Stroke Thrombolysis Awareness. Initial patient assessment. Using F.A.S.T., Rosier, & NIHSS Tools

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Charla Casey
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1 Stroke Thrombolysis Awareness Initial patient assessment Using F.A.S.T., Rosier, & NIHSS Tools Adapted from 5 Acute Trusts - 6 Primary Care Trusts Ambulance Trust 4 Local Authorities

2 Aims Improve recognition of stroke and TIA Develop skills for assessment and triage in acute settings Gain familiarity with procedures required for thrombolysis

3 Background Information Incidence of stroke now higher than that of acute coronary syndromes For 1 million inhabitants, There will be 2400 strokes per year (1800 first ever, 600 recurrent or after TIA) Of these 700 (29%) will die 600 (25%) will be dependent 1100 (46%) will be independent

strokes per year (1800 first ever, 600 recurrent or after TIA) Of these

4 Background Information Stroke varies All begin suddenly ¼ patients do not leave hospital ⅓ survivors need help every day due to: Weakness Speech problems Swallowing problems Visual problems Memory problems Urgent recognition & stroke unit admission improves recovery

Weakness Speech problems Swallowing problems Visual problems

5 Initial Diagnosis

6 Clinical presentations of stroke Acute onset combination of Face / arm / leg weakness or sensory loss Loss of co-ordination Speech disturbance Visual disturbance Acute onset does not mean total deficit within seconds Most TIAs are < 20 minutes

co-ordination Speech disturbance Visual disturbance Acute

7 Stroke? ACT FAST National Stroke Strategy QM1, Raising Awareness, QM2 Time is Brain

8 F.A.S.T. Instructions FACIAL MOVEMENTS Ask patient to show teeth, Is there an unequal smile or grimace, Note which side does not move well ARM MOVEMENTS Lift the patient s arms together to 90º if sitting, 45º if supine and ask them to hold the position for 5 seconds before letting go, does one arm drift down or fall rapidly? If one arm drifts down or falls, note whether it is the patient s left or right SPEECH Listen for NEW disturbance of speech Listen for slurred speech, get patient to say British Constitution or Baby Hippopotamus Listen for word-finding difficulties with hesitations. This can be confirmed by asking the patient to name objects that may be nearby such as a cup, chair, table, keys, pen Check with any person who knows the patient, IS THIS NORMAL FOR THEM TIME to ring 999

if supine and ask them to hold the position for 5 seconds before letting go, does one arm drift down or fall rapidly?

9 ROSIER 1 st. Check Patient s B.M. and correct if low Score Yes No Has there been loss of consciousness or syncope? -1 0 Has there been seizure activity? -1 0 Has there been NEW ACUTE onset (including on wakening from sleep) of Asymmetric facial weakness +1 0 Asymmetric arm weakness +1 0 Asymmetric leg weakness +1 0 Speech disturbance +1 0 Visual field deficit +1 0

10 Sudden onset People with stroke or witnesses can usually tell you the moment it happened There should be no prodrome Particular care with common differentials Bell s palsy Labyrinthitis Demyelination Space occupying lesion Worsening previous neurology with infection

with common differentials Bell s palsy Labyrinthitis Demyelination

11 Symptoms and signs of loss of function Abnormal movements are rare after stroke Seizure at stroke onset is rare and a contraindication to thrombolysis Positive visual phenomena more likely to be migraine Headache is rare after stroke and rarely prominent when present consider SAH

to thrombolysis Positive visual phenomena more likely to be migraine

12 Stroke mimics Seizures Syncope (hypotension) Sugar (hypo or hyper) Sepsis (+ previous stroke) Severe migraine Space occupying lesions Si-chological

14 So what s the rush? Confirm stroke or TIA is the problem Help prevent complications i.e. aspiration, chest infections Consider emergency treatments E.G. Thrombolysis Admission to a stroke unit Proved to be the best place for stroke patients

16 National Guidance On arrival at A&E or the stroke unit, the diagnosis of a stroke or TIA should be checked using an accepted test such as ROSIER (Recognition of Stroke in the Emergency Room). NICE clinical guideline 68 Issue date: July 2008

accepted test such as ROSIER (Recognition of Stroke in the

17 Stroke mimics Seizures Syncope (hypotension) Sugar (hypo or hyper) Sepsis Severe migraine Space occupying lesions Si-chological

18 Why? Onset never established for ¼ patients When the first symptom began Not just when deteriorated later Sleep backdate to bedtime Witnesses when was last seen to be OK Very important for Thrombolysis potential TIA risk stratification

backdate to bedtime Witnesses when was last seen to be OK

19 NIHSS National Institutes of Health Stroke Scale Systematic neurological assessment for stroke Quantitative measure of neurological deficit Reliable & reproducible tool ~ 5 mins to complete Score from 0-42

Quantitative measure of neurological deficit

20 Why use the NIHSS? Identify and assess neurological deficits in stroke patients Understand the measurement scale for quantifying neurological deficits in stroke patients Consistently apply appropriate scores for neurological deficits in stroke patients Use the scale to assess changes in neurological deficits in stroke patients over time

measurement scale for quantifying neurological deficits in stroke patients

21 How to use NIHSS Only score the first attempt at each instruction Do not help the patient Score what the patient actually does (not what you think they should be able to do) Attempt all tests, even if patient is aphasic

22 Training for NIHSS Available on-line Simple to do Certificated for 2 years Link available on Network Website The more you do it, the easier it is

23 Any Questions

WMAS Clinical Guidelines CLN PRO - 027 I Version - 4

WMAS Clinical Guidelines CLN PRO - 027 I Version - 4 Guideline ID CLN PRO - 027 Version Version 4 Title WMAS Stroke Guidelines Approved by Clinical Steering Group Date Issued 4 May 2016 Review Date May