Emergency Medical Services (EMS) Agency

CASE OF THE MONTH – NOVEMBER 2018

Case Presentation

Paramedics respond to the home of a 64 year-old man with weakness and difficulty speaking.  His wife reports that he woke up at around 8am this morning.  Upon waking he was drooling, unable to talk, and unable to move his right side.  The wife states that the patient went to bed last night at 8:30pm and seemed fine. His only medical problem is hypertension controlled by medication.  He is typically very active and runs recreationally.

– Stroke/CVA/TIA

– The patient has local neurological signs with speech disturbances and unilateral weakness, suggesting a stroke.

– Assess the airway.  Initiate necessary airway maneuvers.

– Administer oxygen as needed.

– Initiate cardiac monitoring

– Establish vascular access as needed

– Check blood glucose

– Assess for signs of trauma

– Perform an mLAPSS

On evaluation the patient is lying in bed, alert, and non-verbal.  His vital signs: BP 184/90; HR 110; RR 22; oxygen saturation 98%.  Cardiac monitoring demonstrates an irregularly irregular rhythm consistent with atrial fibrillation.  His neurologic exam shows right facial droop and eyes are deviated to the left.  The patient is noted to have no grip on the right, he cannot move his right leg, and his right arm falls rapidly when checking for drift.  He has normal strength on the left.  His blood glucose is 123 mg/dL.  There are no signs of trauma.

– Yes.

– “Symptom duration < 6 hours” is no longer an mLAPSS requirement

– A positive mLAPSS includes:

    • No history of seizures or epilepsy
    • Age 40 years or older
    • At baseline, patient is not wheelchair bound or bedridden
    • Blood glucose between 60 and 400 mg/dL
    • Obvious asymmetry-unilateral weakness with any of the following motor exams:

a. Facial Smile/Grimace

b. Grip

c. Arm Strength

– The patient’s LAMS is 5:  Right facial droop (1 point), right arm falls rapidly (2 points), no grip strength on right (2 points)

– LAMS scoring is as follows:

    •  Facial Droop

a. Absent = 0
b. Present = 1

    •  Arm Drift

a. Absent = 0
b. Drifts down = 1
c. Falls rapidly = 2

    • Grip Strength

a. Normal = 0
b. Weak Grip = 1
c. No Grip = 2

– The mLAPSS is a validated tool that helps to identify stroke mimics and excludes patients that will not benefit from stroke care.   It does not identify all strokes but is a useful screening tool.

– If the mLAPSS is positive, the Los Angeles Motor Scale (LAMS) should be calculated.  The LAMS is a tool used to quantify stroke severity in the field and the likelihood of a large vessel occlusion that may benefit from specialized care at a Comprehensive Stroke Center (CSC).

– One may always use judgement in discussion with base to transport to an appropriate stroke center if stroke is suspected.  Final authority for patient destination rests with the base hospital.

– Documentation of the mLAPSS and LAMS is critical for ensuring quality of care.

– 2030 the previous night (time should be documented in military time and date should be documented)

– LKWT, as per Ref. 521, is defined as, “The time (military time) at which the patient was last known to be without the signs and symptoms of the current stroke, or at his or her prior baseline”.

– Comprehensive Stroke Center (CSC)

– All patients who have a positive mLAPSS and LKWT within 24 hours shall be transported to a LA County EMS Agency designated stroke center.

– Per Stroke Patient Destination, Ref. No. 521, patients with suspected acute onset (LKWT within 24 hours) stroke symptoms and a LAMS of 4 or greater are transported to the CSC, if transport time is less than 30 minutes.

– Patients with suspected acute onset (LKWT within 24 hours) stroke symptoms and a LAMS of 3 or less are transported to the closest stroke center.

– Note that most “wake up strokes” will have an LKWT within 24 hours.

– The patient bypasses a Primary Stroke Center (PSC) en route to the closest Comprehensive Stroke Center (CSC).  He is taken directly to CT scan where he is determined to have an acute occlusion of his left middle cerebral artery.  He is administered TPA in the emergency department and then taken to interventional radiology where the clot is removed from his middle cerebral artery and cerebral blood flow is restored.  The patient’s symptoms markedly improve and after 3 days he walks out of the hospital with minimal residual deficits.  He is discharged on anticoagulation for atrial fibrillation.

– Stroke is a vascular injury reducing cerebral blood flow to a specific region of the brain causing neurologic impairment.  The categories of stroke include ischemic stroke, intracerebral hemorrhage and subarachnoid hemorrhage.   The prompt recognition and management of stroke is important because every minute 1.9 million neurons, 14 billion synapses and 7 miles of myelinated fibers are destroyed.

– Timely access to specialized stroke care improves patient outcomes.

– Stroke care is a dynamic field.  The DAWN and DEFUSE-3 trials are recent studies that have demonstrated outcome benefit for a subset of stroke patients that receive thrombectomy for treatment of their stroke.  These trials demonstrated clinical benefit beyond the 6 hour time frame previously established, with potential clinical benefit up to 24 hours from symptom onset.

– DAWN Trial – https://www.ncbi.nlm.nih.gov/pubmed/29129157

– DEFUSE-3 Trial – https://www.ncbi.nlm.nih.gov/pubmed/29364767

Information MD19