Prehospital and Emergency Department Care of the Patient With Acute Stroke

Key Points

Prehospital and emergency department care of the stroke patient must be focused on identification of potential stroke victims, rapid assessment, and prompt initiation of treatment for eligible individuals.
Time from initiation of symptoms to first medical contact represents a significant source of delay in care of the stroke patient. Outreach efforts to educate the lay public on stroke symptoms and immediate activation of emergency medical services (EMS) can mitigate these delays.
Patients suffering a potential stroke should be transported to the nearest Acute Stroke-Ready Hospital or Primary Stroke Center. In selected cases, it is reasonable to transport patients suspected of having a large vessel occlusion to endovascular thrombectomy (EVT)-capable centers bypassing other centers.
EMS prenotification of potential stroke patients is recommended to allow mobilization of emergency department (ED) resources prior to the patient’s arrival.
Advanced imaging should be performed as quickly as possible upon arrival to the ED, and efforts should be made to obtain all necessary imaging in one epoch. Delays in obtaining computed tomography angiography should not delay treatment of patients eligible to receive intravenous tissue plasminogen activator.
Multidisciplinary pathways and protocols should be developed to facilitate initiation of thrombolysis and EVT in eligible patients as rapidly as possible. Delays in thrombolysis and EVT are associated with worse outcomes in stroke patients.
Management of subarachnoid hemorrhage and intracranial hemorrhage in the ED should focus on reversal of possible coagulopathy, patient stabilization, and management of hypertension often associated with these conditions.

Special recognition is given to Anna Gensic, MD, and Art Pancioli, MD, for their work in publishing the previous version of this chapter.

Introduction

Prehospital care providers and emergency departments must work together in concert to optimize care for patients suffering acute ischemic or hemorrhagic strokes. The 2018 American Heart Association/American Stroke Association (AHA/ASA) guidelines for management of acute ischemic stroke (AIS) reflect the emergence of endovascular thrombectomy (EVT) as an evidence-based treatment strategy and the need for development of regional stroke systems of care that integrate prehospital/emergency medical services (EMS) providers with hospitals capable of providing thrombolysis (Acute Stroke-Ready Hospitals and Primary Stroke Centers) and regional referral centers capable of performing EVT (Comprehensive Stroke Centers or Thrombectomy-Capable Centers). Acute stroke protocols are typically developed to facilitate rapid treatment of eligible AIS patients, but given the overlap in symptoms, patients with intracranial hemorrhage and subarachnoid hemorrhage will often be initially triaged as “possible stroke” patients. Management priorities for these patients differ greatly from AIS patients, but in both disease processes, critical actions taken in the first few hours of a patient’s hospital course can have dramatic effects on the degree of long-term disability and mortality from these diseases.

The Course of Events for the Acute Stroke Patient

Speed and efficiency of initial evaluation, diagnosis, management, and communication are significant components of the contribution to acute stroke care provided by prehospital and emergency department (ED) teams. The major components in the evaluation and treatment process of patients with acute stroke can be divided into prehospital and ED phases, as follows:

Prehospital Components

1.
Recognition of stroke symptoms by the patient or family members
2.
First contact with medical care (e.g., dialing 911 in the United States)
3.
Dispatch of appropriate level of prehospital care providers
4.
Prehospital evaluation, management, and transport
5.
Prehospital identification of stroke
6.
Prehospital notification of pending ED arrival

Emergency Department

1.
ED triage
2.
ED evaluation and management
3.
Determine if the patient is suffering an ischemic or hemorrhagic stroke (imaging)
4.
Administration of intravenous (IV) thrombolytics for eligible patients
5.
Selection of patients with AIS with large vessel occlusion syndromes (LVOs) for EVT
6.
Appropriate disposition of patient from the ED (i.e., angiography suite, stroke unit, neuroscience intensive care unit)

The single largest component of the delay between symptom onset and definitive therapy exists between symptom onset and ED arrival. In an evaluation of the Get With The Guidelines–Stroke national database, from 2002 to 2009, only 25.1% of stroke patients arrived to the ED in less than 3 hours after symptom onset, with only an additional 10.7% arriving from 3 to 8 hours after onset. A recent systematic review found no meaningful changes in the proportion of patients arriving within the acute treatment window (2–3 hours from symptom onset to ED arrival) over the last 20 years. Thus, it is clear that prehospital times must be decreased if the number of patients eligible for immediate therapy is to be improved.

