Initial patient assessment

Using F.A.S.T., Rosier, & NIHSSTools

5 Acute Trusts - 6 Primary Care Trusts – Ambulance Trust – 4 Local Authorities

Stroke Thrombolysis Awareness

Adapted from

Aims

Improve recognition of stroke and TIA

Develop skills for assessment and triage in acute settings

Gain familiarity with procedures required for thrombolysis

• Incidence of stroke now higher than that of acute coronary syndromes

• For 1 million inhabitants ,There will be 2400 strokes per year 

(1800 first‐ever, 600 recurrent or after TIA)Of these

– 700 (29%) will die– 600 (25%) will be dependent– 1100 (46%) will be independent

Background Information

• Stroke varies• All begin suddenly• ¼ patients do not leave hospital• ⅓ survivors need help every day due to:

WeaknessSpeech problemsSwallowing problemsVisual problemsMemory problems

• Urgent recognition & stroke unit admission improves recovery

Background Information

Initial Diagnosis

Clinical presentations of stroke

Acute onset combination ofFace / arm / leg weakness or sensory lossLoss of co-ordinationSpeech disturbanceVisual disturbance

Acute onset does not mean total deficit within secondsMost TIAs are < 20 minutes

Stroke? → ACT FAST

National Stroke Strategy

QM1, Raising Awareness, QM2 Time is Brain

F.A.S.T. Instructions

FACIAL MOVEMENTSAsk patient to show teeth, Is there an unequal smile or grimace,Note which side does not move well

ARM MOVEMENTSLift the patient’s arms together to 90º if sitting, 45º if supine and ask them to hold the position for 5 seconds before letting go, does one arm drift down or fall rapidly?If one arm drifts down or falls, note whether it is the patient’s left or right

SPEECH Listen for NEW disturbance of speechListen for slurred speech, get patient to say “British Constitution or Baby Hippopotamus”Listen for word-finding difficulties with hesitations. This can be confirmed by asking the patient to name objects that may be nearbysuch as a cup, chair, table, keys, pen

• Check with any person who knows the patient, IS THIS NORMAL FOR THEM

TIME to ring 999

ROSIER1st. Check Patient’s B.M. and correct if low

Score

Yes No

Has there been loss of consciousness or syncope? -1 0Has there been seizure activity? -1 0Has there been NEW ACUTE onset (including on wakening from sleep) ofAsymmetric facial weakness +1 0Asymmetric arm weakness +1 0Asymmetric leg weakness +1 0Speech disturbance +1 0Visual field deficit +1 0

• People with stroke or witnesses can usually tell you the moment it happened

• There should be no prodrome• Particular care with common differentials

– Bell’s palsy– Labyrinthitis– Demyelination– Space occupying lesion– Worsening previous neurology with infection

Sudden onset

• Abnormal movements are rare after stroke• Seizure at stroke onset is rare and a

contraindication to thrombolysis• Positive visual phenomena more likely to be

migraine• Headache is rare after stroke and rarely

prominent when present – consider SAH

Symptoms and signs of loss of function

• Seizures• Syncope (hypotension)• Sugar (hypo or hyper)• Sepsis (+ previous stroke)• Severe migraine• Space occupying lesions• Si-chological

Stroke mimics

So what’s the rush?

• Confirm stroke or TIA is the problem

• Help prevent complicationsi.e. aspiration, chest infections

• Consider emergency treatmentsE.G. Thrombolysis

• Admission to a stroke unitProved to be the best place for stroke patients

On arrival at A&E or the stroke unit, the diagnosis of a stroke or TIA

should be checked using an accepted test such as

ROSIER (Recognition of Stroke in the Emergency Room).

NICE clinical guideline 68Issue date: July 2008

National Guidance

• Seizures• Syncope (hypotension)• Sugar (hypo or hyper)• Sepsis• Severe migraine• Space occupying lesions• Si-chological

Stroke mimics

• Onset never established for ¼ patients• When the first symptom began• Not just when deteriorated later• Sleep – backdate to bedtime• Witnesses – when was last seen to be OK• Very important for

– Thrombolysis potential– TIA risk stratification

Why ?

• Systematic neurological assessment for stroke

• Quantitative measure of neurological deficit

• Reliable & reproducible tool

• ~ 5 mins to complete

• Score from 0 - 42

NIHSSNational Institutes of Health Stroke Scale

•Identify and assess neurological deficits in stroke patients

• Understand the measurement scale for quantifying neurological deficits in stroke patients

• Consistently apply appropriate scores for neurological deficits in stroke patients

• Use the scale to assess changes in neurological deficits in stroke patients over time

Why use the NIHSS ?

• Only score the first attempt at each instruction

• Do not help the patient

• Score what the patient actually does (not what you think they should be able to do)

• Attempt all tests, even if patient is aphasic

How to use NIHSS

Training for NIHSS

• Available on-line

• Simple to do

• Certificated for 2 years

• Link available on Network Website

• The more you do it, the easier it is

http://nihss-english.trainingcampus.net/UAS/Modules/TREES/windex.aspx

Any Questions