apid rterial o clusion xam RACE - AmericanCME...symptoms of stroke, and improve stroke recognition...
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Contact American CME by email at [email protected] with any questions regarding the contents of the RACE Supplemental Skill Guide. Rapid Arterial oCclusion Exam RACE Supplemental Skill Guide Purpose: The American CME RACE Supplemental Skill Guide has been produced to enhance the EMS provider’s ability to recognize LVO strokes by practicing the necessary hands on skills associated with the Rapid Arterial oCclusion Exam (RACE) stroke severity scale. This document has been produced as a supplement to the American CME EMS video-based continuing education course, “Stroke: A New Standard of Care for Large Vessel Occlusion (LVO)”. Visit www.AmericanCME.com to create an account and complete this video- based EMS CE. It is recommended to complete the online course prior to utilizing this guide to understand the science and the necessary background information. This guide provides step-by-step instructions that any EMS provider or EMS instructor may use for EMS training and education. In addition, multiple scenarios are included to aid in learning comprehension. Please note that this guide is not preapproved for EMS continuing education credits by any State agency. American CME encourages any EMS agency or jurisdiction to utilize this guide as they see fit.
Transcript of apid rterial o clusion xam RACE - AmericanCME...symptoms of stroke, and improve stroke recognition...
ContactAmericanCMEbyemailatAmericanCME@AmericanCME.comwithanyquestionsregardingthecontentsoftheRACESupplementalSkillGuide.
RapidArterialoCclusionExam
RACESupplementalSkillGuide
Purpose:TheAmericanCMERACESupplementalSkillGuidehasbeenproducedtoenhancetheEMSprovider’sabilitytorecognizeLVOstrokesbypracticingthenecessaryhandsonskillsassociatedwiththeRapidArterialoCclusionExam(RACE)strokeseverityscale.ThisdocumenthasbeenproducedasasupplementtotheAmericanCMEEMSvideo-basedcontinuingeducationcourse,“Stroke:ANewStandardofCareforLargeVesselOcclusion(LVO)”.Visitwww.AmericanCME.comtocreateanaccountandcompletethisvideo-basedEMSCE.Itisrecommendedtocompletetheonlinecoursepriortoutilizingthisguidetounderstandthescienceandthenecessarybackgroundinformation.Thisguideprovidesstep-by-stepinstructionsthatanyEMSproviderorEMSinstructormayuseforEMStrainingandeducation.Inaddition,multiplescenariosareincludedtoaidinlearningcomprehension.PleasenotethatthisguideisnotpreapprovedforEMScontinuingeducationcreditsbyanyStateagency.AmericanCMEencouragesanyEMSagencyorjurisdictiontoutilizethisguideastheyseefit.
ContactAmericanCMEbyemailatAmericanCME@AmericanCME.comwithanyquestionsregardingthecontentsoftheRACESupplementalSkillGuide.
TableofContents
SAMPLEEMSCONTINUINGEDUCATIONLESSONPLAN..................1-2
INTRODUCTION................................................................................3
LARGEVESSELOCCLUSION(LVO)STROKES........................................3
RAPIDARTERIALOCCLUSIONEXAM(RACE).......................................4
PERFORMINGRACE........................................................................5-6
SAMPLERACEFORM.........................................................................7
EMSTRANSPORTOPTIONS................................................................8
RACESCENARIOS.........................................................................9-18
WORKSCITED................................................................................19
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SampleEMSContinuingEducationLessonPlan
NOTE:EMSagenciesshouldmodifythissamplelessonplantomeettheirlocalorStateEMSeducationstandards,asneeded.Title:IdentifyingLVOStrokeswithRACECreditCategory:PatientAssessmentTopic:IdentifyingLargeVesselOcclusion(LVO)StrokesusingtheRapidArterialoCclusionEvaluation(RACE)Presenter:TBDCourseDescription:RecognitionofLVOinthefieldandtriagetotheclosestappropriatestrokecenterisacriticalskillforEMSproviders.ThisCEsessionisdesignedtoallowstudentstodeveloppsychomotorcompetencyperformingRapidArterialoCclusionEvaluation,orRACE,throughscenario-basedtraining.Students(EMSproviders)willperformapatientassessmentonasimulatedpatient,quantifystrokeseverityusingRACE,andindicatetheclosestappropriatestrokecentertotransportthepatient.Competencywillbegainedthroughrepetitionandguidancefromtheinstructors.ThispracticalisdesignedtogiveEMSprofessionalstheconfidencetoperformacompletestrokeassessmentutilizingRACEinthefieldandmakequalityemergencytransportdecisionsbasedonthecapabilitiesandlimitationsofvariousstrokecenters.EMSContinuingEducationCredits:
MFR/EMR:1Hour EMT:1Hour AEMT:1HourParamedic:1Hour
CourseObjectives:● Defineanddescribelargevesselocclusion(LVO)stroke. ● DefineanddescribetheRapidArterialoCclusionExam(RACE)andhowitidentifiesstrokeseverity. ● PerformapatientassessmentonasimulatedpatientandincludetheperformanceofRACE. ● IdentifytheclosestappropriatestrokecenterforthesimulatedpatientbasedontheRACEscore,aswell
asotherassessmentfindings. NOTE:AmericanCMEhasdevelopedthisCElessonplanandoutlinetobeusedormodifiedbyanyEMSproviderorinstructorfortheirspecificeducationalandtrainingneeds.Thislessonplancanbemodifiedtosuittheneedsofaninstructor'sagencyorgoverningbody.ItistheresponsibilityofanyinstructorthatutilizesthisinformationtogainapprovalfromtheirlocaljurisdictionorstatethatapprovesEMSCE.
