LCEMS Stroke Update

1. Leon County EMS

2. Objectives:
• Identify the different causes and types of stroke.
• Assess stroke patients using the Cincinnati Prehospital Stroke Scale (CPSS) and
Rapid Arterial Occlusion Evaluation (RACE) scale.
• Understand the differences between a Primary and Comprehensive stroke
center.
• Identify the Primary and Comprehensive Stroke Centers in the region.
• Utilize the results of the CPSS and RACE scales to formulate a treatment plan
and determine the appropriate receiving facility .

3. “Stroke is a "brain attack". It can happen to anyone at
any time. It occurs when blood flow to an area of brain is
cut off. When this happens, brain cells are deprived of
oxygen and begin to die. When brain cells die during a
stroke, abilities controlled by that area of the brain such
as memory and muscle control are lost.
How a person is affected by their stroke depends on
where the stroke occurs in the brain and how much the
brain is damaged. For example, someone who had a
small stroke may only have minor problems such as
temporary weakness of an arm or leg. People who have
larger strokes may be permanently paralyzed on one side
of their body or lose their ability to speak. Some people
recover completely from strokes, but more than 2/3 of
survivors will have some type of disability”
http://www.stroke.org/understand-stroke/what-stroke

4. Types of Stroke
“Ischemic Stroke:
Ischemic stroke occurs when a blood vessel carrying
blood to the brain is blocked by a blood clot. This causes blood
not to reach the brain. High blood pressure is the most
important risk factor for this type of stroke. Ischemic strokes
account for about 87% of all strokes. An ischemic stroke can
occur in two ways.”
• “Embolic stroke, a blood clot or plaque fragment forms somewhere in
the body (usually the heart) and travels to the brain. Once in the
brain, the clot travels to a blood vessel small enough to block its
passage. The clot lodges there, blocking the blood vessel and causing
a stroke. About 15% of embolic strokes occur in people with atrial
fibrillation (Afib). The medical word for this type of blood clot is
embolus.”
• “Thrombotic Stroke, occurs when a blood clot that forms inside one of
the arteries supplying blood to the brain. This type of stroke is usually
seen in people with high cholesterol levels and atherosclerosis. The
medical word for a clot that forms on a blood-vessel deposit is
thrombus.”

5. Thrombotic Stroke
Thrombotic Strokes can be broken down into two groups as well
• “Large Vessel Thrombosis
The most common form of thrombotic stroke (large vessel thrombosis) occurs in the brain’s larger
arteries. In most cases it is caused by long-term atherosclerosis in combination with rapid blood
clot formation. High cholesterol is a common risk factor for this type of stroke.”
• “Small Vessel Disease
Another form of thrombotic stroke happens when blood flow is blocked to a very small arterial
vessel (small vessel disease or lacunar infarction). Little is known about the causes of this type of
stroke, but it is closely linked to high blood pressure.”

6. Types of Stroke
Hemorrhagic Stroke:
“A hemorrhagic stroke is either a brain aneurysm burst or a
weakened blood vessel leak. Blood spills into or around the brain and creates
swelling and pressure, damaging cells and tissue in the brain. There are two
types of hemorrhagic stroke called intracerebal and subarachnoid.”
Intracerebal Hemorrhage:
“The most common hemorrhagic stroke happens when a blood vessel inside the brain bursts and
leaks blood into surrounding brain tissue (intracerebal hemorrhage). The bleeding causes brain cells
to die and the affected part of the brain stops working correctly. High blood pressure and aging blood
vessels are the most common causes of this type of stroke. Sometimes intracerebral hemorrhagic
stroke can be caused by an arteriovenous malformation (AVM). AVM is a genetic condition of
abnormal connection between arteries and veins and most often occurs in the brain or spine. If AVM
occurs in the brain, vessels can break and bleed into the brain. The cause of AVM is unclear but once
diagnosed it can be treated successfully.”
Subarachnoid Hemorrhage:
“A Subarachnoid Hemorrhage stroke involves bleeding in the area between the brain and the tissue
covering the brain, known as the subarachnoid space. This type of stroke is most often caused by a
burst aneurysm. “

7. Stroke Assessment:
Quick and correct identification of stroke patient is one of the most important
interventions provided in the prehospital setting.
When stroke is suspected an onset of symptoms is a crucial factor in treating
ischemic strokes. A slight terminology change accompanies this update as well,
instead of “Last Seen Normal” use “Last Time Known Well”. Remember to Clearly
Document a “Last Time Known Well” or LTKW in the EPCR.
If the onset of symptoms is less than 6 hours notify dispatch of a “Stroke Alert” and
restate this during your radio report to the facility. Please also include symptoms and
a RACE scale in your radio report.

