Fast Thinking

     Attack One responds to a call for a woman who is ill. The crew arrives on the scene to find a 72-year-old female with facial droop and weakness on her left side. Her family had discovered these new developments when they fed her breakfast. She has a pulse rate of 64, a blood pressure of 210/100, a respiratory rate of 24 and a pulse oximeter reading of 95%. She is afebrile and, on complete assessment, has no other signs of trauma.

     The patient is not speaking, but she can follow the crew's directions, and responds to simple commands to lift her right arm and move her right leg. She is able to shake her head no when asked if she has any pain. She is attached to the cardiac monitor and pulse oximeter and provided four liters a minute of O2 via cannula. The patient is not drooling, and when asked to swallow, she complies. She is then asked to swallow a sip of water, which she can do. This makes the medic crew comfortable that she can protect her airway, so they will be able to give her aspirin if requested by medical direction.

Prehospital Impressions
     This patient is having an acute neurologic event, one which we would generally call a stroke. The Attack One responders perform a rapid assessment they organize by "Think FAST," an algorithm created to improve the timeliness of care for stroke patients. This evaluation includes the elements of the Cincinnati Prehospital Stroke Scale, a scale that predicts the patients most likely to benefit from activation of a stroke team. The Stroke Scale focuses the prehospital exam on abnormal findings in the examination of the face, arm and speech (FAS). Think FAST adds time of onset (T) to the elements to be evaluated.

     The Cincinnati Prehospital Stroke Scale asks the EMT to evaluate and record abnormal findings on any one of three exam points:

     Facial Droop

• Normal: Both sides of the face move equally well.
  
• Abnormal: One side of the face does not move as well as the other.

     Arm Drift

• Normal: Both arms move the same or don't move at all.
  
• Abnormal: One arm doesn't move or drifts down compared to the other.

     Speech

• Normal: Patient says the correct words without slurring. Ask the patient to say, "The sky is blue in Cincinnati."
  
• Abnormal: Patient slurs words, says the wrong words or is unable to speak.

Time of onset
     This is the time when the first abnormal findings are noted by the patient or those around him (family, friends, caregivers). Some stroke patients are "found down" and not able to communicate when their symptoms began. The time of onset on these patients, then, is the last time they were known to be functioning well.

     The most important new therapies for stroke treatment are dedicated to those patients who have care available within three hours of time of onset.

Think FAST Evaluation of This Patient
     The patient has a significant droop of her face on the left side, is unable to lift her left arm and is unable to speak. The time of onset is marked by the family as approximately 30 minutes prior to EMS activation. The Attack One crew therefore calculates it as 0810 hours.

Hospital Course
     A hospital with a developed stroke evaluation and rapid management program is located within a 15-minute transport time, and is an acceptable treatment destination for both the patient and her family. Medical control is contacted at that hospital and, with the excellent stroke history and evaluation performed by the Attack One crew, activates its stroke response team. The emergency physician requests that four baby aspirin be administered to the patient. On arrival at the hospital, a CT scan is prepared for her. She has an expedited ED evaluation, and within 10 minutes is en route for a CT scan of her head. The scan shows no evidence of bleeding in the head, no signs of cancer and no other abnormalities. The patient is a candidate for aggressive treatment of a stroke caused by a clot in the cerebral circulation. She is taken to the intervention lab before the medic crew is able to complete its documentation and return to service.

     A grateful family calls the fire station that evening and reports that the patient had a successful procedure to reopen a clotted artery providing blood to the area of the right cerebral cortex that controls the musculature of the left side of the body. The patient is now able to speak and relays her personal gratitude to the medics.

Case Discussion
     This patient had an underlying history of hypertension and no prior history of neurologic problems. She had the classic onset of a stroke caused by arterial occlusion. A stroke caused by sudden bleeding into the brain, or a ruptured aneurysm, has symptoms that are much more dramatic and striking to the family and EMS providers. Strokes caused by arterial occlusion are painless; associated with deficits in movement, speech and sensation; and rarely cause vomiting or loss of consciousness.

     This patient had a classic presentation of expressive aphasia, which is commonly associated with strokes from arterial occlusion. These strokes impair the patient's ability to form words and use the muscles needed to express those words. The patient retains the ability to understand the speaker, follow directions and react in nonverbal ways. The patient may be very frustrated, even tearful, at his or her inability to communicate using speech to family and rescuers. Fortunately, the stroke treatment delivered to this patient allowed her to recover all speech function.