Recognition of Stroke Symptoms by the Patient or Family Members

Recognition of stroke symptoms is the first step to activating a stroke response network and arranging for timely treatment. Unfortunately, a myriad of factors have been associated with delays in arrival of stroke patients to the ED in the United States. These include:

Patient (or family member) initially phones the primary care physician instead of the local emergency service phone number
The patient lives alone
Stroke begins while the patient is asleep
Symptoms appear while the patient is at home versus at work
The stroke is mild rather than severe
Stroke syndrome includes aphasia or neglect

International work on the subject has found similar factors influencing prehospital delay in stroke recognition. Given the neurologic deficits typically associated with acute stroke, it is unsurprising that only a small minority of stroke patients activate EMS themselves. ^, ^,

A number of community outreach efforts have been developed to attempt to improve public recognition of stroke signs and symptoms and the importance of rapid response. Beginning in 1995, telephone surveys have documented baseline knowledge of stroke signs and risk factors. These studies found between 57% and 70% of respondents in a major metropolitan area within the US “Stroke Belt” could name one stroke warning sign and a similar proportion could name one or more risk factors for stroke. Similar studies throughout the United States and Europe have shown between 50% and 78% of respondents can correctly name one or more stroke warning signs. ^, ^, Disparities in stroke awareness have been well documented among marginalized racial/ethnic groups, leading to increase in prehospital delays in these populations. Results from telephone surveys demonstrate lower stroke awareness among Hispanics, African Americans, and respondents from the Western United States. Stroke awareness was higher among females, Caucasians, and insured individuals.

It appears that the activation of EMS for stroke-like symptoms is not driven primarily by knowledge of those symptoms, but by an understanding of the seriousness and treatable nature of stroke. Given this knowledge gap, several public education campaigns have attempted to improve community awareness, including the American Stroke Association’s Power to End Stroke Campaign, the National Stroke Association’s Act Face-Arm-Speech-Time (FAST) campaign, and local projects such as the Beauty Shop Stroke Education Project, the “Hip-hop” Stroke project, and the Kids Identifying and Defeating Stroke project. The most recent AHA guidelines reinforce this concept, calling for targeted public awareness campaigns for racial/ethnic, age, and sex diverse populations. ^, Further follow-up of ongoing public education efforts is essential to ensure that the target audience is internalizing the intended message regarding stroke symptoms and the necessity of rapid recognition and intervention. Meaningful and sustained efforts to increase stroke literacy may result in improvements in outcomes among underserved and historically disadvantaged populations.

First Contact With Medical Care

In the United States, the EMS system is the point of first medical contact for about ½ of people having acute stroke. ^, ^, In other countries, reported EMS use for acute stroke varies from 18% to 45%. ^, ^, Although the symptomatology and presentation of many acute strokes are dramatic enough to lead patients or bystanders toward prompt action, less dramatic presentations often lead to significant delay.

Unfortunately, any action other than the immediate activation of the EMS system via 911 or equivalent will lead to significant delays in treatment. The Second Delay in Accessing Stroke Healthcare study (DASH II) was a prospective multicenter study that enrolled 617 patients with suspected stroke. EMS use was found to be associated with decreased prehospital and in-hospital delays to care. Patients who used EMS had a median prehospital delay time of 2.85 hours compared with 4.03 hours for those who did not use EMS ( P = .002). Those who used EMS had significantly shorter times from symptom onset to arrival, time to seeing an emergency physician, time to computed tomography (CT) scan, and time to evaluation by a neurologist.

