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1 polleverywhere.com To Join: Text KERRYAHRENS516 to For all future texts, you text your choice A-E

2

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4 Kerry Ahrens, MD MS

5 I have no financial disclosures at this time.

6 Kerry Ahrens MD, MS Emergency Physician BayCare Clinic Medical Director Oshkosh Fire Dept Medflight Physician Co-Chair Wisconsin Stroke Coalition Associate Professor EM UW School of Medicine

7 Prehospital Stroke Scale: Objectives Function & Purpose What scales in general are good at What they miss Individual scales, their field validation

8 A Call comes into your 911 call center

9 MJ, 53 yo M 08:08 53 yo M pmh of obesity, mild aortic stenosis here as a interfacility transfer from County X Hospital with acute onset of L-sided weakness L facial droop. OSH did found large vessel occlusion L-MCA. Patient presumed to be out of tpa window at the time & tpa not given. Sent here for intervention. Neg ROS. He did have some right-sided neck pain earlier this week was unclear if it was related to today's events. His wife reports that he woke up 0500 was able to put his glasses on, stood, walked a few steps then collapsed. Wife called 911.

10 Your EMS Basic/Int/Paramedic has a lot to figure out Their clinical decision making is assisted by providing them with a tool Their clinical decision making is assisted by providing them with a tool a consistent scoring system to give us the BEST objective information from a field evaluation by using a Prehospital Scoring System

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12 WI EMS Structure EMR Basic/BLS 180 hrs 350 hrs Intermed-I Paramedic Critical Care hrs hrs **EMR cannot transport, but can render first aid

13 Scope of Practice: Access, Drugs EMR Basic/BLS Cannot Start IV!! Can Give: Nebs SubQ Epi po glucose Asst pt w/own Nitro Intermed-I IV/IO, po Critical Care Paramedic IV/IO, po IV Pump State-approved list of medications for paramedics; critical care can do more

14 Scope of Practice: Airway, ACLS EMR Basic/BLS Can use AED CCR/CPR Limited airways (NP) pulse ox hemorrhage control Intermed-I Same as BLS, can provide IVF Critical Care Paramedic Same as BLS/Intermed + Cardioversion transcutaneous pacing ETT Surgical Airway **vents

15 Which Stroke Scale Should EMS Use?

16 Clinical Decision Support Tools Improves EMS ID stroke to 90% +Assist with EMS ability to identify stroke patients who should be diverted to an embolectomy-ready hospital Avoid the unnecessary transfer of ineligible/futile patients into the embolectomy-ready centers* Acute Stroke Treatment Main Goals (EMS, ED) IV tpa w/in 30 min Picture (CT) to puncture for LVO <90 min *van Gaal et al. 2017, **Brandler et al 2014

17 Stroke EMS Destination Protocol Data Based on improving functional outcomes, act to avoid tpa/recanalization delays* Every 15 reduction from sx onset to recanalization 34/1000 treated had improved disability outcome Decreased functional outcomes: by 3-4% for every 15 min delay tpa by 12% for every 30 min delay in endovascular tx MR CLEAN - 7% probability of good outcome for each 1 hour delay in revascularization Unadjusted relative risk for worse outcome for every 30-min delay in recanalization 0 85* AHA recommends EMS bypass ASRH/PSC for a CSC IF additive transport time < 20 min *Khatri 2014, Higashida 2013, Sheth et al 2015; Berkhemer et al 2015, Fransen et al. 2016

18 Mokin et al 2017 Evaluated decay in ASPECTS score during inter-hospital transfer Alberta Stroke Program Early CT Score (ASPECTS) 10 pt scoring system of early ischemic changes in 10 anterior circulation regions of the brain. Is a strong predictor of outcome following thrombectomy - Higher ASPECTS = more likely to achieve favorable outcome retrospective study 13 of 42 patients (31%) who initially had favorable outcome profile at outside hospital had significant ASPECTS decay following inter hospital transfer 1/3 became ineligible for IA thrombectomy because of unfavorable ASPECT deterioration Mokin 2017

19 Stroke Scales: CPSS LAMS MEND MASS C-STAT FAST FAST-ED MedPACS SNOW RACE OPSS ROSIER EMSA

20 Stroke Scale Format 1. Define & describe each scale 2. Field Validated? 3. Does it have an APP?

21 Cincinnati Stroke Scale, main exam components Face, Arm, Speech, Score = high risk LVO Simplicity = greatest attribute Validated in the Field: Sn 89%, Sp 73% Probability of acute CVA 1 of 3 = 72% 2 of 3 = 85% > 2 predicts severe CVA

