Educating Paramedics on the Finger-to-Nose Test Improves Recognition of Posterior Stroke

Abstract

Background and Purpose— Emergency medical services (EMS) stroke recognition facilitates rapid care, however, prehospital stroke screening tools rely on signs that are often absent in posterior circulation strokes. We hypothesized that addition of the finger-to-nose (FTN) test to the Cincinnati Prehospital Stroke Scale would improve EMS posterior stroke recognition. Methods— In this controlled before and after study of consecutive EMS transported posterior ischemic strokes, paramedics in a single EMS agency received in-person training in the use of the FTN test. Paramedics at 2 other local EMS agencies served as controls. We compared the change in posterior stroke recognition, door-to-CT times, and alteplase delivery between the FTN (intervention) and control agencies. Results— Over 21 months, 51 posterior circulation strokes were transported by the FTN agency and 88 in the control agencies. Following training, posterior stroke recognition improved from 46% to 74% ( P =0.039) in the FTN agency, whereas there was no change in the control agencies (32% before versus 39% after, P =0.467). Mean door-to-CT time in the FTN agency also improved following training (62–41 minutes, P =0.037) but not in the control agencies (58–61 minutes, P =0.771). There was no difference in alteplase delivery. Conclusions— Paramedics trained in the FTN test were more likely to identify posterior stroke. If future studies confirm these findings, such training may expedite the care of posterior stroke patients transported by EMS.

A Dynamic Nomogram to Predict the Risk of Stroke in Emergency Department Patients With Acute Dizziness

“…Compared with the ABCD2 score, our nomogram model yielded a better diagnostic performance with higher AUC value. We hypothesize that the inclusion of the finger to nose and tandem gait tests might partly account for high accuracy of our model to a certain extent since both are reportedly powerful predictors for posterior circulation ischemia and minor stroke (35,40,41). In comparison, ABCD2 score was initially generated to assess the risk of early stroke after a transient ischemic attack and incorporate signs of anterior circulation abnormal and features of medical history (61).…”

“…We searched for predictors of stroke from keynote papers (3,31,(40)(41)(42)(43)(44)(45)(46)(47)(48)(49)(50). Candidate predictors were identified when the factors were consistently reported in predictive research on patients with dizziness, easily ascertained, and routine diagnostic tests for patients with stroke.…”

Pitfalls in the Diagnosis of Posterior Circulation Stroke in the Emergency Setting

“…One ambulance service in the UK added nausea to their prehospital stroke screening tool, which also includes vertigo, visual problems, and ataxia as further signs indicative of PCS (88). Another study demonstrated that an initiative as simple as training paramedics to perform the finger-to-nose test may facilitate PCS identification (89). The particular relevance of such efforts is also emphasized in the context of a recent study suggesting that ED staff does appear to rely on EMS staff 's diagnostic impression (31).…”

Optimising Prehospital Pathways to Improve Acute Stroke Reperfusion Therapy Delivery: Systems-Based Approaches

“…Training of EMS to better use these tools is a possible avenue to improve screening, as is the creation of a tool that balances ease of use with high sensitivity and specificity and that ensures high interrater reliability and ease of use for inter-linguistic communication. Moreover, these tools are poor in identifying posterior circulation stroke patients [49].…”

“…One study reported a median onset to door time of 60 min longer compared to anterior circulation stroke patients [51]. They are often not identified as the most common symptoms including eye deviation, visual disturbance and dizziness [52] are not accounted for in many stroke screening tools [49]. It has been noted that the basic FAST (Face, Arm, Speech and Time) screen missed 40% of PCS [53], however, if vertigo, ataxia and visual symptoms were added only 8% of PCS were missed [53].…”