Tessa Quinn
Stroke is a medical emergency that requires immediate attention and early recognition. In England and Wales, almost 90,000 people are hospitalized annually due to acute strokes, with a significant impact on their health and well-being. As such, pre-hospital stroke assessment and management are crucial to improving patient outcomes. This includes the use of stroke scales such as the commonly used Face, Arms, Speech, Time (FAST) test, which aids in the rapid identification of stroke patients and facilitates quick mobilization of stroke teams upon their arrival at the hospital. However, there are limitations to the available scales, especially in recognizing posterior circulation strokes. This highlights the need for further research to improve the diagnostic utility of pre-hospital assessments, ensuring timely and accurate stroke care.
| Characteristics | Values |
|---|---|
| Definition | The World Health Organization (WHO) defines a stroke as a 'clinical syndrome consisting of rapidly developing clinical signs of focal (or global in case of coma) disturbance of cerebral function lasting more than 24 hours or leading to death with no apparent cause other than a vascular origin' |
| Prevalence | In England and Wales, almost 90,000 individuals are hospitalized annually with an acute stroke, with 85% of these being ischemic, 10% due to primary hemorrhage, and 5% due to subarachnoid hemorrhage. |
| Mortality Rate | Stroke deaths account for 11% of all deaths. |
| Recurrence | The risk of a second stroke within 5 years is 26%, increasing to 39% by 10 years. |
| Impact | Currently, 900,000 people in England are living with the effects of a stroke, with 50% dependent on others for everyday activities. |
| Leading Cause | Stroke is the leading cause of disability in the UK. |
| Early Recognition | Early recognition, rapid transportation to a designated stroke center, and early activation of a stroke team are critical for successful stroke care. |
| Stroke Scales | Several stroke scales are available for early recognition and evaluation of stroke severity, including FAST, G-FAST, BE-FAST, NIHSS, and RACE. |
| Most Recommended Scale | The National Institutes of Health Stroke Scale (NIHSS) is the most recommended tool for evaluating stroke patients in hospital settings and has variants for emergency services. |
| Limitations of Scales | Current scales have limitations in recognizing certain signs and symptoms, especially in posterior circulation strokes, and may not differentiate between stroke subtypes, affecting clinical decision-making. |
| Standard Assessments | Standard assessments for suspected acute stroke include neurological examinations, monitoring vital signs, blood work, imaging, cardiovascular investigations, dysphagia screens, and seizure assessment. |
| Temperature Monitoring | Temperature should be routinely monitored and treated according to local protocols. |
| Oxygen Supplementation | Supplemental oxygen is not required for patients with normal oxygen saturation levels. |
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What You'll Learn
Recognising stroke symptoms
The "Face" assessment involves checking for facial weakness or drooping by asking the person to smile. An uneven smile or a drooping mouth or eye could indicate a stroke. For "Arms," check if the person can raise both arms; stroke patients may experience arm weakness, with one arm drifting downward. The "Speech" test checks for speech difficulties, such as slurred or strange speech, by asking the person to repeat a simple phrase.
Additionally, the "Time" element of the FAST test underscores the urgency of calling emergency services (e.g., 911, 999) immediately upon recognising any of the above symptoms. It is crucial to note the time when the symptoms first appeared, as this information guides healthcare providers in determining the best treatment. Every minute counts, as approximately 1.9 million brain cells die every minute a stroke goes untreated.
While the FAST test is a valuable tool, it primarily detects anterior circulation strokes. To enhance stroke recognition, particularly for posterior circulation strokes, modifications such as the G-FAST (Gaze, Face, Arms, Speech, Time) test have been proposed. Assessing gaze evaluation, balance (B), and eye (E) symptoms, as in the BE-FAST test, can improve the detection of posterior circulation strokes. Furthermore, the FAST-ED scale, which includes eye deviation and anosognosia/neglect, has shown higher predictive value for large vessel occlusion strokes.
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Prehospital transport strategies
Early Recognition and Activation of Stroke Teams
When Emergency Medical Services (EMS) identify a potential stroke patient, they play a vital role in reducing delays by promptly notifying the receiving hospital. This early notification allows for rapid mobilisation of the hospital's stroke team and ensures quick access to necessary scanning upon arrival. This early activation of stroke teams is a crucial step in improving stroke care.
Pre-Hospital Stroke Assessment Scales
Several stroke scales are available to aid in the early recognition and severity assessment of strokes in prehospital settings. The most commonly used tool is the Face, Arms, Speech, Time (FAST) test, which has been incorporated into standard ambulance report forms in the UK. FAST helps identify anterior circulation strokes and facilitates the administration of intravenous tissue plasminogen activator within 3 hours of acute stroke onset. However, it may miss posterior circulation strokes, so modifications like G-FAST (adding gaze evaluation) and BE-FAST (including balance and eye symptoms) have been suggested.
Choice of Transport Destination
It is essential to transport the patient to a designated stroke centre equipped to handle stroke cases. In cases where a hospital lacks acute stroke capabilities, local bypass protocols dictate that patients should be immediately transferred to the closest Level 3, 4, or 5 stroke centre. This ensures that patients receive the specialised care they need.
Monitoring and Stabilisation
During prehospital transport, paramedics play a crucial role in monitoring and stabilising the patient's condition. This includes monitoring vital signs, such as fluid status, temperature, and oxygen saturation, as well as managing elevated blood pressure, which requires caution and diligence in the first hours after stroke onset. Additionally, dysphagia screens and seizure assessments are essential components of prehospital care for stroke patients.