22 Cincinnati Stroke Scale, 1997 There is an app Daniel Juergens $0.99

23 LA Motor Score (LAMS), exam components face, arm grip Score 0-5 > 4 = LVO Other Caveats Geared for age > 45 no h/o seizure/epilepsy symptoms < 24 hrs BG mg/dL Easy to train all levels ~1-3hrs Validated in field, multiple live sites tested, internationally accepted van Gaal et al 2017

24 LAMS Kidwell et al 2000 Prospective study LAFD, 60 min training session 206 pts in field 31 ID as CVA 167 as not CVA Sp 97%, Sn 91% NPV 98%

25 LA Motor Score (LAMS), 1997 Validated in field, multiple live sites tested, internationally accepted feasibility confirmed through multiple large-sale implementations w/in regionalized systems for thrombolysis App - not its own, but included in free app: van Gaal et al 2017

26 Devised 1998, UK group of stroke physicians, ambulance personnel, & ED physician was integral part of training for UK ambulance staff Designed to expedite tpa administration w/in 3 hours of CVA onset

27 RACE, 2007 Rapid Arterial occlusion Evaluation 5 items, total of 10 points: face, arm, leg, gaze-eye deviation, aphasiaagnosia

28 RACE, 2014 Rapid Arterial occlusion Evaluation **Correlates best w NIHSS EMS education 1hr +4 hour refresher >5 LVO likely, go to CSC 85% Sn, 68% Sp, NPV 94%* disadvantages: more complex to learn variable results<4 can still be a LVO but intervention is less likely *Ossa 2014

29 SNOW Stroke Networks of Wisconsin Milwaukee Area BEFAST is screened 1st in field SNoW LKWT < 24hrs +LVO field screen & transport to CSC< 15 min from nearest PSC If BEFAST+ then: Eye Gaze Aphasia Neglect Any of 3 positive then transport to CSC/thrombectomy capable center

30 FAST-ED The Field Assessment Stroke Triage for Emergency Destination Score: LVO likelihood: 0-1: <15% 2-3: ~30% 4: ~60%+ Out of Hot-Lanta Lima 2016

31 FAST-ED The Field Assessment Stroke Triage for Emergency Destination Lima et al comparable accuracy to NIHSS LVO prediction higher accuracy than RACE, CPSS Lima 2016

32 CPSS MASS Melbourne Ambulance Stroke Scale

33 MASS: Melbourne Ambulance Stroke Scale, 2005 Clinical Physical History Exam Age 45 No Hx epilepsy/convusions Not in med/wheelchair BG mg/dL Facial droop strength in arms hand shake speech Presence of ANY of the exam elements & Affirmative answer in all the elements of clinical history = STROKE CODE Bray 2005: 100 MASS field assessments Goal: good recognition of patients suitable for thrombolytic therapy 73 strokes, 27 mimics Their findings: Equal SENSITIVITY as CPSS (90% MASS vs 95% CPSS) superior sensitivity to LAPSS (90% vs 78% - Kidwell data) Equal SPECIFICITY as LAPSS (74% MASS vs 85% LAPSS) superior specificity to CPSS (MASS 74% vs CPSS 54%) All Patients missed by MASS - 7 strokes, 7 mimics were ineligible for thrombolytic tx No App

34 MASS: Melbourne Ambulance Stroke Scale, 2005 Clinical Physical History Exam Age 45 No Hx epilepsy/convusions Not in med/wheelchair BG mg/dL Facial droop strength in arms hand shake speech Presence of ANY of the exam elements & Affirmative answer in all the elements of clinical history = STROKE CODE Bray another validation study, 850 pts Sn 93% (higher than 2005 MASS, equal to CPSS 88% Sp 87%, higher than CPSS 79% Sp truly statistically significant Bray 2010

35 MEND Miami Emergency Neurologic Deficit Examination used to gauge both PROBABILITY & SEVERITY of stroke in patients more detailed assessment than its more wellknown cousin CPSS takes more time than CPSS to perform Made up of 12 tests 9 more than CPSS There is an app devised by U-Miami Gordon Ctr $1.99 itunes

36 MEND: Miami Emergency Neurologic Deficit Exam 1. Mental Status level of consciousness speech (CPSS) question/response respond to command 2. Cranial Nerves 1. Facial droop (CPSS) 2. Visual Fields 3. Horizontal gaze 3. Limb Function - 5 tests 1. Arm drift 2. leg drift 3. sensory arms/legs 4. coordination - finger to nose 5. coordination - heel to shin initial field triage used typically is CPSS, if this is positive, they load and perform MEND ** Most systems using MEND in field routinely advising crews to complete entire exam EN ROUTE to hospital