In another study, use of the EMS system shortened time to arrival as well as time to treatment in patients with acute stroke. Patients arriving by ambulance were more likely to arrive earlier (odds ratio [OR] for arrival within 3 hours, 3.7) than individuals arriving via other modes of transport and were more likely to be seen by a physician within 15 minutes of arrival (OR 2.3).

Use of the EMS system is one critical link in reducing delay to ED arrival for patients with acute stroke. In the Get With The Guidelines-Stroke data set, the two most important predictors of onset-to-arrival times of 60 minutes or less are greater National Institutes of Health Stroke Scale (NIHSS) score and use of EMS. Further analysis of this data set has shown that activation of EMS for stroke patients is associated with earlier ED arrival times, quicker evaluation and more likely treatment within a 60-minute door-to-needle [DTN] window, and higher likelihood of receiving alteplase for stroke symptoms lasting ≤2 hours. ^, Unfortunately only approximately 60% of stroke patients use EMS. ^, Activation of 911 systems by patients or bystanders and priority dispatch of EMS crews to suspected stroke patients were given Level IB recommendations in the most recent edition of the AHA Guidelines for Management of AIS.

Dispatch of Prehospital Providers

Following activation of the 911/EMS system, EMS dispatchers are responsible for gathering initial patient information, including location, demographics, and a brief summary of events leading to the call to generate a dispatch call for prehospital care providers. This conversation is the first form of triage by a medically trained provider. However, retrospective studies of prehospital personnel impressions vs. discharge diagnoses have demonstrated a positive predictive value of 34%–51% for diagnosis of transient ischemic attack (TIA)/ischemic stroke, with sensitivity of 64%.

Immediate dispatcher recognition of stroke symptoms has been shown to improve immediate patient care, including more frequent dispatch of ALS-level ambulances, increased assistance to the caller, and decrease in total transport times when compared to stroke cases that were unrecognized by the dispatch personnel. Following this, suspected stroke cases should be treated as a priority dispatch, with transport times minimized. AHA guidelines recommend first aid providers, including dispatch personnel, use a stroke assessment scale and stroke protocol (Level 1B). Historically, the Cincinnati Prehospital Stroke Scale (CPSS), FAST, and Los Angeles Prehospital Stroke Screen (LAPSS) have all been validated as standardized stroke assessment tools in the AHA/ASA guidelines. Fig. 52.1 and Table 52.1 review the components of each exam. Systematic reviews have identified both the LAPSS and CPSS as having favorable ROC curves for prehospital stroke prediction. When identified appropriately, eligible patients experience shorter time to IV thrombolysis. ^,

Fig. 52.1, The Los Angeles Prehospital Stroke Screen. 44 , 45

TABLE 52.1

The Cincinnati Prehospital Stroke Scale.

From Kothari R, Pancioli A, Liu T, et al. Cincinnati Prehospital Stroke Scale: reproducibility and validity. Ann Emerg Med . 1999;33:373–378.

Facial Droop	Have patient smile or show teeth
Normal	Both sides move equally
Abnormal	One side does not move as well
Arm Drift	Patient closes eyes and holds both arms out
Normal	Both sides move equally
Abnormal	One side does not move as well
Speech	Have patient say, “You can’t teach an old dog new tricks.”
Normal	Patient uses correct words without slurring
Abnormal	Slurs words, uses inappropriate words, or is unable to speak

Any one or more abnormal findings is suggestive of acute stroke.

