ASSESSING THE ACUTE POSTERIOR STROKE LIZ NABER, RN, BSN, CEN JONAH SALYERS, RN, CEN, TCRN, EMT-B POSTERIOR CIRCULATION STROKES IN THE ED LIZ NABER, RN, BSN, CEN CASE STUDY A 65 y.o. male presents to your emergency department via squad at 1905 stanng I feel really dizzy. CPSS is neganve per squad. FSBS is 114. VSS. NIHSS He has a history of hypertension, Diabetes, and coronary artery disease with mulnple stents. He says these symptoms started at 1815 when he got up to use the bathroom. VS: BP 166/90 HR 92 RR 14 T 98.3 EKG NSR WNL: urinalysis, drug screen, CBC, CMP, PT/PTT/INR CT: no acute intracranial abnormalines NIHSS: 0 Administered 324 ASA and admiaed to the hospital for further evaluanon 1
INTRODUCTION In the US, Stroke: Ø Is the 5 th leading cause of death and number one cause of major disability (CDC, 2016) Ø Annual incidence: 800, 000 each year (CDC, 2016) Ø Ischemic Strokes account for 87% of all strokes (ASA, 2016) Ø Posterior Strokes account for 20-25% of these Ischemic Strokes (Knight, 2016) THE MATH 800, 000 x 87% = 696, 000 ischemic strokes 696, 000 x 20% = 139, 200 posterior strokes (low end) 696, 000 x 25% = 174, 000 (high end) 139, 200 to 174, 000 posterior strokes annually in the US POSTERIOR CIRCULATION (PC) A posterior circulanon (PC) stroke is classically defined by infarcnon occurring within the vascular territory supplied by the vertebrobasilar (VB) arterial system. Posterior circulanon supplies the brainstem, cerebellum, and occipital cortex 2
9/18/16 PC STROKE SYMPTOMS 5 Ds of Posterior Stroke Symptoms Dizziness Dystaxia- shaky limb movements or unsteady gait Dysphagia- difficulty swallowing Dysarthria- slurred speech Diplopia- double vision Knight, 2016 NATIONAL INSTITUTE OF HEALTH STROKE SCALE (NIHSS) MISSED OPPORTUNITIES NIH Stroke Scale: The preferred method of assessing strokes (Knight, 2016) Shows LITTLE sensinvity to posterior circulanon strokes (Arch, 2016) Posterior strokes are 3x as likely to be missed in the Emergency Room 3
ASSESSING THE POSTERIOR CIRCULATION Dizziness or VerNgo Is the most common symptom in posterior strokes being seen in about 56% of cases (Knight, 2016) Acute VesNbular Syndrome (AVS) (Lee, 2011) Clinical condinon characterized by dizziness or verngo that develops acutely Accompanied by nausea/vominng, gait instability, nystagmus and head-monon intolerance This is seen from peripheral or central causes The inability for the NIH Stroke Scale to reliably detect posterior strokes represents a prac;ce gap BRIDGING THE GAP How are we going to assess posterior circulanon in a busy emergency room? BRIDGING THE GAP An Evidence Based PracNce EvaluaNon AmbulaNon assessment will assess posterior circulanon of the brain (Lever, et al, 2013) Push back That s a fall risk! Appropriate indicanons Dizziness/verNgo Low scoring NIH Stroke Scales No idennfied major neurologic impairment 4
AMBULATION ASSESSMENT CASE STUDY UPDATE A 65 y.o. male presents to your emergency department via squad at 1905 stanng I feel really dizzy. He has a history of hypertension, Diabetes, and coronary artery disease with mulnple stents. He says these symptoms started at 1815 when he got up to use the bathroom. VS: BP 166/90 HR 92 RR 14 T 98.3 EKG NSR CT: no acute intracranial abnormalines NIHSS: 0 Administered 324 ASA and admiaed to the hospital for further evaluanon MRI the next morning: Cerebellar Stroke CASE STUDY CONTINUED At 2330 (5hrs and 15min aper symptoms onset) the panent is snll in the ED wainng for a neurology floor bed. At this Nme the admirng hospitalist comes to evaluate the panent. The MD walks up to the nurse who has been caring for the panent and asks if the panent has walked at all tonight. The nurse informed him that he had not stood or walked in the ED for fear of falling due to his dizziness. The hospitalist asked the nurse to come help him walk the panent. Upon standing the panent immediately started leaning heavily onto the physician who was standing on the panents right. The panent was unable to stand up straight or ambulate without the physician and nurse physically holding up the panent. This is why we must further assess our low scoring stroke panents. 5
HINTS+ JONAH SALYERS, RN, CEN, TCRN, EMT-B HINTS+ Head Impulse Nystagmus Test of Skew HEAD IMPULSE 6
NYSTAGMUS TEST OF SKEW 7
REFERENCES Arch, A. E., Weisman, D.C., Coca, S., Nystrom, K.V., Wira C.R., & Schindler, J. L. (2016). Missed ischemic stroke diagnosis in the emergency department by emergency medicine and neurology services. American Stroke AssociaNon. doi:10.1161/strokeaha.115. 010613 Knight, W. (2016). Focus on Stroke: Beyond the NIHSS-Assessing stroke panents with low NIHSS scores. [Genentech Webinar] March 9, 2016. Retrieved from hap://idmeenngs.com/focusonstroke/aaend Lee, H. (2014). Isolated Vascular VerNgo. Journal of Stroke, 16(3), 124-130. Lee, W., Chen, L., & Waterston, J. (2011). Vertebrobasilar ischaemia (sic) presennng as recurrent isolated verngo. Acta Oto-Laryngologica, 131(8), 887-889. doi:10.3109/00016489.2011.562920 Weingart, S. (2010). Video for diagnosing posterior stroke. Retrieved from hap://emcrit.org/misc/ posterior-stroke-video/ 8