Part 9: Adult stroke E ach year in the United States about 700 000 people of all Stroke Recognition and EMS Care ages suffer a new or repeat stroke. Approximately 158 000 of these people will die, making stroke the third Stroke Warning Signs eading cause of death in the United States . Many advances important because fibrinolytic treatment must be provided itation 3.4 For example, fibrinolytic therapy can limit the within a few hours of onset of symptoms.5. 12 Most strokes extent of neurologic damage from stroke and improve out- occur at home, and only half of all victims of acute stroke use EMS for transport to the hospital. 3-15 In addition, stroke come, but the time available for treatment is limited.5.b victims often deny or rationalize16 their symptoms. This can Healthcare provider velop systems to increase the efficiency and effectiveness of delay EMs access and treatment and result in increased stroke care 3 The "7 D's of Stroke Care"detection. dis- morbidity and mortality. Even high-risk patients fail to recognize the signs of a stroke. 6 Community and profes- patch, delivery, door(arrival and urgent triage in the emer- sional education is essential, I7 and it has successfully in gency department ED]), data, decision, and drug administra tion--highlight the major steps in diagnosis and treatment lytic therapy.19 creased the proportion of stroke victims treated with fibrino- This chapter sum the management of acute stroke The signs and symptoms of a stroke may be subtle. They in the adult patient. It summarizes out-of-hospital include sudden weakness or numbness of the face, arm, or leg, especially on one side of the body; sudden confusion, about the management of acute ischemic stroke, see the trouble speaking or understanding: sudden trouble seeing in AHA/American Stroke Association(ASA)guidelines for the one or both eyes; sudden trouble walking, dizziness, loss of management of acute ischemic stroke. 9 balance or coordination: or sudden severe headache with no Management goals EMS Dispatch The goal of stroke care is to minimize brain injury and maximize patient recovery. The AHA and AsA developed urrently <10% of patients with acute ischemic stroke are community-oriented"Stroke Chain of Survival"that links ultimately eligible for fibrinolytic therapy because they fail to actions to be taken by patients, family members, and health arrive at the receiving hospital within 3 hours of onset of care providers to maximize stroke recovery. These links are symptoms. 20-24 EMS systems must provide education and training to Rapid recognition and reaction to stroke warning signs minimize delays in prehospital dispatch, assessment, and Rapid emergency medical services(EMS ) dispatch transport. Emergency medical dispatchers must identify po Rapid EMS system transport and hospital prenotification tential stroke victims and provide high-priority dispatch to Rapid diagnosis and treatment in the hospital patients with possible stroke. EMS providers must be able to the initial support cardiopulmonary function, perform rapid stroke as The AHA ECC stroke guidelines focus on the initial sessment, establish time of onset of symptoms (or last time out-of-hospital and ED assessment and management of the the patient was known to be normal), triage and transport the patient with acute stroke as depicted in the algorithm Goals patient, and provide prearrival notification to the receiving for Management of Patients With Suspected Stroke(Figure). hospital(Box 2). 25-22 The time goals of the National Institute of Neurological Disorders and Stroke(NINDS) I are illustrated along the left Stroke assessment Tools side of the algorithm as clocks with a sweep hand depicting EMS providers can identify stroke patients with reasonable the goal in minutes from ED arrival to task completion to sensitivity and specificity, using abbreviated out-of-hospital remind the clinician of the time-sensitive nature of manage- tools such as the Cincinnati Prehospital Stroke Scale ment of acute ischemic stroke (CPSS)7,( Table 1)or the Los Angeles Prehospital The sections below summarize the principles and goals of Stroke Screen(LAPSS)(Table 2). 32.33 The CPSS is based or stroke assessment and management, highlighting key contro- physical examination only. The EMS provider checks for 3 ries, new recommendations, and training issues. The text physical findings: facial droop, arm weakness, and speech refers to the numbered boxes in the algorithm abnormalities. The presence of a single abnormality on the CPSS has a sensitivity of 59% and a specificity of 89% when scored by prehospital providers. 0 The LAPSS requires the (Circulation. 2005: 112: IV-1ll-IV-120) examiner to rule out other causes of altered level of con o 2005 American Heart Association sciousness(eg, history of seizures, hypoglycemia) and ther This special supplement to Circulation is freely available at identify asymmetry in any of 3 examination categories: facial smile or grimace, grip, and arm strength. The LAPSS has a DOI: 10.1161/CIRCULATIONAHA. 