8. Beware of Mimics:
Remember that other conditions can mimic symptoms of a stroke and should be
considered during a stroke assessment!
• Hypoglycemia (Always Check a Suspected Stroke Patient’s Glucose).
• Drug Overdose.
• Hypoxia.
• Todd’s Paralysis.
• And others
“Todd's paralysis is a neurological condition characterized by a brief period of
transient (temporary) paralysis following a seizure. The paralysis - which may be
partial or complete - generally occurs on one side of the body and usually
subsides completely within 48 hours. Todd's paralysis may also affect speech or
vision. The cause is not known. Remember to consider possible seizure activity
in your stroke assessment and relay this information the receiving facility.”

9. Assessing the Stroke Patient
The initial exam performed will be the CPSS
If any of the 3 criteria in the CPSS are found to be “Abnormal” the CPSS is
considered positive for stroke and should move to the RACE scale for further
assessment.

10. Assessing the Stroke Patient:
The Rapid Arterial Occlusion Evaluation (R.A.C.E.) is based on an abbreviated version
of the National Institutes of Health Stroke Scale (NIHSS), the “gold standard” for
evaluating stroke victims. The maximum score is 9 (not 11) because the evaluation of
the final two components is done based on the left or right side presentation, not
both simultaneously
Please Clearly Document the RACE Score in the Narrative Section of the EPCR

11. Assessing the Stroke Patient:
To clarify this assessment
If your patient is exhibiting symptoms (weakness or paralysis) on the RIGHT you will
complete
• Facial Palsy
• Arm Motor Function
• Leg Motor Function
• Head and Gaze Deviation
• Aphasia
If your patient is exhibiting symptoms (weakness or paralysis) on the LEFT you will
complete
• Facial Palsy
• Arm Motor Function
• Leg Motor Function
• Head and Gaze Deviation
• Agnosia

12. Assessing the Stroke Patient:
Comparing CPSS to RACE,
CPSS: Determines the presence of a stroke. 1 abnormal finding in the CPSS finds a
probability of stroke at 72%.
Race: Aids in determining the severity of a stroke and attempts to predict the presence
of a Large Vessel Occlusion in the event of an Ischemic Stroke. These particular patients
benefit from interventional neurosurgery that is available at Comprehensive Stroke
Center but not at Primary Stroke Center.

13. Assessing the Stroke Patient:
All patients with a score of 5 or greater on the RACE should be
transported to a Comprehensive Stroke Center.
This assessment tool should be considered the primary factor for determining patient
destination even above patient’s choice.

14. Primary Vs. Comprehensive Centers:
Primary:
• Patient care: Takes care of most cases of ischemic (blood vessel blockage) types of
stroke.
• Minimally invasive catheter procedures: Not available.
• Specialized ICU: No requirement for a separate intensive care for stroke patients.
• Neurosurgery: Access to neurosurgery within 2 hours.
• Patient transfers: Sends complex patients to a Comprehensive Stroke Center.

15. Primary Vs. Comprehensive Centers:
Comprehensive:
• Patient care: Cares for all types of stroke patients, (blood vessel blockage) including
bleeding (or hemorrhagic) strokes, such as those caused by brain aneurysms.
• Minimally invasive catheter procedures: 24/7 access to minimally invasive catheter
procedures to treat stroke.
• Specialized ICU: Dedicated neuroscience intensive care unit for unit stroke patients.
• Neurosurgery: On-site neurosurgical availability 24/7 with the ability to perform
complex neurovascular procedures, such as brain aneurysm clipping, vascular
malformation surgery and carotid endarterectomy.
• Patient transfers: Receives patients from Primary Stroke Centers.

16. Primary Vs. Comprehensive Centers:
So… When Caring for the Citizens or Visitors of Leon County
Patients with Suspected Stroke Greater that 6 hours (Patients suffering from a stroke that
are not “Stroke Alerts”) can go to either Primary or Comprehensive Centers
Patients with Suspected Stroke “Stroke Alerts” but a RACE of Less than 5 (No clear
evidence of Large Vessel Occlusion) can go to either primary or Comprehensive Centers
Patients with Suspected Stroke “Stroke Alerts” with a RACE of Greater than 5 Will Go To A
Comprehensive Center .
Local Centers
Primary
Capital Regional Medical Center
Comprehensive
Tallahassee Memorial Hospital (Main)

17. Summary:
To conclude, good assessment and identification, proper documentation and transition
at the most appropriate receiving facility will undoubtedly lead to the best possible
outcomes for these patients suffering from stroke.
All strokes must go to a Primary or Comprehensive Stroke Center
All Stroke Alerts with a RACE score of greater than 5 will go to a Comprehensive Stroke
Center if available.
Please keep reference material handy during the video that follows.

18. References:
http://www.epilepsy.com/connect/forums/living-epilepsy-adults/todds-paralysis
http://www.stroke.org/understand-stroke/what-stroke
https://www.ems1.com/mobile-healthcare/articles/3014604-Stroke-scales-10-things-
you-need-to-know-to-save-lives/
http://www.emsworld.com/video/12249915/race-stroke-assessment-for-prehospital-
providers