Patient Support and Education
The period immediately following a stroke can be frightening for patients, especially when they are faced with unfamiliar procedures like CT or MRI scans. Healthcare providers should offer support, validate the patient's feelings, and provide information about the scan process to help them through this experience. This aspect of prehospital transport strategies focuses on the psychological and emotional needs of the patient during this critical time.
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Stroke severity screening
The Face, Arms, Speech, Time (FAST) test is the most commonly used tool in pre-hospital settings for stroke recognition. It includes assessments for facial weakness, arm weakness, and speech disturbance, allowing paramedics to quickly identify stroke patients. However, the FAST test has limitations, particularly in detecting posterior circulation strokes, where it can miss over 70% of cases.
To address this, modifications of the FAST scale have been proposed, such as the Gaze, Face, Arms, Speech, Time (G-FAST) test, which includes an evaluation of gaze. For an even more comprehensive assessment, the BE-FAST test adds balance and eye symptoms to the FAST scale, improving the diagnosis of posterior circulation strokes. Another variation is the FAST-ED scale, which includes eye deviation and anosognosia/neglect, and has been found to be predictive of strokes related to large vessels.
The Los Angeles Prehospital Stroke Screen (LAPSS) is another widely recognised scale, with the highest sensitivity and specificity for confirming stroke diagnosis. The Cincinnati Prehospital Stroke Scale (CPSS) is also recognised, and both of these scales were used to derive the FAST test.
The National Institutes of Health Stroke Scale (NIHSS) is the most recommended tool for evaluating stroke patients in hospital settings and research. It involves a numerical scale to determine stroke severity, assessing neurological function and deficits through a checklist of questions and physical and mental tests. The NIHSS has two variants: the shortened version for Emergency Medical Services and the modified version.
While these scales provide a framework for stroke severity screening, ongoing research is needed to improve their diagnostic utility and address limitations, particularly in recognising specific stroke subtypes and ensuring proper training and validation.
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Stroke patient stabilisation
Stabilising a stroke patient begins with supporting their airway, breathing, and circulation (ABC). This is a critical step in the immediate general assessment and stabilisation of the patient. Once this is achieved, the patient should be given oxygen if they are hypoxemic.
The next steps involve obtaining IV access, running lab tests, and checking the patient's glucose levels. A neurological screening should also be performed, which includes a CT scan or MRI of the brain, and a 12-lead ECG. The stroke team should be activated during this time, and they will review the patient's history and establish a timeline of symptom onset.
The Face, Arms, Speech, Time (FAST) test is a commonly used tool for stroke recognition, especially in emergency settings. It includes assessments of facial weakness, arm weakness, and speech disturbance. The National Institutes of Health Stroke Scale (NIHSS) is another widely used tool, consisting of 15 evaluating segments that measure stroke severity.
The initial management of elevated blood pressure in acute stroke patients is an area of ongoing debate due to limited evidence. However, blood pressure recommendations emphasise caution and diligent monitoring, especially in the first few hours after stroke onset.
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Stroke scales and imaging
Stroke scales are useful in the routine clinical setting as they aid in improving diagnostic accuracy, determining the appropriateness of specific treatments, monitoring a patient's neurologic deficits, and predicting and gauging outcomes. Several stroke rating scales are available, each with its own advantages and limitations. The choice of scale depends on the specific needs and context of the patient and the healthcare setting.
The Face, Arms, Speech, Time (FAST) test is the most commonly used tool in prehospital settings for stroke recognition. It was designed to expedite the administration of intravenous tissue plasminogen activator to patients within 3 hours of acute stroke symptom onset. FAST includes three key elements: Facial Weakness, Arm Weakness, and Speech Disturbance. However, it has been noted that FAST may miss over 70% of patients with posterior circulation strokes. To address this limitation, modifications such as G-FAST (which includes gaze evaluation) and BE-FAST (which assesses balance and eye symptoms) have been proposed.
The Los Angeles Prehospital Stroke Screen has the highest sensitivity and specificity for confirming a stroke diagnosis. It has been validated in hospital trials, but studies have shown mixed results when applied by Emergency Medical Services (EMS) personnel. The Cincinnati Prehospital Stroke Scale (CPSS) is another established assessment, which the FAST test was derived from.
The National Institutes of Health Stroke Scale (NIHSS) is the most recommended tool for evaluating stroke patients in hospital settings and research. It is a numerical scale that assesses stroke severity by measuring neurological function and deficits. The NIHSS comprises 11 components that are summed to correlate with stroke severity. Modifications of the NIHSS have been proposed, such as the mNIHSS and sNIHSS, to simplify the scale and improve its applicability in prehospital settings and for posterior circulation strokes.
While stroke scales provide a structured framework for stroke assessment, imaging techniques such as transcranial ultrasonography can also aid in diagnosis and evaluation. Imaging techniques provide visual information about the brain, complementing the findings from stroke scales. Together, stroke scales and imaging techniques contribute to accurate and timely stroke assessment, enabling healthcare providers to make informed decisions about patient care.
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Frequently asked questions
Standard assessments include a neurological examination, monitoring of vital signs, blood work, imaging and cardiovascular investigations, dysphagia screens, and seizure assessment.
The FAST test, which stands for Face, Arms, Speech, Time, is the most commonly used tool for stroke recognition. It was created to expedite the administration of intravenous tissue plasminogen activator to patients within 3 hours of acute stroke symptom onset.
Currently available scales have limitations in recognizing signs and symptoms, especially in posterior circulation strokes. They are also unable to differentiate between stroke subtypes, which may affect clinical decision-making.
EMS often provide the first medical contact for stroke patients, so they play a crucial role in reducing delays in presentation and treatment. Reliable identification of stroke patients by EMS allows for early notification of hospitals, rapid mobilization of stroke teams, and prompt access to necessary scanning upon hospital arrival.
