R apid A rterial o C clusion E valuation created by SCD DHEC Bureau of EMS History Historical Context EMS is the first medical contact in over 50 of all stroke victims in US Unless the patient had altered LOC strokes were treated as nonemergent events and transported routine ID: 1033727
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1. Stroke by the numbersSouth Carolina Stroke RACERapid Arterial oCclusion Evaluationcreated by SCD DHEC Bureau of EMSHistory
2. Historical ContextEMS is the first medical contact in over 50% of all stroke victims in U.S.Unless the patient had altered LOC, strokes were treated as non-emergent events and transported routine to ER Prehospital care seen only as supportive and permanent disability was seen as inevitable, much like cardiac arrest in the 70’sTypically Cincinnati Stroke Scale used to confirm stoke eventMEND and NIHSS taught in school but rarely used in field EMS & StrokesSystem
3. Stroke Care in South CarolinaSouth Carolina now has the third best “door to balloon” time for STEMI care in the United States.1No reason why stroke care should not follow suitCurrently there are 21 designated stroke centers in South Carolina: HFAP – 1, DNV – 2 TJC – 18Most EMS services have adopted State Stroke Protocol: “The Reperfusion Checklist should be completed for any suspected stroke patient. With a duration of symptoms of less than 8 hours, scene times should be limited to 10 minutes, early destination notification / activation should be provided and transport times should be minimized based on the EMS System Stroke Plan.”(1) SCHA, 2013How we work
4. How we have to do business at BEMSPOLICIES / PROCEDURES - EMT manuals, protocols, formularyREGULATION 61-7, 61-96, 61-116STATUTE 44-61 series – Articles – 1, 3, 5, 6, etc
5. What the Law says….(5) It is also in the best interest of the people of South Carolina to modify the state's emergency medical response system to ensure that potential stroke patients are quickly identified and transported to and treated in facilities that have the capability for providing timely and effective treatment for stroke patients.(B) The department, in consultation with the Stroke System of Care Advisory Council, shall adopt and distribute a nationally recognized, standardized stroke-triage assessment tool. The department must post the stroke-triage assessment tool on its website and provide a copy, which may be an electronic copy, of the stroke-triage assessment tool to each licensed emergency medical services provider before January 31, 2012. Each licensed emergency medical services provider must establish a stroke assessment and triage system that incorporates the department approved stroke-triage assessment tool.Your text heretime
6. Time ContextGreatest portion of delay between onset of symptoms and emergency care is the time it takes for a patient to recognize the signs of stroke and decide to seek medical attention.Between 50-75% of ischemic stroke patients do not arrive at hospital within 3-hours.Value of early identifying an LVO in the field and pre-notifying the stroke centerEMS & StrokesCriteria
7. What criteria do we use / need?Following the model and success of STEMI care in the field, (TIME =Cardiac muscle) prehospital pre-notification is essential to advance stroke care since (TIME = Brain)There are many developed stroke scale models available for field use. Most used by EMS only capture sensitivity for + or – to rule in/out a strokeEarly detection of LVO (or ELVO) is as essential to stroke care as ST elevation to STEMIsQualitative Score (+/-) vs. Quantitative Score (# value)NIHSS is the “gold standard” by which all stroke scales are based. Need for a quantitative SS that has been validated with EMS data and is correlated to the NIHSS (“gold standard”) that can detect an LVO.12
8. “We need a 12 Lead for your head”
9. For the Record…
10. Stroke by the NumbersStroke Scale ItemsNIHSSCPSSFASTFAST -EDzNIHSSsNIHSS5sNIHSS8MENDSLAPSSLAMSMENSAVPURACELOCXXXXXLOC QuestionsXXXLOC CommandsXXXXXXGazeXXXXXXXXVisual FieldsXXXXXXFacial PalsyXXXXXXXMotor Arm Drift LeftXXXXXXXXMotor Arm Drift RightXXXXXXXXMotor Leg Drift LeftXXXXXXMotor Leg Drift RightXXXXXXLimb AtaxiaXXSensoryXXLanguageXXXXXXXDysarthriaXXXXXXXExtinctionXXXGripX