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SampleCELessonPlanOutline
NOTE:EMSagenciesshouldmodifythissamplelessonplanoutlinetomeettheirlocalorStateEMSeducationstandards,asneeded.
1. Introductiona. StudentwillbegivenanoverviewofthisCEandinformedoftheexpectations.
2. LargeVesselOcclusion(LVO)Strokesa. Defineanddescribelargevesselocclusion(LVO)stroke.
3. RapidArterialoCclusionExam(RACE)a. DefineanddescribetheRapidArterialoCclusionExam(RACE)andhowitidentifiesstrokeseverity.
4. PerformingRACE:
a. List,describeanddemonstratethecomponentsofRACE.
5. EMSTransportOptionsa. IdentifytheclosestappropriatestrokecenterforthesimulatedpatientbasedontheRACEscore,aswellas
otherassessmentfindings.
6. RACEScenariosa. PerformacompletepatientassessmentonasimulatedpatientandincludetheperformanceofRACE.
b. Students(EMSproviders)will:
i. Performanassessmenton5separatesimulatedpatientsii. IdentifytheseverityofastrokeusingRACEiii. Indicatetheclosestappropriatestrokecentertotransportthepatientiv. Performasimulated“AcuteStrokeAlert”,whichcommunicatesthekeycriteriathatshouldbe
relayedtothereceivinghospital.
c. Scenario1-5i. Studentsareprovideddispatchinformationii. Studentsareprovidedasimulatedpatientthatmatchesdispatchinformationiii. Studentsperformacompletepatientassessment
1. Obtainnecessaryhistoryandvitalsigns2. PerformRACE3. Triagethepatienttoanappropriatedestination4. Providean“AcuteStrokeAlert”tothereceivingfacility
iv. Theinstructorwillobservethestudentsforstrengthsandareasthatcoulduseimprovement.Theseobservationswillbeusedtofacilitateabriefconversationbetweeneachscenario.
NOTE:AmericanCMEhasdevelopedthisCElessonplanandoutlinetobeusedormodifiedbyanyEMSproviderorinstructorfortheirspecificeducationalandtrainingneeds.Thislessonplancanbemodifiedtosuittheneedsofaninstructor'sagencyorgoverningbody.ItistheresponsibilityofanyinstructorthatutilizesthisinformationtogainapprovalfromtheirlocaljurisdictionorstatethatapprovesEMSCE.
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1. Introduction
a. StudentwillbegivenanoverviewofthisCEandinformedoftheexpectations.RecognitionofLVOinthefieldandtriagetotheclosestappropriatestrokecenterisacriticalskillforEMSproviders.ThisCEsessionisdesignedtoallowstudentstodeveloppsychomotorcompetencyperformingRapidArterialoCclusionEvaluation,orRACE,throughscenario-basedtraining.Students(EMSproviders)performapatientassessmentonasimulatedpatient,identifytheseverityofastrokeusingRACE,andindicatetheclosestappropriatestrokecentertotransportthepatient.Competencywillbegainedthroughrepetitionandguidancefromtheinstructors.ThispracticalisdesignedtogiveEMSprofessionalstheconfidencetoperformacompletestrokeassessmentutilizingRACEinthefieldandmakequalityemergencytransportdecisionsbasedonthecapabilitiesandlimitationsofvariousstrokecenters.
2. LargeVesselOcclusion(LVO)Strokes:
a. Defineanddescribelargevesselocclusion(LVO)stroke.
Allstrokesarenotequal.Justasstrokescanpresentwithdifferentsetsofsignsandsymptoms,dependingonwhatpartofthebrainisaffected,theycanalsovaryinseveritydependingonthesizeofthebloodvesselaffected.Alargevesselocclusion,orLVO,isakindofischemicstrokethataffectsanyoftheproximalbloodvesselsofthebrain,including;theinternalcarotidarteries,themiddlecerebralarteries,thebasilarartery,andtheanteriorcerebralarteries.TheobstructionofcerebralbloodflowinthepresenceofaLVOismoresevereduetotheinvolvementofthelargecerebralarteries.Greaterdeclinesincerebralbloodflowcorrelatewithmoreextensiveregionsofischemiaandincreasedbraintissuedeath.Infact,oneprospectivestudyshowedthepresenceofanLVOwasassociatedwitha5-foldincreaseindeath,anda3-folddecreaseingoodoutcomes(1).EvenmorealarmingistheprevalenceofLVOstrokes.StudieshaveshownthatnearlyhalfofallischemicstrokesareLVOs.(1)NotonlyarethestakesmuchhigherforstrokepatientswithLVOs,butstandardthrombolytictreatmentistypicallyineffective.ThelikelihoodoftPAclearingaclotdecreasesasthesizeoftheclotincreases.Asaresult,thesepatientsrequireearlyidentificationinthefieldandpriority1transporttoaninterventionalstrokecentercapableofmechanicalthrombectomywithastentretriever.Remember,timeisbrain.Merelyidentifyingthatastrokeisoccurringinthefieldisnolongergoodenough,EMSprovidersmustnowtriagestrokepatientstoanappropriatestrokecenterthatcanprovidernecessaryinterventions.
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3. RapidArterialoCclusionExam(RACE):
a. DefineanddescribetheRapidArterialoCclusionExam(RACE)andhowitidentifiesstrokeseverity.
