# Cincinnati stroke scale and other stroke symptoms



## RedheadErin (Aug 25, 2013)

Some questions abou tstroke, because I really cant find the answers: 

1. Is there a way to distinguish between ischemic and hemorrhagic stroke in the field? 

2. Is the Cincinnati Stroke Scale helpful for both kinds of sttoke or only ischemic stroke? 

3.  What kind of vitals are commonly found with iscehmic stroke?


----------



## VFlutter (Aug 25, 2013)

RedheadErin said:


> Some questions abou tstroke, because I really cant find the answers:
> 
> 1. Is there a way to distinguish between ischemic and hemorrhagic stroke in the field?
> 
> ...



1. No
2. Both
3. Vital signs may be WNL, they may be in A fib RVR, or may have Cushing's triad if it is accompanied by cerebral edema.


----------



## DesertMedic66 (Aug 25, 2013)

Chase said:


> 1. No
> 2. Both
> 3. Vital signs may be WNL, they may be in A fib RVR, or may have Cushing's triad if it is accompanied by cerebral edema.



Same answers


----------



## VFlutter (Aug 25, 2013)

I should mention that the Cincinatti Stroke Scale is more specific to ischemic strokes and was originally created to quickly identify stroke patients who would benefit from rapid thrombolytic therapy. However it is still valid with hemorrhagic stroke. 

Also, you can get a pretty good idea of the type and location of a stroke based off presentation and symptoms but that requires a solid understanding of neuroanatomy and a lot of practice. Just like a coronary artery occlusion an occluded cerebral artery will present in a very predictable way. Not that it really matters anyway, your treatment will not change.


----------



## RedheadErin (Aug 25, 2013)

Awesome! So then it seems like a test like the Cinci Stroke Scale is really the only reliable indicator of stroke in the field, unless they get so far as cerebral edema/ Cushing's Triad?


----------



## VFlutter (Aug 25, 2013)

RedheadErin said:


> Awesome! So then it seems like a test like the Cinci Stroke Scale is really the only reliable indicator of stroke in the field, unless they get so far as cerebral edema/ Cushing's Triad?



It is not the only realible indicator but it is the quickest and simplest scale that still has good sensitivity, Around 75-85%. 

A full NIHSS would be ideal but is no practical in the prehospital environment. It usually takes ~10 mins to complete. 

Cushing's triad is a very late sign and is not always present. If the patient is having an ischemic stroke and has Cushing's triad it means that a large area of tissue has infarcted and is now swelling (edema). You are past the point of intervention. If they are having a hemorrhagic stroke and have Cushing's triad then you know there is a large enough accumulation of blood to raise ICP and potentially displace tissue or herniate. Either way it is not really a useful sign for early recognition.


----------



## Wheel (Aug 25, 2013)

Chase said:


> It is not the only realible indicator but it is the quickest and simplest scale that still has good sensitivity, Around 75-85%.
> 
> A full NIHSS would be ideal but is no practical in the prehospital environment. It usually takes ~10 mins to complete.
> 
> Cushing's triad is a very late sign and is not always present. If the patient is having an ischemic stroke and has Cushing's triad it means that a large area of tissue has infarcted and is now swelling (edema). You are past the point of intervention. If they are having a hemorrhagic stroke and have Cushing's triad then you know there is a large enough accumulation of blood to raise ICP and potentially displace tissue or herniate. Either way it is not really a useful sign for early recognition.



With longer transport times I don't see how it would hurt to do a more in depth stroke scale like the NIHSS. True, not all of it would be feasible to do in the back of the ambulance, but much could. I'd think it would be a much better (and impressive in my opinion) use of time than sitting on your hands and monitoring vitals.


----------



## VFlutter (Aug 25, 2013)

Wheel said:


> With longer transport times I don't see how it would hurt to do a more in depth stroke scale like the NIHSS. True, not all of it would be feasible to do in the back of the ambulance, but much could. I'd think it would be a much better (and impressive in my opinion) use of time than sitting on your hands and monitoring vitals.



If you have the time then by all means go for it. It would provide valuable information for the hospital and a detailed baseline to evaluate changes in condition. However, the NIHSS is somewhat difficult to do correctly. If you are going to do it makes sure you do it properly. 

The NIH Stroke certifications was one of the hardest courses to get through. It was very intense and in-depth.


----------



## Wheel (Aug 25, 2013)

Chase said:


> If you have the time then by all means go for it. It would provide valuable information for the hospital and a detailed baseline to evaluate changes in condition. However, the NIHSS is somewhat difficult to do correctly. If you are going to do it makes sure you do it properly.
> 
> The NIH Stroke certifications was one of the hardest courses to get through. It was very intense and in-depth.



Are you referring to the online course? Reading about that made me a little wary, but if it's thorough and in depth I may go through with it.

http://learn.heart.org/ihtml/application/student/interface.heart2/nihsscomputer.html


----------



## mycrofft (Aug 25, 2013)

Good thread!!!

I feel doing something because you're bored and "alone" in the back of an ambulance could _maybe_ become negative if you are rehearsing something (reinforcing it) the wrong way (no feedback), but I've done it myself. As long as the pt can benefit from it and the risk is nil...

My understanding hereabouts is that, once the pt is admitted, no thrombolytic Rx is given until someone has done some STAT imaging. Screening is screening, not reaching a firm-enough provisional diagnosis to indicate treatment path.

(As in, on scene, "Oh, Harry had this killer headache before dinner and took a couple aspirin, it didn't go away so he took three Advils...").