11. Stroke by the NumbersStroke Scale ItemsNIHSSCPSSFASTFAST -EDzNIHSSsNIHSS5sNIHSS8MENDSLAPSSLAMSMENSAVPURACELOCXXXXXLOC QuestionsXXXLOC CommandsXXXXXXGazeXXXXXXXXVisual FieldsXXXXXXFacial PalsyXXXXXXXMotor Arm Drift LeftXXXXXXXXMotor Arm Drift RightXXXXXXXXMotor Leg Drift LeftXXXXXXMotor Leg Drift RightXXXXXXLimb AtaxiaXXSensoryXXLanguageXXXXXXXDysarthriaXXXXXXXExtinctionXXXGripX
12. Stroke by the NumbersStroke Scale ItemsNIHSSFASTEDzNIHSSsNIHSS5sNIHSS8LAMSMENSRACELOCXXXLOC QuestionsXLOC CommandsXXXGazeXXXXXXXVisual FieldsXXXXXFacial PalsyXXXXMotor Arm Drift LeftXXXXMotor Arm Drift RightXXXXMotor Leg Drift LeftXXXXXMotor Leg Drift RightXXXXXLimb AtaxiaXSensoryXLanguageXXXXXXXDysarthriaXXXXExtinctionXXGripXAll NIHSS-based scales validated from ED admission or ED presentation; not prehospital collected.RACE validated by EMS data.Perez, et al; 2014
13. RACE: Stroke by the NumbersThe Rapid Arterial oCclusion Evaluation (RACE) scale was designed based on the National Institutes of Health Stroke Scale (NIHSS) – the validated neuroscience “gold standard”It is a Quantitative Scale vs. Qualitative Scale More Objective (number value) vs. Less Subjective (+ or -)Cincinnati Stroke Scale , LAPSS, and MENDS are all QualitativeA scale based on the NIHSS that is more user-friendly for prehospital field usageRACE would allow the State to capture quantifiable data for research
14. RACE: Stroke by the NumbersThe Tirschwell et al study (Stroke. 2002;33:2801-2806) noted that sNIHSS-8 and sNIHSS-5 (shortened versions of the full NIHSS or NIHSS-15) retained the predictive ability (90-day outcomes) of the original NIHSS and could be of value for prehospital use.The Zandieh et al study (Clinical Neurology & Neurosurgery. 2012;10:034) developed an even shorter, parsimonious NIHSS-based tool with prehospital implications that was equally predictive (28-day mortality) as the original NIHSS.Pérez de la Ossa et al study (Stroke. 2014;45:87-91.) validated RACE and recommended it for prehospital care usage.Technically, the RACE is a mNIHSS-6.
15. RACEFacial Palsy None present = 0Mild = 1Moderate to Severe = 2Arm Motor FunctionNormal to Mild = 0Moderate = 1Severe = 2Leg Motor FunctionNormal to Mild = 0Moderate = 1Severe = 2SUBSCORE ____
16. RACEHead Gaze DeviationAbsent = 0Present = 1Aphasia* (if right side hemiparesis) Performs both tasks correctly = 0Performs 1 task correctly = 1Performs neither tasks = 2Agnosia † (if left side hemiparesis) Patient recognizes his/her arm and the impairment = 0Does not recognized his/her arm or the impairment = 1Does not recognized his/her arm nor the impairment = 2SUBSCORE ____* † see next slide for explanation
17. RACERACE is a 5 or 6 item scale based on the side of weakness* Aphasia (if right side hemiparesis) : Ask the patient and evaluate if the patient obeys. “Close your eyes” “Make a fist”† Agnosia (if left side hemiparesis): Ask the patient: while showing him/her the paretic arm: “Whose arm is this” and evaluate if the patient recognizes his own arm.“Can you lift both arms and clap” and evaluate if the patient recognizes his functional impairment.
18. RACE: Stroke by the Numbers Test ItemRACENIHSS EquivalentFacial Palsy0-10-3Arm Motor Function0-20-4Leg Motor Function0-20-4Head Gaze Deviation0-10-2Aphasia (R side)0-20-2Agnosia (L side)0-20-2https://www.youtube.com/watch?v=9Sx0pJueV50
19. RACE: Stroke by the NumbersThe cut-score value of RACE for recommendation to divert to a CSC is ≥4The global accuracy of the RACE for large vessel occlusion (LVO) is (c-statistic, 0.84; 95% Confidence Interval (CI), ρ = 0.79–0.89).RACE is comparable with NIHSS to predict LVO (c-statistic, 0.85; 95% CI, ρ = 0.81–0.89).RACE has a high sensitivity (89%) and specificity (55%) with a cutoff point of 4 for LVO. A sensitivity (85%) and specificity (65%) with a cutoff of 5 for LVO. Last
20. RACE: Stroke by the NumbersQuestions?
21. Stay in Tune with EMS !SCEMSPORTAL. ORG@SCEMS1WRONSKRA@DHEC.SC.GOVHAVE A GOOD EMAIL IN CIS !!!!