TheroleoftheEMSproviderisnolongerlimitedtojustidentifyingstrokepatientsinthefield.NowEMSmustquantifystrokeseverityinordertoidentifythemostseverecasesofischemicstrokeandensurethatthesepatientsaretakentoaninterventionalstrokecentercapableofmechanicalthrombectomywithastentretriever.LVOstrokesarethemostsevereformofischemicstroke,andrecognizingtheminthefieldisessentialtoachievingfunctionalindependenceforstrokepatients.tPAalonehasproventobeanunreliableandineffectivetreatmentforLVOs.Themostpopularvalidatedstrokescalesofrecognitiondesignedforprehospitaluseinclude:theCincinnatiPrehospitalStrokeScale(CPSS)andtheLosAngelesPrehospitalStrokeScreen(LAPPS).Eachofthesestrokescaleswerecreatedinthe1990sfromelementsoftheNIHstrokescaletoidentifythevarioussignsandsymptomsofstroke,andimprovestrokerecognitioninthefield.Basically,thesestrokescalesidentifythatastrokehasoccurred,buttheydon’tidentifytheseverityofastroke.Inaddition,theydonotpredictifthestrokeisanLVO.Asstroketreatmenthasevolvedoverthelast20years,theneedforfieldrecognitionofLVOshasarisen.ThenewfoundabilitytosuccessfullytreatLVOsusingmechanicalthrombectomywithastentretrieverhasestablishedtheneedforEMSproviderstotriagethesepatientstointerventionalstrokecenters.ThenextgenerationofstrokescalesdesignedforLVOrecognitioninthefieldistheRACEscale,whichisdrawingagreatdealofattentionduetoitsabilitytodetectLVOswithahighdegreeofaccuracy.RACEstandsforRapidArterialoCclusionExam.Likeotherscalesofrecognition,itisalsoderivedfromtheNIHstrokescaleandwasdesignedspecificallyforEMSproviderstodetectLVOsintheprehospitalsetting.RACEscoresapatient’sstrokebasedontheextentandseverityoftheirdeficits.Theoverallscorerangesfrom0to9.0meaningnodeficitswerepresent.Anyscoregreaterthan0meansthatastrokehasoccurred.LVOsarelikelywhenastrokepatienthasaRACEscoreofgreaterthanorequalto5(2).
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4. PerformingRACE:
a. List,describeanddemonstratethecomponentsofRACE.TheRACEscaleexamines5categories:
1. Facialpalsy2. Armmotorfunction3. Legmotorfunction4. Head&eyedeviation5. Aphasia(ifright-sideddeficitsareidentified)ORagnosia(ifleft-sideddeficitsareidentified)
Eachcategoryisscoredbasedonthepatient’sdegreeofdisability;0meaningnodeficit,1meaningamildtomoderatedeficit,and2meaningaseveredeficitispresent.TocompleteaRACEexam,conducttheassessmentsbelow:
FacialPalsy
● HOWTOASSESS:Askthepatienttoshowyoutheirteethorsmile. ● SCORINGCRITERIA:
NODEFICIT=0(faceissymmetrical)MILD=1(slightlyasymmetrical)MODERATETOSEVERE=2(completelyasymmetrical)
ArmMotorFunction
● HOWTOASSESS:Askthepatienttoclosetheireyesandextendtheirarmsat90degreesandholdthemforacountoftenwiththeirpalmsup.Theirarmanglecanbemodifiedto45degreesifthepatientissupine.
● SCORINGCRITERIA: NODEFICIT=0(abletoraisearmandholdfor10seconds)MODERATE=1(abletoraisearm,butunabletoholdfor10seconds)SEVERE=2(unabletoliftanarm)
LegMotorFunction
● HOWTOASSESS:Askthepatienttoraiseonelegatatimetoa30-degreeangleandholditupfor5seconds.
● SCORINGCRITERIA: NODEFICIT=0(abletoraiselegandholdfor5seconds)MODERATE=1(abletoraiseleg,butunabletoholdfor5seconds)SEVERE=2(unabletoraisealeg)
HeadandGazeDeviationNoteifthepatient’sheadoreyesaredeviatedtooneside.Inthepresenceofseverestrokesthepatient’sheadwilloftenbeturnedtowardsthesideofthestrokeandthepatient’seyesmayalsobeturnedtowardthatside.
● HOWTOASSESS:Ifpatient’sheadoreyesaretowardsoneside,askthemtolooktowardstheotherside. ● SCORINGCRITERIA:
○ NODEFICIT=0(noheadorgazedeviation) ○ GAZEPRESENT=1(unabletoshiftgazepastmidline)
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Aftercompletingtheassessmentsoffacialpalsy,armmotorfunction,legmotorfunctionandheadandgazedeviation,performoneofthefinaltwocategoriesbasedonearlierassessmentfindings:
● Right-sideddeficits=AssessforAphasia ● Left-sideddeficits=AssessforAgnosia
Aphasia(forpatientspresentingwithright-sideddeficits)Ifright-sideddeficitswereobservedcheckforaphasia.Aphasiaisthelossofabilitytounderstandorexpressspeech.Right-sideddeficitsresultfromthelefthemisphereofthebrainbeingaffectedbyastroke.Theleftcerebralhemispherecontainstheregionofthebrainresponsibleforcomprehendinglanguage.
● HOWTOASSESS:Ifright-sideddeficitsarefound,askthepatienttodothefollowing:1-Closeyoureyes.2-Makeafist.
