Initial Assessment Tools

Triage of the patient with a possible stroke must be immediate and accompanied by rapid assessment and intervention. Several prehospital stroke scales are available; the most widely used are the Cincinnati Prehospital Stroke Scale (Table 24-1) and the Los Angeles Prehospital Stroke Screen (Table 24-2). These instruments help identify the patient with a probable stroke and are used by many emergency medical systems (EMS) and emergency departments (EDs) as a quick triage tool. Patients with suspected stroke who present to the ED other than by EMS should be assessed within 10 minutes of arrival. Further assessment should include immediate computed tomography (CT).

TABLE 24-1 CINCINNATI PREHOSPITAL STROKE SCALE

^* Probability of stroke is 72% if any one of these three signs is abnormal.

TABLE 24-2 LOS ANGELES PREHOSPITAL STROKE SCREEN (LAPSS)

Ischemic Stroke

Ischemic events account for 80% to 85% of all strokes.³ These strokes occur when a local thrombus or embolus occludes a cerebral artery. Emboli generally originate in the heart or large arteries following atrial fibrillation, acute myocardial infarction (MI), or surgery. Symptom onset is sudden and, as with acute MI, frequently occurs in the early morning hours.

Further Assessment and Diagnosis

The emergency department staff must be skilled in recognizing acute stroke to triage and treat patients in a rapid, efficient manner. Communication must be streamlined between EMS and the stroke care team, ensuring that appropriate treatment options based on symptoms and time of symptom onset are available for all patients who present with stroke-like symptoms. To facilitate assessment and diagnosis, five questions need to be explored.

Five basic questions should be answered when a patient presents with stroke-like symptoms:

1. Is this a stroke?

2. When did the symptoms begin?

3. Are airway, breathing, and circulation adequate?

4. Are focal deficits present?

5. What immediate diagnostic procedures are recommended?

Question 1: Is This a Stroke?

Determine whether the following symptoms are the result of a stroke or a stroke mimic:

• Seizures

• Migraine

• Syncope

• Hypoglycemia or hyperglycemia

• Metabolic encephalopathy

• Central nervous system (CNS) tumor

• Other neurologic disease: subdural hematoma, peripheral neuropathy, Bell’s palsy, or benign positional vertigo

• Conversion disorder

Always err on the side of caution and assume that the patient has a true neurologic illness first.

Question 2: When Did the Symptoms Begin?

One of the most challenging parts of the initial assessment is establishing when the symptoms occurred, yet the entire treatment plan hinges on this piece of information. Creative interrogation of the patient, family, EMS personnel, or bystanders is necessary, as is asking the question in several different ways.

• Most witnesses to the event are certain the symptoms occurred when they first were aware of them, so be sure to establish when, without a doubt, someone last saw the patient at his or her baseline.

The “last seen normal” time for the patient who woke up with stroke symptoms would not be the time he or she woke up, but rather when he or she was last seen normal before going to bed.

• The Brain Attack Coalition has established goals (Table 24-3) for delivering stroke care for all patients arriving within 6 hours of symptom onset or “last seen normal.” If symptoms are present on waking, most likely the patient will be outside the time frame for thrombolytic therapy.

TABLE 24-3 TIME GOALS FOR STROKE MANAGEMENT

ED door to physician examination	10 minutes
ED door to CT scan completed	25 minutes
ED door to CT interpretation	45 minutes
ED door to needle (rt-PA started)	60 minutes

CT, Computed tomography; ED, emergency department; rt-PA, recombinant tissue-type plasminogen activator.

Data from Jauch, E. C., Cucchiara, B., Adeoye, O., Meurer, W., Brice, J., Chan, Y., … Hazinski, M. F. (2010). 2010 American Heart Association guidelines for cardiopulmonary resuscitation and emergency cardiovascular care science. Part 11: Adult stroke: Circulation, 122, S818–S828.

Question 3: Are Airway, Breathing, and Circulation Adequate?

Obtaining a CT scan to determine the type of stroke is a high priority. However, as with all emergency patients, airway, breathing, and circulation (ABC) take top priority. ABC should be rapidly assessed before transporting the patient for CT scan.