105.166562 pecificity of 97% and a sensitivity of 93% IV-IlIPart 9: Adult Stroke Each year in the United States about 700 000 people of all ages suffer a new or repeat stroke. Approximately 158 000 of these people will die, making stroke the third leading cause of death in the United States.1,2 Many advances have been made in stroke prevention, treatment, and rehabil￾itation.3,4 For example, fibrinolytic therapy can limit the extent of neurologic damage from stroke and improve out￾come, but the time available for treatment is limited.5,6 Healthcare providers, hospitals, and communities must de￾velop systems to increase the efficiency and effectiveness of stroke care.3 The “7 D’s of Stroke Care”— detection, dis￾patch, delivery, door (arrival and urgent triage in the emer￾gency department [ED]), data, decision, and drug administra￾tion— highlight the major steps in diagnosis and treatment and the key points at which delays can occur.7,8 This chapter summarizes the management of acute stroke in the adult patient. It summarizes out-of-hospital care through the first hours of therapy. For additional information about the management of acute ischemic stroke, see the AHA/American Stroke Association (ASA) guidelines for the management of acute ischemic stroke.9,10 Management Goals The goal of stroke care is to minimize brain injury and maximize patient recovery. The AHA and ASA developed a community-oriented “Stroke Chain of Survival” that links actions to be taken by patients, family members, and health￾care providers to maximize stroke recovery. These links are ● Rapid recognition and reaction to stroke warning signs ● Rapid emergency medical services (EMS) dispatch ● Rapid EMS system transport and hospital prenotification ● Rapid diagnosis and treatment in the hospital The AHA ECC stroke guidelines focus on the initial out-of-hospital and ED assessment and management of the patient with acute stroke as depicted in the algorithm Goals for Management of Patients With Suspected Stroke (Figure). The time goals of the National Institute of Neurological Disorders and Stroke (NINDS)11 are illustrated along the left side of the algorithm as clocks with a sweep hand depicting the goal in minutes from ED arrival to task completion to remind the clinician of the time-sensitive nature of manage￾ment of acute ischemic stroke. The sections below summarize the principles and goals of stroke assessment and management, highlighting key contro￾versies, new recommendations, and training issues. The text refers to the numbered boxes in the algorithm. Stroke Recognition and EMS Care Stroke Warning Signs Identifying clinical signs of possible stroke (Box 1) is important because fibrinolytic treatment must be provided within a few hours of onset of symptoms.5,12 Most strokes occur at home, and only half of all victims of acute stroke use EMS for transport to the hospital.13–15 In addition, stroke victims often deny or rationalize16 their symptoms. This can delay EMS access and treatment and result in increased morbidity and mortality. Even high-risk patients fail to recognize the signs of a stroke.16 Community and profes￾sional education is essential,17 and it has successfully in￾creased the proportion of stroke victims treated with fibrino￾lytic therapy.18,19 The signs and symptoms of a stroke may be subtle. They include sudden weakness or numbness of the face, arm, or leg, especially on one side of the body; sudden confusion, trouble speaking or understanding; sudden trouble seeing in one or both eyes; sudden trouble walking, dizziness, loss of balance or coordination; or sudden severe headache with no known cause. EMS Dispatch Currently
10% of patients with acute ischemic stroke are ultimately eligible for fibrinolytic therapy because they fail to arrive at the receiving hospital within 3 hours of onset of symptoms.20 –24 EMS systems must provide education and training to minimize delays in prehospital dispatch, assessment, and transport. Emergency medical dispatchers must identify po￾tential stroke victims and provide high-priority dispatch to patients with possible stroke. EMS providers must be able to support cardiopulmonary function, perform rapid stroke as￾sessment, establish time of onset of symptoms (or last time the patient was known to be normal), triage and transport the patient, and provide prearrival notification to the receiving hospital (Box 2).25–28 Stroke Assessment Tools EMS providers can identify stroke patients with reasonable sensitivity and specificity, using abbreviated out-of-hospital tools such as the Cincinnati Prehospital Stroke Scale (CPSS)27,29 –31 (Table 1) or the Los Angeles Prehospital Stroke Screen (LAPSS) (Table 2).32,33 The CPSS is based on physical examination only. The EMS provider checks for 3 physical findings: facial droop, arm weakness, and speech abnormalities. The presence of a single abnormality on the CPSS has a sensitivity of 59% and a specificity of 89% when scored by prehospital providers.30 The LAPSS requires the examiner to rule out other causes of altered level of con￾sciousness (eg, history of seizures, hypoglycemia) and then identify asymmetry in any of 3 examination categories: facial smile or grimace, grip, and arm strength. The LAPSS has a specificity of 97% and a sensitivity of 93%.32,33 (Circulation. 2005;112:IV-111-IV-120.) © 2005 American Heart Association. This special supplement to Circulation is freely available at http://www.circulationaha.org DOI: 10.1161/CIRCULATIONAHA.105.166562 IV-111