● SCORINGCRITERIA: NODEFICIT=0(performsbothtaskscorrectly)MODERATE=1(performsonetaskcorrectly)SEVERE=2(performsneithertask)
Agnosia(forpatientspresentingwithleft-sideddeficits)
Ifleft-sideddeficitswereobservedcheckforagnosia.Ifthepatientpresentswithleft-sideddeficitsthatmeanstherighthemisphereofthebrainisbeingaffectedbythestroke.Therightcerebralhemispherecontainstheregionofthebrainresponsibleforinterpretingsensationsandrecognizingthings.Agnosiaistheinabilitytointerpretsensations,or“recognizethings,”typicallyasaresultofbraindamage.Basically,agnosiaistheinabilitytoprocesssensoryinformation.Thiscanresultinthepatientfailingtorecognizetheirleftarm,orthefactthatamotordeficitispresentintheirleftarm.Remember,youasanEMSproviderknowthattheyhaveleft-sideddeficits,whichiswhyyou’reassessingagnosiaatthispoint.Essentially,thispartoftheassessmentistoidentifyifthepatientrecognizestheirleftarm,andiftheyrecognizetheweaknessintheirleftarm.
● HOWTOASSESS:Ifleft-sideddeficitsarefound,askthepatientthefollowing:1-“Whosearmisthis”,whileshowingthemtheirleftarm.2-“Canyoumoveyourarm?”
● SCORINGCRITERIA: NODEFICIT=0(recognizesleftarmandacknowledgesleftarmweakness)MODERATE=1(doesnotrecognizeleftarmORdoesnotacknowledgeleftarmweakness)SEVERE=2(doesnotrecognizeleftarmANDdoesnotacknowledgeleftarmweakness)
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SampleRACEForm:This1pageformwillassistEMSinutilizingRACEmoreeffectivelyintheprehospitalsetting.ThisresourcewillactasareferencetoolforthisnewandeffectivemeansofidentifyingLVOsintheprehospitalsetting.
RapidoCclusionArterialExam(RACE)Form
FACIALPALSYAskthepatienttoshowyoutheirteethorsmile.
● NODEFICIT=0(faceissymmetrical) ● MILD=1(slightlyasymmetrical) ● MODERATETOSEVERE=2(completelyasymmetrical)
SCORE
ARMMOTORFUNCTIONAskthepatienttoclosetheireyesandextendtheirarmsat90degreesandholdthemforacountoftenwiththeirpalmsup.Theirarmanglecanbemodifiedto45degreesifthepatientissupine.
● NODEFICIT=0(abletoraisearmandholdfor10seconds) ● MODERATE=1(abletoraisearm,butunabletoholdfor10seconds) ● SEVERE=2(unabletoliftanarm)
SCORE
LEGMOTORFUNCTIONAskthepatienttoraiseonelegatatimeuptoa30-degreeangleandholditupfor5seconds.
● NODEFICIT=0(abletoraiselegandholdfor5seconds) ● MODERATE=1(abletoraiseleg,butunabletoholdfor5seconds) ● SEVERE=2(unabletoraisealeg)
SCORE
HEADANDGAZEDEVIATIONIfpatient’sheadoreyesaretowardsoneside,askthemtolooktowardstheotherside.
● NODEFICIT=0(noheadorgazedeviation) ● GAZEPRESENT=1(unabletoshiftgazepastmidline)
SCORE
APHASIA(Inabilitytounderstandorexpressspeech)Ifright-sideddeficitsarefound,askthepatienttodothefollowing:1)Closeyoureyes.2)Makeafist.
● NODEFICIT=0(performsbothtaskscorrectly) ● MODERATE=1(performsonetaskcorrectly) ● SEVERE=2(performsneithertask)
SCORE
AGNOSIA(Inabilitytoprocesssensoryinformation)Ifleft-sideddeficitsarefound,askthepatientthefollowing:1-“Whosearmisthis”,whileshowingthemtheirleftarm.2-“Canyoumoveyourarm?”
● NODEFICIT=0(recognizesleftarmandacknowledgesleftarmweakness) ● MODERATE=1(doesnotrecognizeleftarmORdoesnotacknowledgeleftarmweakness) ● SEVERE=2(doesnotrecognizeleftarmANDdoesnotacknowledgeleftarmweakness)
SCORE
TOTALSCORE
TransportanypatientwithaRACEscore>5totheclosestComprehensiveStrokeCenterorinterventionalstrokecentercapableofmechanicalthrombectomywithastentretriever,ifprotocolsallow.
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5. EMSTransportOptions:
a. IdentifytheclosestappropriatestrokecenterforthesimulatedpatientbasedontheRACEscore,aswellasotherassessmentfindings.Remember,ifthepatienthasaRACEscoreof5orgreaterthereisahighprobabilityofalargevesselocclusion(LVO)(2).ThepatientshouldbetransportedtotheclosestComprehensiveStrokeCenter,oraPrimaryStrokeCentercapableofperforminginterventionalstroketreatmentssuchasmechanicalthrombectomy,whenavailableandifprotocolsallow.
6. RACEScenarios:
Outlinea. PerformapatientassessmentonasimulatedpatientandincludetheperformanceofRACE.
b. Students(EMSproviders)will:
i. Performanassessmenton5separatesimulatedpatientsii. IdentifytheseverityofastrokeusingRACEiii. Indicatetheclosestappropriatestrokecentertotransportthepatient
c. Scenario1–5:
i. Studentsareprovideddispatchinformationii. Studentsareprovidedasimulatedpatientthatmatchesdispatchinformationiii. Studentsperformapatientassessment
1. PerformRACE2. Triagethepatienttoanappropriatedestination
iv. Theinstructorwillobservethestudentsforstrengthsandareasthatcoulduseimprovement.Theseobservationswillbeusedtofacilitateabriefconversationbetweeneachscenario.
