Cardiac & Resuscitation, Columns, Commentary, Patient Care

Prehospital Assessment for Stroke Isn’t Perfect

Issue 5 and Volume 43.

Prehospital assessment tools for neurological deficits aren’t perfect

An approximately 30-year-old male answers the door to let you and your partner into the house you’ve been called to. Hank introduces himself and thanks you for coming, quickly adding that he’s concerned about his mother who’s “acting weird.”

Hank tells you he stopped by his mom’s house for lunch and found her using paper plates to heat food on the stove. He stopped her before the plate ignited. His mother seemed confused and so he called 9-1-1.

Patient Assessment

Margaret, Hank’s 53-year-old mother, appears to be in good health. She’s awake and her eyes track your approach. She greets you by saying “Hello” and after you ask how’s she’s feeling, she tells you, “I’m fine, just a little confused.”

Margaret denies having a medical history and says she doesn’t think she’s taking any medication. Hank interjects, telling you his mother has hypothyroidism and that she takes Synthroid (levothyroxine) to manage her condition.

When you ask Margaret what she was doing in the kitchen, she tells you she was cooking a grilled cheese sandwich in the skillet to have for lunch with her son.

Your physical exam finds the patient’s pulse is 80, blood pressure is 138/88 mmHg, and her respirations of 16 are uncompromised with a pulse oximeter reading of 98% on room air.

Margaret denies any complaint including headache, shortness of breath, chest pain or dizziness. Her blood glucose is 88 mg/dL, and both Margaret and her son deny any history of diabetes.

Following your protocols, you ask Margaret to extend both arms, palms up and hold them. She accomplishes this without arm drift, can smile without facial droop, and is able to accurately repeat, “You can’t teach an old dog new tricks.”

Margaret is hesitant to be transported to the hospital, preferring to stay home and rest, but changes her mind after prodding from Hank.

There are no changes on reassessment during transport, and you hand over her care to the ED staff upon arrival.

An emergency physician repeats the Cincinnati stroke assessment, with no change from prehospital findings. The physician then holds up a card with simple pictures and asks Margaret to identify the objects in the picture. She’s unable to identify all the objects. She’s also unable to read a series of simple phrases, despite being able to repeat phrases without difficulty.

The physician then orders a CT scan, and you later learn that Margaret was treated for a posterior fossa stroke.

Discussion

This case offers an interesting presentation for EMS. Providers considered common causes of confusion or altered mental status, such as hypotension, hypoxia and changes in glucose levels.

EMS assessed for possibility of stroke using the Cincinnati Prehospital Stroke Scale, but identified no deficits, such as unilateral weakness in the arms or face and slurred or incomprehensible speech.

Despite the proven efficacy of the Cincinnati Prehospital Stroke Scale, a small percentage of strokes will be missed when using this scale.1

Some strokes require additional assessment to be identified. The ED physician used components of the National Institute of Health (NIH) stroke scale, which not only includes a neuromuscular assessment, but patients also undergo a sensory ability assessment. This includes asking patients to read simple phrases and recognize common objects and situation. Although not conclusive, this additional assessment may offer early identification of cerebral vascular events.

Recent advancements in the treatment of patients experiencing a stroke now offer a great outlook for patient recovery.

Effective care and treatment relies largely on early recognition. The first recognition must come from family or bystanders, who must know to call 9-1-1 when they recognize the signs and symptoms of stroke. When EMS arrives, they must work quickly and thoroughly to identify the possibility of stroke. Reversible and identifiable causes of altered mental status, such as blood glucose, must be identified and corrected by EMS as they’re able.

Stroke should be considered as a possibility in any patient with altered neurologic function, regardless of age. In one study, EMS missed 25% of patients experiencing a stroke. This study also showed that use of a neurological assessment tool, such as the Cincinnati Prehospital Stroke Scale, correlates with a higher rate of stroke recognition.2

Conclusion

EMS providers must remember that even when neurologic deficits aren’t identified during their assessment, it doesn’t rule out the possibility of stroke.

Other tools, such as the NIH Stroke Scale, offer alternative ways to identify possible stroke victims. Once a stroke or possible stroke is identified, early notification to a stroke center or specialized receiving facility and rapid transport equates to better patient outcomes.

References

1. Zohrevandi B, Monsef Kasmaie V, Asadi P, et al. Diagnostic accuracy of Cincinnati pre-hospital stroke scale. Emerg (Tehran). 2015;3(3):95–98.

2. Oostema JA, Konen J, Chassee T, et al. Clinical predictors of accurate prehospital stroke recognition. Stroke. 2015;46(6):1513–1517.