• Administer supplemental oxygen for pulse oximetry value less than 94%.

• Measure blood pressure (BP) accurately; make sure the BP cuff is the correct size and check the BP at least twice at 5-minute intervals.

• Obtain a 12-lead electrocardiogram. It is rare to have acute MI concurrently with a stroke, although this can occur. Cardiac enzymes should be part of the initial laboratory studies.

Question 4: Are Focal Deficits Present?

The initial examination is a brief, not full, neurological examination; the Cincinnati Prehospital Stroke Scale is adequate for this brief assessment. If deficits are present and likely associated with stroke, immediately obtain a CT scan of the head.

• For patients who arrive by EMS, this initial neurological examination should be done with the patient still on the EMS stretcher. Do not waste time transferring the patient to a bed, changing monitors, etc.

• For patients presenting to triage, the patient should be placed on a stretcher and have a portable monitor attached, in anticipation of immediate CT scan.

• A mechanism must be in place for having the CT scan read immediately and the results reported to the emergency physician or stroke team as quickly as possible.

Question 5: What Immediate Diagnostic Procedures Are Recommended?

Timing of diagnostic procedures for stroke is controversial. Most stroke centers draw blood for laboratory studies prior to the patient going for CT scan since processing the laboratory work is more time consuming than having the CT scan done. Based on the American Heart Association’s 2010 guidelines,² the following diagnostic procedures should be done:

• Immediate CT scan of the head to rule out hemorrhage and determine course of management

• CT scan completed within 25 minutes and interpreted with 45 minutes of the patient’s arrival at the ED.² Figure 24-1 shows the CT scan of a patient experiencing a hemorrhagic event.

• Blood glucose

• Serum electrolytes and renal function tests

• 12-lead electrocardiogram

• Cardiac biomarkers

• Complete blood count, including platelet count

• Prothrombin time and international normalized ratio (PT/INR)

• Activated partial thromboplastin time (aPTT)

• Oxygen saturation

Fig. 24-1 CT scan of intracerebral hemorrhage.

(From Moser, D., & Riegel, B. [2007]. Cardiac nursing: A companion to Brunwald’s heart disease [1st ed.]. Philadelphia, PA: Saunders.)

Based on the patient’s history, other diagnostic procedures that may influence the treatment plan and that may be considered are:

• Hepatic function tests

• Toxicology screen

• Blood alcohol level

• Pregnancy test

• Arterial blood gas test (if hypoxia is suspected)

• Chest radiograph

• Lumbar puncture if subarachnoid hemorrhage (SAH) is suspected and CT is negative for blood

• Electroencephalogram (EEG) if seizures are suspected

Therapeutic Interventions

• The goals of treating the stroke patient are to restore blood flow (arterial recanalization) and to optimize hemodynamics to maintain cerebral perfusion. Minimizing the damage and salvaging the penumbra (area of insulted but viable brain cells around the stroke) are best achieved by maximizing brain perfusion. Establish adequacy of ABCs.

• Administer supplemental oxygen if oxygen saturation via pulse oximetry is less than 92%.

• Consider advanced airway as needed.

• Obtain second intravenous (IV) line with normal saline solution.

• Initiate continuous cardiac monitoring.

• Treat hypoglycemia: do not treat hyperglycemia unless serum glucose is over 185 mg/dL.⁴

• An elevated BP is often noted in the first few hours of a stroke event and is perhaps a stress response. This will often normalize without intervention.

• If the patient is not eligible for recombinant tissue-type plasminogen activator (rt-PA) administration, do not treat elevated BP unless systolic blood pressure is greater than 220 mm Hg and diastolic blood pressure is greater than 120 mm Hg.

• See Management of Blood Pressure below.

• Maintain normal body temperature; treat fever greater than 37.5° C (99.5° F).

• Keep patient “nothing by mouth” (NPO) until he or she can be screened for dysphagia.

• Insertion of indwelling urinary catheter is optional but if the patient is a candidate for fibrinolytic therapy, all invasive procedures and tubes (nasogastric, urinary) must be performed or inserted prior to initiating therapy.

• Continuously reassess the patient’s neurologic status.

• Initiate venous thromboembolism (VTE) prophylaxis.

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