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Scenario#1:Dispatch:Dispatchedtoapatientwithone-sidedweakness.ArrivetoFind:A55year-oldmalepatientsittinginhislivingroom.Thepatient’sfamilystatesthepatientwasfoundinthisconditionaftertheyreturnedhomefromshopping.Thepatienthasobviousright-sidedweaknessanddifficultyspeaking.RACEStrokeScale:RACEscoreof5.SeetheRaceGuidethathasbeencompletedforScenario#1.StudentsshouldarriveatthesamescorewhencompletingtheirownRaceGuide.Symptomsdemonstratedbysimulatedpatient:
● FacialPalsy:Scoreof1.Slightlyasymmetrical. ● Armmotorfunction:Scoreof2.Unabletoliftrightarm. ● Legmotorfunction:Scoreof1.Abletoraiserightlegbutunabletoholdfor5seconds. ● Headand/oreyegazedeviation:Scoreof1.Present;unabletoshiftgazepastmidline. ● AssessforAphasia:Scoreof0.Nodeficitpatientisabletoperformbothtaskscorrectly. ● AssessforAgnosia:Notassessed.(Onlyassessedforleft-sideddeficits)
TriageDecision:ThepatientispresentingwithsignsofaLVOasdemonstratedbyaRACEscoreof5.ThispatientshouldbetriagedandrapidlytransportedtotheclosestComprehensiveStrokeCenterorinterventionalstrokecentercapableofmechanicalthrombectomywithastentretriever.TransportanypatientwithaRACEscore>5totheclosestComprehensiveStrokeCenterorinterventionalstrokecentercapableofmechanicalthrombectomywithastentretriever,ifprotocolsallow.
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RACEScenario#1:ThecompletedRACEform.
RapidoCclusionArterialExam(RACE)Form
FACIALPALSYAskthepatienttoshowyoutheirteethorsmile.
● NODEFICIT=0(faceissymmetrical) ● MILD=1(slightlyasymmetrical) ● MODERATETOSEVERE=2(completelyasymmetrical)
SCORE1
ARMMOTORFUNCTIONAskthepatienttoclosetheireyesandextendtheirarmsat90degreesandholdthemforacountoftenwiththeirpalmsup.Theirarmanglecanbemodifiedto45degreesifthepatientissupine.
● NODEFICIT=0(abletoraisearmandholdfor10seconds) ● MODERATE=1(abletoraisearm,butunabletoholdfor10seconds) ● SEVERE=2(unabletoliftanarm)
SCORE2
LEGMOTORFUNCTIONAskthepatienttoraiseonelegatatimeuptoa30-degreeangleandholditupfor5seconds.
● NODEFICIT=0(abletoraiselegandholdfor5seconds) ● MODERATE=1(abletoraiseleg,butunabletoholdfor5seconds) ● SEVERE=2(unabletoraisealeg)
SCORE1
HEADANDGAZEDEVIATIONIfpatient’sheadoreyesaretowardsoneside,askthemtolooktowardstheotherside.
● NODEFICIT=0(noheadorgazedeviation) ● GAZEPRESENT=1(unabletoshiftgazepastmidline)
SCORE1
APHASIA(Inabilitytounderstandorexpressspeech)Ifright-sideddeficitsarefound,askthepatienttodothefollowing:1)Closeyoureyes.2)Makeafist.
● NODEFICIT=0(performsbothtaskscorrectly) ● MODERATE=1(performsonetaskcorrectly) ● SEVERE=2(performsneithertask)
SCORE0
AGNOSIA(Inabilitytoprocesssensoryinformation)Ifleft-sideddeficitsarefound,askthepatientthefollowing:1-“Whosearmisthis”,whileshowingthemtheirleftarm.2-“Canyoumoveyourarm?”
● NODEFICIT=0(recognizesleftarmandacknowledgesleftarmweakness) ● MODERATE=1(doesnotrecognizeleftarmORdoesnotacknowledgeleftarmweakness) ● SEVERE=2(doesnotrecognizeleftarmANDdoesnotacknowledgeleftarmweakness)
SCORE
N/A
TOTALSCORE 5
TransportanypatientwithaRACEscore>5totheclosestComprehensiveStrokeCenterorinterventionalstrokecentercapableofmechanicalthrombectomywithastentretriever,ifprotocolsallow.
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Scenario#2:Dispatch:Dispatchedtoapatientwithslurredspeech.ArrivetoFind:A70year-oldmalepatientalertandorientedtimes4sittingathiskitchentable.Thepatient’swifestatesshecamehomefrombookclubandnoticedherhusband’sspeechwasslurred.RACEStrokeScale:RACEscoreof4.SeetheRaceGuidethathasbeencompletedforScenario#2.StudentsshouldarriveatthesamescorewhencompletingtheirownRaceGuide.Symptomsdemonstratedbysimulatedpatient:
● FacialPalsy:Scoreof1.Slightlyasymmetrical. ● Armmotorfunction:Scoreof1.Abletoraiseleftarmbutunabletoholdfor10seconds. ● Legmotorfunction:Scoreof1.Abletoraiseleftlegbutunabletoholdfor5seconds. ● Headand/oreyegazedeviation:Scoreof0.Nodeficit;Noheadorgazedeviationpresent. ● AssessforAphasia:Notassessed.(Onlyassessedforright-sideddeficits) ● AssessforAgnosia:Scoreof1.Thepatientrecognizeshisleftarmbutdoesnotacknowledgetheleftarmweakness.
TriageDecision:ThepatientispresentingwithsignsofastrokeasdemonstratedbyaRACEscoreof4.ThispatientshouldbetriagedandrapidlytransportedtotheclosestStrokeCenter.TransportanypatientwithaRACEscore>5totheclosestComprehensiveStrokeCenterorinterventionalstrokecentercapableofmechanicalthrombectomywithastentretriever,ifprotocolsallow.
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RACEScenario2:ThecompletedRACEform.
