Pre-Hospital Stroke Care

The UC Division of EMS has recorded a series of podcasts to celebrate EMS Week 2016.  We are honored to be able to engage EMS Providers throughout the world with this forum.  If you practice pre-hospital medicine, we would like to say thank you and that we appreciate everything you do to provide a high level of care to ill and injured patients in a wide variety of austere environments.  For this podcast, we were joined by UC Air Care Flight Physicians Dr. Bill Hinckley, Air Care Medical Director, and Dr. Andrew Latimer, Air Care Resident Assistant Medical Director, to talk about EMS Stroke Care

Pre-hospital stroke care begins with a quick, simple assessment tool used to help identify patients that are suffering a stroke.  In Southwest Ohio, this tool is the Cincinnati Pre-hospital Stroke Scale (CPSS).  There are three simple components of the CPSS – facial droop, arm drift, and slurred speech.  When assessing for facial droop, it is best to ask patients to bear their teeth.  Arm drift is assessed by asking the patient to hold both arms outstretched in front of them with their palms facing up.  If one arm drifts down or one hand rotates to a palm-down position, this aspect of the scale is positive.  Lastly, ask the patient to repeat a sentence to assess for slurred speech or any other type of speech abnormality.

When a stroke is identified, the EMS provider then must make a decision on transport destination.  This is an area that could see some significant change in the next few years as studies are ongoing to validate tools that will help the EMS provider classify the severity of a stroke.  More severe strokes are typically identified as those caused by a large vessel occlusion, or LVO.  Strokes caused by LVO are managed better at a Comprehensive Stroke Center as opposed to a Primary Stroke Center.  LVO strokes typically don’t do as well when managed by tPA, as is likely to occur at a Primary Stroke Center.  LVO strokes commonly require more advanced care, such as mechanical thrombectomy, that is more commonly performed at a Comprehensive Stroke Center.  Until a specific assessment tool is validated for pre-hospital use, providers should consider transporting patients with obvious stroke symptoms, such as complete hemiparesis or gaze deviation, to a Comprehensive Stroke Center.  If it is not reasonable to transport such a patient by ground, consideration of air medical transport may be reasonable.  But, providers should resist the temptation to utilize a HEMS service for the suspected stroke patient that is not exhibiting obvious, severe, signs and symptoms.  Often times, these patients fall outside the treatment window for tPA or turn out to not be having a stroke.  For this reason, the risk of air medical transport does not outweigh the benefit for patients without obvious LVO stroke symptoms. 

Pre-hospital management of the stroke patient is, however, time dependent.  Clear identification of the last-known-well time is critical to the long term care the patient will receive It is important to note that last-known-well is not the same as symptom onset.  Providers must be vigilant to determine when the stroke victim was last seen as their normal self by family members or bystanders. 

Other EMS management priorities include: a pre-arrival notification call, ECG acquisition, vital signs, and blood glucose determination.  Providers should also attempt to obtain IV access with a 20 gauge angiocatheter, or larger, in the patient’s right AC.  This will help facilitate the acquisition of a CT angiogram once patient care is transferred to the hospital staff.  It is also important to realize that ischemic stroke patients often times do not need definitive airway management.  In fact, paralytics and sedatives that are typically administered to the intubated patient may hinder the neurologic exam performed at the hospital and may ultimately delay tPA administration or other definitive care.  Recognition, establishment of the last-known-well time, appropriate destination determination, and pre-arrival notification are the key tenets of pre-hospital stroke care. 

Written by: Joshua Borkosky, BS, FP-C, EMSI