Prehospital Evaluation and Management

Prehospital/EMS providers begin every encounter with a rapid assessment of the patient’s airway patency, breathing, and circulation (ABCs) and measurement of vital signs, including pulse oximetry. For suspected stroke patients, rapid finger stick blood glucose values should be obtained in this initial triage. Table 52.2 lists additional measures for prehospital assessment and treatment of potential stroke victims. Placement on cardiac telemetry, initiation of IV access, and administration of supplemental oxygen are also typical interventions. Regardless, on-scene times should be minimized unless resuscitative measures to address hemodynamic instability or airway management are required.

TABLE 52.2

Guidelines for Prehospital Management of Stroke.

Do …	Do Not …
Assess and manage ABCs Initiate cardiac monitoring Establish IV access Treat hypotension Give supplemental oxygen to maintain O ₂ saturation >94% Measure blood glucose level and treat accordingly Determine time of symptom onset or last known normal, and obtain family contact information, preferably a cell phone Triage and rapidly transport patient to the nearest most appropriate stroke hospital Pre-notify hospital of pending stroke patient arrival	Initiate interventions for hypertension unless directed by medical command Administer excessive IV fluids Administer dextrose without evidence of hypoglycemia Administer medications by mouth (maintain NPO) Delay transport for pre-hospital interventions

Do …

Do Not …

Assess and manage ABCs
Initiate cardiac monitoring
Establish IV access
Treat hypotension
Give supplemental oxygen to maintain O ₂ saturation >94%
Measure blood glucose level and treat accordingly
Determine time of symptom onset or last known normal, and obtain family contact information, preferably a cell phone
Triage and rapidly transport patient to the nearest most appropriate stroke hospital
Pre-notify hospital of pending stroke patient arrival

Initiate interventions for hypertension unless directed by medical command
Administer excessive IV fluids
Administer dextrose without evidence of hypoglycemia
Administer medications by mouth (maintain NPO)
Delay transport for pre-hospital interventions

ABC , Airway, breathing, and circulation; IV, intravenous; NPO, nothing by mouth.

Prehospital assessment of the exact time of onset of symptoms or last known/seen well tie (LSW) is a critical component of stroke care for patients who may be candidates for IV thrombolysis. Additional important historical components include recent trauma, presence of seizure activity or migraine at onset of symptoms, and medical history including prior cerebrovascular accident history, presence of diabetes, hypertension or atrial fibrillation, and a current medication list. Critical medications include anticoagulants (warfarin or direct oral anticoagulants), antiplatelet agents, and insulin or oral hypoglycemic agents. Collateral information from family members or witnesses is critical for patients who are aphasic or otherwise unable to communicate. Transport of a family member with the patient can be useful to facilitate further history taking or consent for thrombolytics, EVT, or research studies.

Critical actions in the prehospital setting include detection and correction of hypoglycemia using D50 or IM glucagon, correction of hypotension using volume expansion (isotonic crystalloid solutions), and provision of supplemental oxygen. If appropriate, airway management may be attempted if the patient is unable to adequately oxygenate, ventilate, or has lost airway reflexes. Cardiac telemetry should be initiated as soon as possible to monitor for atrial fibrillation or other arrhythmias. A copy of the initial rhythm strip should be printed and given to ED personnel during patient handoff. Notably, treatment of hypertension should be avoided in the prehospital setting for suspected stroke patients as this may be protecting cerebral perfusion pressure (CPP) or supporting collateral circulation for patients with AIS. Hospital prenotification of incoming stroke patients is strongly recommended by current guidelines (Level 1B) and is associated with improved in-hospital metrics, including shorter times to imaging, administration of alteplase, and an increased proportion of strokes treated within 3 hours of symptoms onset. ^,

Prehospital Identification of Stroke

The development of hyperacute management options (IV alteplase and EVT) has required the EMS community to develop rapid approaches to recognize stroke symptoms, and work is underway to develop and validate screening tools to identify patients suffering LVOs who may require EVT. Two tools, the LAPSS and the CPSS, have been validated for use by prehospital care providers to allow for early stroke recognition and communication with hospital-based teams.