RapidoCclusionArterialExam(RACE)Form
FACIALPALSYAskthepatienttoshowyoutheirteethorsmile.
● NODEFICIT=0(faceissymmetrical) ● MILD=1(slightlyasymmetrical) ● MODERATETOSEVERE=2(completelyasymmetrical)
SCORE1
ARMMOTORFUNCTIONAskthepatienttoclosetheireyesandextendtheirarmsat90degreesandholdthemforacountoftenwiththeirpalmsup.Theirarmanglecanbemodifiedto45degreesifthepatientissupine.
● NODEFICIT=0(abletoraisearmandholdfor10seconds) ● MODERATE=1(abletoraisearm,butunabletoholdfor10seconds) ● SEVERE=2(unabletoliftanarm)
SCORE1
LEGMOTORFUNCTIONAskthepatienttoraiseonelegatatimeuptoa30-degreeangleandholditupfor5seconds.
● NODEFICIT=0(abletoraiselegandholdfor5seconds) ● MODERATE=1(abletoraiseleg,butunabletoholdfor5seconds) ● SEVERE=2(unabletoraisealeg)
SCORE1
HEADANDGAZEDEVIATIONIfpatient’sheadoreyesaretowardsoneside,askthemtolooktowardstheotherside.
● NODEFICIT=0(noheadorgazedeviation) ● GAZEPRESENT=1(unabletoshiftgazepastmidline)
SCORE0
APHASIA(Inabilitytounderstandorexpressspeech)Ifright-sideddeficitsarefound,askthepatienttodothefollowing:1)Closeyoureyes.2)Makeafist.
● NODEFICIT=0(performsbothtaskscorrectly) ● MODERATE=1(performsonetaskcorrectly) ● SEVERE=2(performsneithertask)
SCORE
N/A
AGNOSIA(Inabilitytoprocesssensoryinformation)Ifleft-sideddeficitsarefound,askthepatientthefollowing:1-“Whosearmisthis”,whileshowingthemtheirleftarm.2-“Canyoumoveyourarm?”
● NODEFICIT=0(recognizesleftarmandacknowledgesleftarmweakness) ● MODERATE=1(doesnotrecognizeleftarmORdoesnotacknowledgeleftarmweakness) ● SEVERE=2(doesnotrecognizeleftarmANDdoesnotacknowledgeleftarmweakness)
SCORE1
TOTALSCORE 4
TransportanypatientwithaRACEscore>5totheclosestComprehensiveStrokeCenterorinterventionalstrokecentercapableofmechanicalthrombectomywithastentretriever,ifprotocolsallow.
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Scenario#3:Dispatch:Dispatchedtoanunknownmedicalatalibrary.ArrivetoFind:A44year-oldfemalepatientsittinginachairwithabookinherlap.Thelibrarianstatesthepatientisnotactingappropriately.Sheinitiallythoughtthepatientwasdrowsybutimmediatelycalled911whenshenoticedthepatienthadfacialdroop.
RACEStrokeScale:RACEscoreof7.SeetheRaceGuidethathasbeencompletedforScenario#3.StudentsshouldarriveatthesamescorewhencompletingtheirownRaceGuide.Symptomsdemonstratedbysimulatedpatient:
● FacialPalsy:Scoreof2.Completelyasymmetrical. ● Armmotorfunction:Scoreof2.Unabletoliftrightarm. ● Legmotorfunction:Scoreof2.Unabletoliftrightleg. ● Headand/oreyegazedeviation:Scoreof1.Present;unabletoshiftgazepastmidline. ● AssessforAphasia:Scoreof0.Patientisabletoperformbothtaskscorrectly. ● AssessforAgnosia:Notassessed(Onlyassessedforleft-sideddeficits)
TriageDecision:ThepatientispresentingwithsignsofaLVOasdemonstratedbyaRACEscoreof7.ThispatientshouldbetriagedandrapidlytransportedtotheclosestComprehensiveStrokeCenterorinterventionalstrokecentercapableofmechanicalthrombectomywithastentretriever.TransportanypatientwithaRACEscore>5totheclosestComprehensiveStrokeCenterorinterventionalstrokecentercapableofmechanicalthrombectomywithastentretriever,ifprotocolsallow.
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RACEScenario#3:ThecompletedRACEform.
RapidoCclusionArterialExam(RACE)Form
FACIALPALSYAskthepatienttoshowyoutheirteethorsmile.
● NODEFICIT=0(faceissymmetrical) ● MILD=1(slightlyasymmetrical) ● MODERATETOSEVERE=2(completelyasymmetrical)
SCORE2
ARMMOTORFUNCTIONAskthepatienttoclosetheireyesandextendtheirarmsat90degreesandholdthemforacountoftenwiththeirpalmsup.Theirarmanglecanbemodifiedto45degreesifthepatientissupine.
● NODEFICIT=0(abletoraisearmandholdfor10seconds) ● MODERATE=1(abletoraisearm,butunabletoholdfor10seconds) ● SEVERE=2(unabletoliftanarm)
SCORE2
LEGMOTORFUNCTIONAskthepatienttoraiseonelegatatimeuptoa30-degreeangleandholditupfor5seconds.
● NODEFICIT=0(abletoraiselegandholdfor5seconds) ● MODERATE=1(abletoraiseleg,butunabletoholdfor5seconds) ● SEVERE=2(unabletoraisealeg)
SCORE2
HEADANDGAZEDEVIATIONIfpatient’sheadoreyesaretowardsoneside,askthemtolooktowardstheotherside.