37 ROSIER, 2005 Recognition of Stroke In the Emergency Room >0 = STROKE Most studies compared MD use in ED.

38 ROSIER Recognition of Stroke In the Emergency Room Mingfeng 2012 (n 540): CPSS vs ROSIER used by ED MDs NO significant difference in sensitivity CPSS Sn 88.77%, Sp 68.79% vs ROSIER Sn 89.97%, Sp No significant difference in determining presence of stroke Fothergill 2013 (n 177) ROSIER vs FAST Used on UK ambulance svcs 64% strokes, 78% non-strokes ID d using ROSIER ROSIER not superior to FAST

39 VAN: Vision Aphasia Neglect tests 4 main items arm strength, vision, aphasia, neglect out of AZ 62 stroke calls % Van+, 39% had NIHSS score 6 both had 100% Sn (100% PPV) VAN better Sp 90% vs 74% NIHSS Teleb 2016

40 VAN: Vision Aphasia Neglect Teleb 2016

41 MedPACS Medic Prehospital Assessment for Code Stroke

42 There is an app with several stroke scales: LAMS, RACE, CPSS, FAST-ED, VAN

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44 Scales with Glucose Measurement Dallas 2015 Sensitivity (CI 95%) Specificity (CI 95%) Number of participants Quality of (number of studies) evidence LAPSS 0.75 ( ) 0.96 ( ) (8) Very low OPSS 0.92 ( ) 0.86 ( ) 554 (1) Moderate KPSS No data in diagnostic study No data in diagnostic study ROSIER 0.88 ( ) 0.52 ( ) (5) Moderate Pooled 0.84 ( ) 0.97 ( ) Low Scales without Glucose Measurement Sensitivity (CI 95%) Specificity (CI 95%) Number of participants (number of studies) Quality of evidence FAST 0.84 ( ) 0.28 ( ) 927 (4) Low MASS 0.88 ( ) 0.72 ( ) 130 (2) Very low LAMS 0.81 ( ) 0.89 ( ) 119 (1) Low CPSS 0.80 ( ) 0.42 ( ) (9) Very low MDPS 0.78 ( ) 0.61 ( ) (2) Moderate Pooled 0.82 ( ) 0.48 ( ) Low

45 Dallas 2015 Risk of Bias: Interventional

46 Why such a variability in Sp, Sn of each stroke scale between various studies?

47 Wow, these are all good for different reasons but which is best? Current data does not provide a strong recommendation for any particular stroke scale - no superiority of any 1 scale has been demonstrated. Per Rudd et al Choice of instrument depends on: intended purpose consequences of a false-negative or falsepositive result Rudd 2016

48 The context of a scale s intended trigger for its use may alter the scales sensitivity & specificity Is it applied to ALL prehospital suspected stroke admissions? Harbison, Nor, Fothergill, Frendl, Studneck Used when certain categories of patient complaints were assessed? Kidwell/LAMS When dispatch already suspects stroke or focal neurologic change present? Bray/MASS Generates heterogeneity of data Rudd 2016

49 And, there aren t just Prehospital Stroke Scales Prehospital Stroke Scales Acute Assessment Scales Canadian Neurologic Scale (CNS) European Stroke Scale Glasgow Coma Scale Hemispheric Stroke Scale Hunt & Hess Scale Mathew Stroke Scale NIHSS Scandinavian stroke scale World Federation of Neurologic Surgeons Grading System for Subarachnoid Hemorrhage Scale Functional Assessment Scales Modified Rankin Berg Balance scale Lawton IADL Scale Stroke Specific Quality of Life Measure (SS-QOL) Outcome Assessment Scales

50 But there aren t just Prehospital Stroke Scales - generates a great deal of confusion Prehospital Stroke Scales Acute Assessment Scales Functional Assessment Scales Outcome Assessment Scales This also also generates heterogeneity in data

51 Some say Why Bother? Turc et al patients - looked at should a stroke scale cut-off be used? patients admitted to their CSC (Hôpital Sainte-Anne, Paris) Criteria: how well do 13 scales predict LVO (post MRI or CTA 6 hours of symptom onset.) CPSS, NIH (modified 9 diff ways), ROSIER, RACE Mean NIH 7, range had LVO False neg 10% for all scales false neg >25% when cut off was used 5, 1, 0 They feel imaging should be performed prior to transport. Turc 2016

52 Which is BEST for stroke identification may not be optimal for the EMS service to utilize

53 States who have published use of a particular stroke scale North Carolina (2012, 98 EMS systems): LAPSS 66% CPSS 49% Miami Emergency Neurologic Deficit exam 17% All these scales but only 50% regularly communicated the results to the destination hospital Wisconsin: CPSS in Madison, Appleton, Green Bay BEFAST then SNoW in Milwaukee LAMS in Oshkosh, DePere, Ashwaubenon, Two Rivers Mehul 2013

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55 Only state I can determine who has currently MANDATED a particular stroke scale Rhode Island - LAMS/LAPSS