The LAPSS was created to be a stroke recognition tool specifically for prehospital care personnel (see Fig. 52.1 ). It is a one-page instrument that takes less than 3 minutes to perform. The LAPSS consists of four history items, three physical examination items, and a serum glucose test. In a prospective validation study of the LAPSS, paramedics identified acute stroke victims with a sensitivity of 91% and a specificity of 97%.

The CPSS is a three-item neurologic examination that was developed to assist prehospital care providers in identifying patients with stroke who may be candidates for thrombolysis (see Table 52.1 ). The CPSS was derived via the selection of the three most sensitive and specific components of the NIHSS —facial palsy, arm weakness, and speech abnormality. When performed by a trained physician, this scale has been shown to be effective in identifying such patients. The CPSS can be taught in approximately 10 minutes and performed in less than 1 minute.

The CPSS has also been shown to identify potential stroke victims accurately when performed by prehospital care providers. Correlation for the total score (number of abnormal items) between prehospital care providers and physicians was excellent. The CPSS is valid in identifying patients with stroke (sensitivity, 66%; specificity, 87%), especially anterior circulation stroke (sensitivity, 88%). In the evaluation study, presence of a single abnormality on the CPSS identified all patients with anterior circulation stroke who would have been candidates for thrombolytic therapy. The addition of a test for ataxia to the CPSS would have identified six of the ten patients with posterior circulation stroke who were not identified in this study. However, ataxia is one of the most poorly reproducible items on the NIHSS and is not included in the CPSS.

Both the LAPSS and the CPSS have been widely utilized in and are accepted tools for the EMS community. The LAPSS has greater overall sensitivity but requires slightly more time to perform. The CPSS is rapidly taught and performed but has a lower sensitivity for posterior circulation stroke. Current AHA/ASA guidelines recommend the use of FAST, LAPSS, or CPSS by EMS agencies as part of triage protocols (Level 1B recommendation).

The advent of EVT has sparked development of a series of prehospital stroke prediction scales that aim to identify stroke patients with LVOs. Multiple scales are currently in development/validation and are summarized in Table 52.3 . The NIHSS is widely considered to be too complex to administer in the field, prompting development of several short, reproducible prehospital LVO detection scales. Recent systematic reviews of the test characteristics of these scales have found no significant difference in sensitivity and specificity between the scales. ^, Further development of an ideal LVO prediction scale should focus on identifying elements present as binary, rather than ordinal degrees of impairment, clinically associated with LVO syndromes, and easy for a prehospital provider to recognize in a brief assessment. Such a scale should then be validated in cohorts of suspected stroke patients. The ultimate goal of any prehospital LVO detection scale would be to generate a different destination decision for EMS agencies—to transport patients to EVT-capable centers rather than primary stroke centers. In the current environment, AHA guidelines still recommend transport of all patients with a positive stroke screen or suspicion of stroke to the closest facility that can administer IV alteplase (i.e., a Primary Stroke Center). If that center is not EVT-capable, it is certain that patients who are candidates for EVT will then need subsequent emergent transfer to an endovascular center. In cases where the transport time to an EVT-capable center is equivalent or negligibly different, transport of severe strokes (based on EMS discretion or use of a prehospital LVO detection tool) to the EVT-capable center is reasonable and may prevent the need for subsequent transfer to an EVT center, reducing time to recanalization. The optimal degree of EMS diversion to an EVT-capable center (bypassing a nearer Primary Stroke Center [PSC]) is still an area of active research. Some regions have developed mobile tools to route patients to the closest tissue plasminogen activator (tPA) or EVT capable center, taking into account real-time traffic patterns, procedural suite availability, and other factors to reduce the time to delivery of hyperacute stroke interventions for eligible patients.

TABLE 52.3

Physical Exam Items Evaluated by Large Vessel Occlusion Prediction Scales

From Keenan KJ, Kircher C, McMullan JT. Prehospital prediction of large vessel occlusion in suspected stroke patients. Curr Atheroscler Rep . 2018;20:34.

