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ASSESSING THE ACUTE POSTERIOR STROKE

LIZNABER,RN,BSN,CEN

JONAHSALYERS,RN,CEN,TCRN,EMT-B

POSTERIOR CIRCULATION STROKES IN THE ED LIZNABER,RN,BSN,CEN

CASE STUDY A65y.o.malepresentstoyouremergencydepartmentviasquadat1905staNng“Ifeelreallydizzy”.CPSSisnegaNvepersquad.FSBSis114.VSS.

Hehasahistoryofhypertension,Diabetes,andcoronaryarterydiseasewithmulNplestents.Hesaysthesesymptomsstartedat1815whenhegotuptousethebathroom.

VS:BP166/90HR92RR14T98.3EKGNSR

WNL:urinalysis,drugscreen,CBC,CMP,PT/PTT/INR

CT:noacuteintracranialabnormaliNes

NIHSS:0

Administered324ASAandadmiaedtothehospitalforfurtherevaluaNon

NIHSS

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INTRODUCTION IntheUS,Stroke:Ø  Isthe5thleadingcauseofdeathandnumberonecauseofmajordisability(CDC,2016)Ø Annualincidence:800,000eachyear(CDC,2016)

Ø  IschemicStrokesaccountfor87%ofallstrokes(ASA,2016)

Ø PosteriorStrokesaccountfor20-25%oftheseIschemic Strokes(Knight,2016)

THE MATH

•  800,000x87%=696,000ischemicstrokes

•  696,000x20%=139,200posteriorstrokes(lowend)

•  696,000x25%=174,000(highend)

• 139,200to174,000posteriorstrokesannuallyintheUS

POSTERIOR CIRCULATION (PC)

•  AposteriorcirculaNon(PC)strokeisclassicallydefinedbyinfarcNonoccurringwithinthevascularterritorysuppliedbythevertebro-basilar(VB)arterialsystem.

•  PosteriorcirculaNonsuppliesthebrainstem,cerebellum,andoccipitalcortex

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PC STROKE SYMPTOMS

•  5DsofPosteriorStrokeSymptoms•  Dizziness•  Dystaxia-shakylimbmovementsorunsteadygait•  Dysphagia-difficultyswallowing•  Dysarthria-slurredspeech•  Diplopia-doublevision

Knight,2016

NATIONAL INSTITUTE OF HEALTH STROKE SCALE (NIHSS)

MISSED OPPORTUNITIES

•  NIHStrokeScale:

•  Thepreferredmethodofassessingstrokes(Knight,2016)

•  ShowsLITTLEsensiNvitytoposteriorcirculaNonstrokes(Arch,2016)

•  Posteriorstrokesare3xaslikelytobemissedintheEmergencyRoom

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ASSESSING THE POSTERIOR CIRCULATION

•  DizzinessorVerNgo•  Isthemostcommonsymptominposteriorstrokesbeingseeninabout56%ofcases(Knight,2016)

•  AcuteVesNbularSyndrome(AVS)(Lee,2011)

•  ClinicalcondiNoncharacterizedbydizzinessorverNgothatdevelopsacutely

•  Accompaniedbynausea/vomiNng,gaitinstability,nystagmusandhead-moNonintolerance

•  Thisisseenfromperipheralorcentralcauses

TheinabilityfortheNIHStrokeScaletoreliablydetectposteriorstrokesrepresentsaprac;cegap

BRIDGING THE GAP

•  “HowarewegoingtoassessposteriorcirculaNoninabusyemergencyroom?”

BRIDGING THE GAP

•  AnEvidenceBasedPracNceEvaluaNon•  AmbulaNonassessmentwillassessposteriorcirculaNonofthebrain(Lever,etal,

2013)

•  Pushback•  That’safallrisk!•  AppropriateindicaNons

•  Dizziness/verNgo•  LowscoringNIHStrokeScales• NoidenNfiedmajorneurologicimpairment

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AMBULATION ASSESSMENT

CASE STUDY UPDATE

•  A65y.o.malepresentstoyouremergencydepartmentviasquadat1905staNng“Ifeelreallydizzy”.Hehasahistoryofhypertension,Diabetes,andcoronaryarterydiseasewithmulNplestents.Hesaysthesesymptomsstartedat1815whenhegotuptousethebathroom.

•  VS:BP166/90HR92RR14T98.3EKGNSR

•  CT:noacuteintracranialabnormaliNes•  NIHSS:0

•  Administered324ASAandadmiaedtothehospitalforfurtherevaluaNon

•  MRIthenextmorning:CerebellarStroke

CASE STUDY CONTINUED

At2330(5hrsand15minapersymptomsonset)thepaNentissNllintheEDwaiNngforaneurologyfloorbed.AtthisNmetheadmirnghospitalistcomestoevaluatethepaNent.TheMDwalksuptothenursewhohasbeencaringforthepaNentandasksifthepaNenthaswalkedatalltonight.ThenurseinformedhimthathehadnotstoodorwalkedintheEDforfearoffallingduetohisdizziness.ThehospitalistaskedthenursetocomehelphimwalkthepaNent.UponstandingthepaNentimmediatelystartedleaningheavilyontothephysicianwhowasstandingonthepaNentsright.ThepaNentwasunabletostandupstraightorambulatewithoutthephysicianandnursephysicallyholdingupthepaNent.

ThisiswhywemustfurtherassessourlowscoringstrokepaNents.

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HINTS+ JONAHSALYERS,RN,CEN,TCRN,EMT-B

HINTS+

•  HeadImpulse

•  Nystagmus

•  TestofSkew

HEAD IMPULSE

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NYSTAGMUS

TEST OF SKEW

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REFERENCES

Arch,A.E.,Weisman,D.C.,Coca,S.,Nystrom,K.V.,WiraC.R.,&Schindler,J.L.(2016).Missedischemicstrokediagnosisintheemergencydepartmentbyemergencymedicineandneurologyservices.AmericanStrokeAssociaNon.doi:10.1161/STROKEAHA.115.010613

Knight,W.(2016).FocusonStroke:BeyondtheNIHSS-AssessingstrokepaNentswithlowNIHSSscores.[GenentechWebinar]March9,2016.Retrievedfromhap://idmeeNngs.com/FocusOnStroke/Aaend

Lee,H.(2014).IsolatedVascularVerNgo.JournalofStroke,16(3),124-130.

Lee,W.,Chen,L.,&Waterston,J.(2011).Vertebrobasilarischaemia(sic)presenNngasrecurrentisolatedverNgo.ActaOto-Laryngologica,131(8),887-889.doi:10.3109/00016489.2011.562920

Weingart,S.(2010).Videofordiagnosingposteriorstroke.Retrievedfrom hap://emcrit.org/misc/posterior-stroke-video/