56 If you don t know what your local EMS system is comprised of That s OK - but maybe ask around Your Stroke ED Liaison MD The Medical Director of your Local EMS - hospital admin will know who that is Don t be afraid to reach out and discuss their stroke protocol & help to optimize it if necessary

57 MJ Case Conclusion CSC 3hr8min Large M1 Occlusion CT Perfusion 08:30 Groin Puncture 09:09 Arrival NIH: 20 Post-Procedure NIH: 8 D/C NIH: 0

58 In Summary: Many scoring systems tend to be regional did your local neurologist devise a scale? some hospital systems pick a given scale and go with it Most frequently used for field treatment & study comparisons CPSS LAMS by default, are the best studied and most robust data for these 2 scoring systems All seem to perform legitimately Simple is often just as good as complex

59 Lastly: If you have not yet met your local EMS, please meet with them - start with their medical director or service director determine if/which stroke scale they use There is significant heterogeneity in stroke scales, which is best depends on many factors No stroke scale can reliably distinguish between LVO vs hemorrhagic

60 Thank You!

61 References American Heart Association (2011). Advanced Cardiovascular Life Support Provider Manual. USA: First American Heart Association Printing. p ISBN Brandler et al. Prehospital stroke scales in urban environments: a systematic review. Neurology. 2014; 82: Bray et al. Paramedic identification of stroke: Community validation of the melbourne ambulance stroke screen. Cerebrovasc Dis : Bray et al. Paramedic diagnosis of stroke: examining long-term use of the Melbourne Ambulance Stroke Screen (MASS) in the field. Stroke : Crocco et al. EMS Management of Acute Stroke-Prehospital Triage (Resource Document to NAEMSP Position Statement). Prehospital Emergency Care (3): Fothergill et al. Does Use of the Recognition of Stroke in the Emergency Room Stroke Assessment Tool Enhance Stroke Recognition by Ambulance Clinicians? Stroke : Higashida et al. American Heart Association Advocacy Coordinating Committee. Interactions within stroke systems of care: a policy statement from the American Heart Association (44): Khatri et al. Good clinical outcomes after ischemic stroke with successful revascularization is time-dependent. Neurology. 2009: (73) Khatri et al. Time to Angiographic Reperfusion & Clinical Outcome after Acute Ischemic Stroke in the Interventional Management of Stroke Phase III (IMS III) Trial: A Validation Study. Lancet Neurol. 2014: 13(6) Kidwell et al. Identifying Stroke in the Field: Prospective Validation of Los Angeles Prehospital Stroke Screen (LAPSS). Stroke (31): Kothari et al. Acute stroke: delays to presentation and emergency department evaluation. Ann Emerg Med (1): 3-8 Lansberg et al. Treatment time-specific number needed to treat estimates for tissue plasminogen activator therapy in acute stroke based on shifts over the entire range of the modified Rankin Scale. Stroke. 2009:

62 References Lima et al. The Field Assessment Stroke Triage for Emergency Destination (FAST-ED): A Simple and Accurate Prehospital Scale to Detect Large Vessel Occlusion Strokes. Stroke (8): Mehul et al. Emergency Medical Services Capacity for Prehospital Stroke Care in North Carolina. Prev Chronic Dis :E149. Mingfeng et al. Validation of the use of the ROSIER scale in prehospital assessment of stroke. Ann Indian Acad Neurol (3): Ossa et al. Design and validation of a prehospital stroke scale to predict large arterial occlusion: the rapid arterial occlusion evaluation scale. Stroke. 2014(45)1: Rudd et al. A systematic review of stroke recognition instruments in hospital and prehospital settings. Emerg Med J : Schroeder et al. Determinants of use of emergency medical services in a population with stroke symptoms: the second delay in accessing stroke healthcare study. Stroke. 2000(31): Schuberg et al. Impact of Emergency Medical Services Stroke Routing Protocols on Primary Stroke Center Certification in California. Stroke (44) Studneck et al. Assessing the validity of the Cincinnati prehospital stroke scale and the medic prehospital assessment for code stroke in an urban emergency medical services agency. Prehosp Emerg Care (3): Teleb et al. Stroke vision, aphasia, neglect (VAN) assessment - a novel emergent large vessel occlusion screening tool: pilot study and comparison with current clinical severity indices. Journal of NeuroInterventional Surgery Published Online First: 17 February doi: /neurintsurg Turc et al. Clinical Scales Do Not Reliably Identify Acute Ischemic Stroke Patients With Large-Artery Occlusion. Stroke. 2016: Vagal et al. Time to angiographic reperfusion in acute ischemic stroke: decision analysis. Stroke. 2014: (45) van Gaal et al. Approaches to the filed recognition of potential thrombectomy candidates. International Journal of Stroke. 2017: 0(0). 1-10