----------



## VFlutter (Aug 25, 2013)

Wheel said:


> Are you referring to the online course? Reading about that made me a little wary, but if it's thorough and in depth I may go through with it.
> 
> http://learn.heart.org/ihtml/application/student/interface.heart2/nihsscomputer.html



This is the course I had to take. 
http://www.apexinnovations.com/store/Hemispheres.php


----------



## CPRinProgress (Aug 25, 2013)

I thought that one thing that a hemorragic stroke will be accompanied by a head ache where an ischaemic stroke will usually not.  Am I remembering that right or an I wrong.


----------



## VFlutter (Aug 25, 2013)

CPRinProgress said:


> I thought that one thing that a hemorragic stroke will be accompanied by a head ache where an ischaemic stroke will usually not.  Am I remembering that right or an I wrong.



A rupturing cerebral aneurysm is commonly described as a sudden intense headache but that does not mean all hemorrhagic stroke patients will have a headache. I have never heard a ischemic stroke patient complain of a headache but then again they are probably more worried about their hemiparesis and aphasia.


----------



## CPRinProgress (Aug 25, 2013)

Ok I must be remebering right.  Thanks though.  But prehospital is there anything different on either paramedic  or basic with treatment.


----------



## mycrofft (Aug 26, 2013)

CPRinProgress said:


> Ok I must be remebering right.  Thanks though.  But prehospital is there anything different on either paramedic  or basic with treatment.



Only difference I can think of for spontaneous CVA with bleed (or head injury with intracranial bleed) versus embolic CVA is keep head elevated some for bleed and doesn't matter do either for embolic. But since only  the traumatic ones can be definitely deduced in the field, why not avoid keeping the head flat to torso for a pt who may have either? (And spinal immobilization IF INDICATED).


----------



## TheLocalMedic (Aug 26, 2013)

The majority of all strokes you will encounter will be ischemic, and the Cincinnati Stroke Scale is a good indicator as to whether or not a CVA is taking place.  For each positive finding there's an increasing percentage that there is an actual CVA occurring (I can't recall the specific numbers off the top of my head, but if you have speech impairment - dysphasic or dysarthic - arm weakness/drift and facial droop, it's something around 98% certainty).  

Roughly 15% of CVAs are bleeds, however those are nearly always associated with trauma or involve a younger population group.  

My rule of thumb is that you can assume an ischemic stroke with one or more positive CSS findings unless there is known trauma or patient is less than 40 years of age.  Spontaneous bleeds are not terribly common, but they do happen...

With that said, you must also be aware of some of the less-common stroke presentations that may not have positive findings on the CSS.  Sudden weakness, acute global amnesia, balance issues and paresthesia may also be indicators of a CVA, among many other symptoms.  

If there's any question about whether or not a patient is having a CVA, always err on the side of caution and assume the worst.  And rely on your gut as well.  If something strikes you as being off with a patient's presentation but you can't say for certain that it's neurological in nature, trust your instincts when that little bell chimes in the back of your head.


----------



## savemachine (Aug 27, 2013)

*Cs*

For #1 and #2, the Cincinnati Stroke indicator provides 72%-85% hit rate on identifying ischemic stroke. That's it. Further identification isn't necessary in an out-of-hospital situation as far as I understand and should be left with the pros in the hospital stroke center.



RedheadErin said:


> Some questions abou tstroke, because I really cant find the answers:
> 
> 1. Is there a way to distinguish between ischemic and hemorrhagic stroke in the field?
> 
> ...


----------



## Bullets (Aug 27, 2013)

For an EMT who can not do BGL, Cincinnati is your front line neuro assessment. If they are positive then you can move on to some more advanced  stroke assessments. CSS wont tell you what type of stroke it is, but the MEND or sometimes called the Miami Scale will.

Also, strokes are not ALS calls. They are BLS calls and require rapid transport to COMPREHENSIVE stroke centers. Only those centers that have been certified as COMPREHENSIVE by The Joint Commission have the full range of treatments to help a stroke victim.  Know your MEND test, and walk into an ER and tell them exactly where to look for the clot...Ive taken the class given by Miami Emergency, and it is awesome.


----------



## DesertMedic66 (Aug 27, 2013)

Bullets said:


> For an EMT who can not do BGL, Cincinnati is your front line neuro assessment. If they are positive then you can move on to some more advanced  stroke assessments. CSS wont tell you what type of stroke it is, but the MEND or sometimes called the Miami Scale will.
> 
> Also, strokes are not ALS calls. They are BLS calls and require rapid transport to COMPREHENSIVE stroke centers. Only those centers that have been certified as COMPREHENSIVE by The Joint Commission have the full range of treatments to help a stroke victim.  Know your MEND test, and walk into an ER and tell them exactly where to look for the clot...Ive taken the class given by Miami Emergency, and it is awesome.



The hospitals around here have us run stroke calls as ALS due to the fact they can get a BGL, 12-lead, 2 IVs, and blood draws.


----------



## Tigger (Aug 27, 2013)

DesertEMT66 said:


> The hospitals around here have us run stroke calls as ALS due to the fact they can get a BGL, 12-lead, 2 IVs, and blood draws.



That's how it is around here minus the blood draws. Hospital wants at least two IVs in place if the transport time is long enough so they can get right to work, or so I am told.


----------



## Bullets (Aug 28, 2013)

DesertEMT66 said:


> The hospitals around here have us run stroke calls as ALS due to the fact they can get a BGL, 12-lead, 2 IVs, and blood draws.



My hospital still has a thing with "thier IVs" and they dont take bloods, so its not really an issue


----------