● NODEFICIT=0(noheadorgazedeviation) ● GAZEPRESENT=1(unabletoshiftgazepastmidline)
SCORE1
APHASIA(Inabilitytounderstandorexpressspeech)Ifright-sideddeficitsarefound,askthepatienttodothefollowing:1)Closeyoureyes.2)Makeafist.
● NODEFICIT=0(performsbothtaskscorrectly) ● MODERATE=1(performsonetaskcorrectly) ● SEVERE=2(performsneithertask)
SCORE0
AGNOSIA(Inabilitytoprocesssensoryinformation)Ifleft-sideddeficitsarefound,askthepatientthefollowing:1-“Whosearmisthis”,whileshowingthemtheirleftarm.2-“Canyoumoveyourarm?”
● NODEFICIT=0(recognizesleftarmandacknowledgesleftarmweakness) ● MODERATE=1(doesnotrecognizeleftarmORdoesnotacknowledgeleftarmweakness) ● SEVERE=2(doesnotrecognizeleftarmANDdoesnotacknowledgeleftarmweakness)
SCORE
N/A
TOTALSCORE 7
TransportanypatientwithaRACEscore>5totheclosestComprehensiveStrokeCenterorinterventionalstrokecentercapableofmechanicalthrombectomywithastentretriever,ifprotocolsallow.
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Scenario#4:Dispatch:Dispatchedtoapatientwithdifficultywalking.
ArrivetoFind:A59year-oldmalepatientalertandorientedtimes4sittingonaparkbench.Thepatientstatesthathewaswalkingwhenhedevelopedweaknessinhisleftarmandleftleg.Thepatientstatesthisbegan15minutespriorandhecalled911immediatelyaftertheonset.
RACEStrokeScale:RACEscoreof3.SeetheRaceGuidethathasbeencompletedforScenario#4.StudentsshouldarriveatthesamescorewhencompletingtheirownRaceGuide.
Symptomsdemonstratedbysimulatedpatient:● FacialPalsy:Scoreof1.Slightlyasymmetrical. ● Armmotorfunction:Scoreof1.Abletoraiseleftarmbutunabletoholdfor10seconds. ● Legmotorfunction:Scoreof1.Abletoraiseleftlegbutunabletoholdfor5seconds. ● Headand/oreyegazedeviation:Scoreof0.Nodeficit;Noheadorgazedeviationpresent. ● AssessforAphasia:Notassessed.(Onlyassessedforright-sideddeficits) ● AssessforAgnosia:Scoreof0.Patientrecognizesleftarmandacknowledgesleftarmweakness.
TriageDecision:ThepatientispresentingwithsignsofastrokeasdemonstratedbyaRACEscoreof3.ThispatientshouldbetriagedandrapidlytransportedtotheclosestStrokeCenter.TransportanypatientwithaRACEscore>5totheclosestComprehensiveStrokeCenterorinterventionalstrokecentercapableofmechanicalthrombectomywithastentretriever,ifprotocolsallow.
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ContactAmericanCMEbyemailatAmericanCME@AmericanCME.comwithanyquestionsregardingthecontentsoftheRACESupplementalSkillGuide.
RACEScenario#4:ThecompletedRACEform.
RapidoCclusionArterialExam(RACE)Form
FACIALPALSYAskthepatienttoshowyoutheirteethorsmile.
● NODEFICIT=0(faceissymmetrical) ● MILD=1(slightlyasymmetrical) ● MODERATETOSEVERE=2(completelyasymmetrical)
SCORE1
ARMMOTORFUNCTIONAskthepatienttoclosetheireyesandextendtheirarmsat90degreesandholdthemforacountoftenwiththeirpalmsup.Theirarmanglecanbemodifiedto45degreesifthepatientissupine.
● NODEFICIT=0(abletoraisearmandholdfor10seconds) ● MODERATE=1(abletoraisearm,butunabletoholdfor10seconds) ● SEVERE=2(unabletoliftanarm)
SCORE1
LEGMOTORFUNCTIONAskthepatienttoraiseonelegatatimeuptoa30-degreeangleandholditupfor5seconds.
● NODEFICIT=0(abletoraiselegandholdfor5seconds) ● MODERATE=1(abletoraiseleg,butunabletoholdfor5seconds) ● SEVERE=2(unabletoraisealeg)
SCORE1
HEADANDGAZEDEVIATIONIfpatient’sheadoreyesaretowardsoneside,askthemtolooktowardstheotherside.
● NODEFICIT=0(noheadorgazedeviation) ● GAZEPRESENT=1(unabletoshiftgazepastmidline)
SCORE0
APHASIA(Inabilitytounderstandorexpressspeech)Ifright-sideddeficitsarefound,askthepatienttodothefollowing:1)Closeyoureyes.2)Makeafist.
● NODEFICIT=0(performsbothtaskscorrectly) ● MODERATE=1(performsonetaskcorrectly) ● SEVERE=2(performsneithertask)
SCORE0
AGNOSIA(Inabilitytoprocesssensoryinformation)Ifleft-sideddeficitsarefound,askthepatientthefollowing:1-“Whosearmisthis”,whileshowingthemtheirleftarm.2-“Canyoumoveyourarm?”
● NODEFICIT=0(recognizesleftarmandacknowledgesleftarmweakness) ● MODERATE=1(doesnotrecognizeleftarmORdoesnotacknowledgeleftarmweakness) ● SEVERE=2(doesnotrecognizeleftarmANDdoesnotacknowledgeleftarmweakness)
SCORE0
TOTALSCORE 3
TransportanypatientwithaRACEscore>5totheclosestComprehensiveStrokeCenterorinterventionalstrokecentercapableofmechanicalthrombectomywithastentretriever,ifprotocolsallow.