	RACE	C-STAT	LAMS	FAST-ED	VAN	3I-SS	G-FAST	PASS	EMSA
Facial droop	0/½	—	0/1	0/1	—	—	0/1	—	0/1
Arm weakness	0/½	0/1	0/½ ^a	0/½	^b	0/½	0/1	0/1	0/1
Speech ^c	—	—	—	0/½	—	—	0/1	—	0/2 ^d
Aphasia specifically	0/½ ^e	—	—	—	0/1	—	—	—	—
Level of consciousness	—	0/1 ^f	—	—	—	0/½	—	0/1 ^g	—
Gaze deviation	0/1	0/2 ^h	—	0/½	— ⁱ	0/½	0/1	0/1	0/1
Neglect	0/½ ^h	—	—	0/½	0/1	—	—	—	—
Visual fields	—	—	—	—	0/1	—	—	—	—
Leg weakness	0/½	—	—	—	—	— ^j	—	—	0/1
Grip strength	—	—	0/½ ^a	—	—	—	—	—	—

—, Not tested.

C-STAT , Cincinnati Stroke Triage Assessment Tool; EMSA , Emergency Medical Stroke Assessment; FAST-ED , Field Assessment Stroke Triage for Emergency Destination; G-FAST , Gaze-Face-Arm-Speech-Time; LAMS , Los Angeles Motor Scale; PASS , Prehospital Acute Stroke Severity; RACE, Rapid Arterial Occlusion Evaluation Scale; VAN , Vision, Aphasia, and Neglect; 3I-SS, 3-Item Stroke Scale.

a Prespecified scoring of both left and right sides.

b Arm weakness is required to continue performing the rest of the scale but is not scored.

c Scored as abnormal if either aphasia or dysarthria is found.

d Two points scored if present.

e Tested only if there is right-sided weakness.

f To score positive must get at least one age or month question wrong and not follow one eye closure or hand opening command.

g Tests for incorrect month or age.

h Tested only if there is left-sided weakness.

i Tested and scored as part of the neglect item.

j Leg weakness is combined with arm weakness for a single score.

Mobile Stroke Units and Future Considerations

Prehospital stroke care will continue to evolve as increasing numbers of community hospitals seek to develop thrombectomy capabilities. The most agile EMS agencies will develop regional agreements regarding preferred destination for suspected stroke patients, use of LVO screening tools to triage patients preferentially to thrombectomy-capable centers, and increasing telemedicine presence to augment these prehospital scoring scales. Real-time IR availability could be incorporated into these decisions. Further discussion of the role of mobile stroke units and prehospital stroke systems can be found in Chapter 51 .

Emergency Department Care of the Stroke Patient

Care of the acute/subacute stroke patient has evolved rapidly since the 2015 publication of the first era of trials establishing the benefit of EVT for proximal LVOs within 0–6 hours from LSW. Stroke systems of care had previously been built exclusively around identifying patients eligible for thrombolysis within an acute time window (0–4.5 hours from LSW). Rapid introduction of vessel imaging in the initial epoch was needed to screen patients for occlusions amenable to thrombectomy. Two large randomized trials extended the time window for thrombectomy to up to 24 hours in selected patients with favorable imaging characteristics. ^, Two subsequent trials have demonstrated safety and efficacy of IV thrombolysis outside the classic 4.5-hour thrombolysis window using screening based on magnetic resonance imaging (MRI) up to 24 hours from LSW or CT perfusion (CTP) up to 9 hours from LSW or upon awakening. ^, Several other trials are currently underway investigating adjuncts to tPA in the acute time window or the use of single bolus-dose thrombolytic (tenecteplase) for selected extended-window patients. Taken together, these data have increased the pool of patients eligible for acute stroke treatment and require wholesale restructuring of acute stroke care in the emergency department.

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