outh Carolina troke RC Rapid rterial occlusion valuation TROK BY TH UMBR History created by CD DHC Bureau of M
Historical Context ystem M & trokes M is the first medical contact in over 50% of all stroke victims in U.. Unless the patient had altered LOC, strokes were treated as non emergent events and transported routine to R Prehospital care seen only as supportive and permanent disability was seen as inevitable, much like cardiac arrest in the 70 s Typically Cincinnati troke cale used to confirm stoke event MD and IH taught in school but rarely used in field
troke Care in outh Carolina outh Carolina now has the third best door to balloon time for TMI care in the United tates. 1 o reason why stroke care should not follow suit Currently there are 21 designated stroke centers in outh Carolina: HFP 1, DV 2 TJC 18 Most M services have adopted tate troke 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 M ystem troke Plan. Time issues (1) CH, 2013
Time Context M & trokes Greatest 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 center Criteria
What criteria do we use / need? Following the model and success of TMI care in the field, (TIM =Cardiac muscle) prehospital pre notification is essential to advance stroke care since (TIM = Brain) There are many developed stroke scale models available for field use. Most used by M only capture sensitivity for + or to rule in/out a stroke arly detection of LVO (or LVO) is as essential to stroke care as T elevation to TMIs Qualitative core (+/ ) vs. Quantitative core (# value) IH is the gold standard by which all stroke scales are based. eed for a quantitative that has been validated with M data and is correlated to the IH ( gold standard ) that can detect an LVO. 12
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troke cale Items I H I I I troke by the umbers C P F T F T - D LOC X X X X X LOC Questions X X X LOC Commands X X X X X X Gaze X X X X X X X X Visual Fields X X X X X X Facial Palsy X X X X X X X Motor rm Drift Left X X X X X X X X Motor rm Drift Right X X X X X X X X Motor Leg Drift Left X X X X X X Motor Leg Drift Right X X X X X X Limb taxia X X ensory X X Language X X X X X X X Dysarthria X X X X X X X xtinction X X X Grip z H s H 5 s H 8 M D L P L M X M V P U R C
troke cale Items I H I I I troke by the umbers C P F T F T - D LOC X X X X X LOC Questions X X X LOC Commands X X X X X X Gaze X X X X X X X X Visual Fields X X X X X X Facial Palsy X X X X X X X Motor rm Drift Left X X X X X X X X Motor rm Drift Right X X X X X X X X Motor Leg Drift Left X X X X X X Motor Leg Drift Right X X X X X X Limb taxia X X ensory X X Language X X X X X X X Dysarthria X X X X X X X xtinction X X X Grip z H s H 5 s H 8 M D L P L M X M V P U R C
troke by Hthe T umbers I I I M troke cale Items I LOC X X X LOC Questions X LOC Commands X X X F D Gaze X X X X X X X Visual Fields X X X X X Facial Palsy X X X X Motor rm Drift Left X X X X Motor rm Drift Right X X X X Motor Leg Drift Left X X X X X Motor Leg Drift Right X X X X X Limb taxia ensory X X Language X X X X X X X Dysarthria X X X X xtinction X X Grip z H s H 5 s H 8 L X M R C ll IH-based scales validated from D admission or D presentation; not prehospital collected. RC validated by M data. Perez, et al; 2014
RC: troke by the umbers The Rapid rterial occlusion valuation (RC) scale was designed based on the ational Institutes of Health troke cale (IH) the validated neuroscience gold standard It is a Quantitative cale vs. Qualitative cale More Objective (number value) vs. Less ubjective (+ or -) Cincinnati troke cale, LP, and MD are all Qualitative scale based on the IH that is more user-friendly for prehospital field usage RC would allow the tate to capture quantifiable data for research
RC: troke by the umbers The Tirschwell et al study (troke. 2002;33:2801-2806) noted that sih-8 and sih-5 (shortened versions of the full IH or IH-15) retained the predictive ability (90-day outcomes) of the original IH and could be of value for prehospital use. The Zandieh et al study (Clinical eurology & eurosurgery. 2012;10:034) developed an even shorter, parsimonious IH-based tool with prehospital implications that was equally predictive (28-day mortality) as the original IH. Pérez de la Ossa et al study (troke. 2014;45:87-91.) validated RC and recommended it for prehospital care usage. Technically, the RC is a mih-6.
RC 1. Facial Palsy one present = 0 Mild = 1 Moderate to evere = 2 2. rm Motor Function ormal to Mild = 0 Moderate = 1 evere = 2 3. Leg Motor Function ormal to Mild = 0 Moderate = 1 evere = 2 UBCOR
RC 4. Head Gaze Deviation bsent = 0 Present = 1 5. phasia * (if right side hemiparesis) Performs both tasks correctly = 0 Performs 1 task correctly = 1 Performs neither tasks = 2 6. gnosia (if left side hemiparesis) Patient recognizes his/her arm and the impairment = 0 Does not recognized his/her arm or the impairment = 1 Does not recognized his/her arm nor the impairment = 2 UBCOR * see next slide for explanation
RC RC is a 5 or 6 item scale based on the side of weakness * phasia (if right side hemiparesis) : sk the patient and evaluate if the patient obeys. 1. Close your eyes 2. Make a fist gnosia (if left side hemiparesis): sk the patient: 1. while showing him/her the paretic arm: Whose arm is this and evaluate if the patient recognizes his own arm. 2. Can you lift both arms and clap and evaluate if the patient recognizes his functional impairment.
RC: troke by the umbers Test Item RC IH quivalent Facial Palsy 0-1 0-3 rm Motor Function 0-2 0-4 Leg Motor Function 0-2 0-4 Head Gaze Deviation 0-1 0-2 phasia (R side) 0-2 0-2 gnosia (L side) 0-2 0-2 https://www.youtube.com/watch?v=9x0pjuev50
RC: troke by the umbers The cut-score value of RC for recommendation to divert to a CC is 4 The global accuracy of the RC for large vessel occlusion (LVO) is (c-statistic, 0.84; 95% Confidence Interval (CI), ρ = 0.79 0.89). RC is comparable with IH to predict LVO (cstatistic, 0.85; 95% CI, ρ = 0.81 0.89). RC has a high sensitivity (89%) and specificity (55%) with a cutoff point of 4 for LVO. sensitivity (85%) and specificity (65%) with a cutoff of 5 for LVO. Last
RC: troke by the umbers Questions?