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ContactAmericanCMEbyemailatAmericanCME@AmericanCME.comwithanyquestionsregardingthecontentsoftheRACESupplementalSkillGuide.
Scenario#5:Dispatch:Dispatchedtoanursinghomeforapossiblestroke.
ArrivetoFind:A69year-oldfemalepatientalerttopersonlyingsupineinahospitalbed.Thepatientstatesthatherrightarmisweak.Staffstatestheynoticedasuddenonsetofweaknessinthepatient’srightarm.Thisbeganwhilethepatientwaseatinglunch20minutesprior.Staffassistedthepatienttoherroom.
RACEStrokeScale:RACEscoreof8.SeetheRaceGuidethathasbeencompletedforScenario#5.StudentsshouldarriveatthesamescorewhencompletingtheirownRaceGuide.
Symptomsdemonstratedbysimulatedpatient:
● FacialPalsy:Scoreof2.Completelyasymmetrical. ● Armmotorfunction:Scoreof2.Unabletoliftleftarm. ● Legmotorfunction:Scoreof2.Unabletoliftleftleg. ● Headand/oreyegazedeviation:Scoreof0.Nodeficit;Noheadorgazedeviationpresent. ● AssessforAphasia:Notassessed.(Onlyassessedforright-sideddeficits) ● AssessforAgnosia:Scoreof2.PatientdoesnotrecognizeleftarmANDdoesnotacknowledgeleftarmweakness.
TriageDecision:ThepatientispresentingwithsignsofaLVOasdemonstratedbyaRACEscoreof8.ThispatientshouldbetriagedandrapidlytransportedtotheclosestComprehensiveStrokeCenterorinterventionalstrokecentercapableofmechanicalthrombectomywithastentretriever.TransportanypatientwithaRACEscore>5totheclosestComprehensiveStrokeCenterorinterventionalstrokecentercapableofmechanicalthrombectomywithastentretriever,ifprotocolsallow.
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ContactAmericanCMEbyemailatAmericanCME@AmericanCME.comwithanyquestionsregardingthecontentsoftheRACESupplementalSkillGuide.
RACEScenario5:ThecompletedRACEform.
RapidoCclusionArterialExam(RACE)Form
FACIALPALSYAskthepatienttoshowyoutheirteethorsmile.
● NODEFICIT=0(faceissymmetrical) ● MILD=1(slightlyasymmetrical) ● MODERATETOSEVERE=2(completelyasymmetrical)
SCORE2
ARMMOTORFUNCTIONAskthepatienttoclosetheireyesandextendtheirarmsat90degreesandholdthemforacountoftenwiththeirpalmsup.Theirarmanglecanbemodifiedto45degreesifthepatientissupine.
● NODEFICIT=0(abletoraisearmandholdfor10seconds) ● MODERATE=1(abletoraisearm,butunabletoholdfor10seconds) ● SEVERE=2(unabletoliftanarm)
SCORE2
LEGMOTORFUNCTIONAskthepatienttoraiseonelegatatimeuptoa30-degreeangleandholditupfor5seconds.
● NODEFICIT=0(abletoraiselegandholdfor5seconds) ● MODERATE=1(abletoraiseleg,butunabletoholdfor5seconds) ● SEVERE=2(unabletoraisealeg)
SCORE2
HEADANDGAZEDEVIATIONIfpatient’sheadoreyesaretowardsoneside,askthemtolooktowardstheotherside.
● NODEFICIT=0(noheadorgazedeviation) ● GAZEPRESENT=1(unabletoshiftgazepastmidline)
SCORE0
APHASIA(Inabilitytounderstandorexpressspeech)Ifright-sideddeficitsarefound,askthepatienttodothefollowing:1)Closeyoureyes.2)Makeafist.
● NODEFICIT=0(performsbothtaskscorrectly) ● MODERATE=1(performsonetaskcorrectly) ● SEVERE=2(performsneithertask)
SCORE
N/A
AGNOSIA(Inabilitytoprocesssensoryinformation)Ifleft-sideddeficitsarefound,askthepatientthefollowing:1-“Whosearmisthis”,whileshowingthemtheirleftarm.2-“Canyoumoveyourarm?”
● NODEFICIT=0(recognizesleftarmandacknowledgesleftarmweakness) ● MODERATE=1(doesnotrecognizeleftarmORdoesnotacknowledgeleftarmweakness) ● SEVERE=2(doesnotrecognizeleftarmANDdoesnotacknowledgeleftarmweakness)
SCORE2
TOTALSCORE 8
TransportanypatientwithaRACEscore>5totheclosestComprehensiveStrokeCenterorinterventionalstrokecentercapableofmechanicalthrombectomywithastentretriever,ifprotocolsallow.
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ContactAmericanCMEbyemailatAmericanCME@AmericanCME.comwithanyquestionsregardingthecontentsoftheRACESupplementalSkillGuide.
CitedReferences1. WadeS.Smith,MD,PhD;MichaelH.Lev,MD,FAHA;JoeyD.English,MD,PhD;EricaC.Camargo,MD,MMSc;Maggie
Chou;S.ClaiborneJohnston,MD,PhD;GilbertoGonzalez,MD,PhD;PamelaW.Schaefer,MD;WilliamP.Dillon,MD;WalterJ.Koroshetz,MD;KarenL.Furie,MD,MPH"SignificanceofLargeVesselIntracranialOcclusionCausingAcuteIschemicStrokeandTIA."Stroke(December,2009).Web.
2. Ossa,Natalia,MD,andDavidCarrera,MD."DesignandValidationofaPrehospitalStrokeScaletoPredictLargeArterialOcclusion."Stroke.AmericanHeartAssociation,26Nov.2013.Web.1Feb.2016.
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