care and rehabilitation, the improved roviders must rapidly deliver the patient to a medical facility outcomes were apparent very early in the stroke care. These capable of providing acute stroke care and provide prearrival results should be relevant to the outcome of dedicated stroke notification to the receiving facility. 25 units staffed with experienced multidisciplinary teams in the EMS providers should consider transporting a witness, United States. When such a facility is available within a family member, or caregiver with the patient to verify the reasonable transport interval, stroke time of onset of stroke symptoms. En route to the facility hospitalization should be admitted there( Class D)With standard training in stroke recognition, paramedics have demonstrated a sensitivity of 61% to 66% for identify￾ing patients with stroke.31,34,35 After training in using a stroke assessment tool, paramedic sensitivity for identifying patients with stroke increased to 86% to 97% (LOE 3 to 5).33,36,37 Therefore, all paramedics and emergency medical technicians-basic (EMT-basic) should be trained in the rec￾ognition of stroke using a validated, abbreviated out-of￾hospital screening tool, such as the CPSS or the LAPSS (Class IIa). Transport and Care Once EMS providers suspect the diagnosis of stroke, they should establish the time of onset of symptoms. This time represents time zero for the patient. If the patient wakes from sleep or is found with symptoms of a stroke, time zero is the last time the patient was observed to be normal. EMS providers must rapidly deliver the patient to a medical facility capable of providing acute stroke care and provide prearrival notification to the receiving facility.25 EMS providers should consider transporting a witness, family member, or caregiver with the patient to verify the time of onset of stroke symptoms. En route to the facility providers should support cardiopulmonary function, monitor neurologic status, and if authorized by medical control, check blood glucose. Patients with acute stroke are at risk for respiratory compromise from aspiration, upper airway obstruction, hy￾poventilation, and (rarely) neurogenic pulmonary edema. The combination of poor perfusion and hypoxemia will exacer￾bate and extend ischemic brain injury, and it has been associated with worse outcome from stroke.38 Although one small randomized clinical trial (LOE 2)39 of selected stroke patients suggested a transient improvement in clinical deficit and MRI abnormalities following 8 hours of high-flow supplementary oxygen (by face mask), a larger quasi￾randomized trial (LOE 3)40 did not show any clinical benefit from routine administration of low-flow (3 L/min) oxygen for 24 hours to all patients with ischemic stroke. In contrast, the administration of supplementary oxygen to the subset of stroke patients who are hypoxemic is indirectly supported by several studies showing improved functional outcomes and survival of stroke patients treated in dedicated stroke units in which higher supplementary oxygen concentrations were used (LOE 7).38,39,41,42 Both out-of-hospital and in-hospital medical personnel should administer supplementary oxygen to hypoxemic (ie, oxygen saturation
92%) stroke patients (Class I) or those with unknown oxygen saturation. Clinicians may consider giving oxygen to patients who are not hypoxemic (Class IIb). The role of stroke centers and stroke units continues to be debated.43 Initial evidence44 –50 indicated a favorable benefit from triage of stroke patients directly to designated stroke centers (Class IIb), but the concept of routine out-of-hospital triage of stroke patients requires more rigorous evaluation. Each receiving hospital should define its capability for treating patients with acute stroke and should communicate this information to the EMS system and the community. Although not every hospital is capable of organizing the necessary resources to safely administer fibrinolytic therapy, every hospital with an ED should have a written plan describing how patients with acute stroke are to be managed in that institution. The plan should detail the roles of healthcare professionals in the care of patients with acute stroke and define which patients will be treated with fibrino￾lytic therapy at that facility and when transfer to another hospital with a dedicated stroke unit is appropriate (Class IIa). Multiple randomized clinical trials and meta-analyses in adults (LOE 1)51–54 document consistent improvement in 1-year survival rate, functional outcomes, and quality of life when patients hospitalized with acute stroke are cared for in a dedicated stroke unit by a multidisciplinary team experi￾enced in managing stroke. Although the studies reported were conducted outside the United States in in-hospital units that provided both acute care and rehabilitation, the improved outcomes were apparent very early in the stroke care. These results should be relevant to the outcome of dedicated stroke units staffed with experienced multidisciplinary teams in the United States. When such a facility is available within a reasonable transport interval, stroke patients who require hospitalization should be admitted there (Class I). TABLE 1. The Cincinnati Prehospital Stroke Scale Facial Droop (have patient show teeth or smile): ● Normal— both sides of face move equally ● Abnormal— one side of face does not move as well as the other side Left: normal. Right: stroke patient with facial droop (right side of face). Kothari R, et al. Acad Emerg Med. 1997;4:986 –990. Arm Drift (patient closes eyes and holds both arms straight out for 10 seconds): ● Normal— both arms move the same or both arms do not move at all (other findings, such as pronator drift, may be helpful) ● Abnormal— one arm does not move or one arm drifts down compared with the other Abnormal 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 the wrong words, or is unable to speak Interpretation: If any 1 of these 3 signs is abnormal, the probability of a stroke is 72%. Part 9: Adult Stroke IV-113