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2015/08/05 - Medical Tidbits: The Rapid Arterial Occlusion Evaluation (RACE) Score

If you have not heard over the past several months about stroke care then probably have to say that your head was in the sand like the proverbial ostrich.   From December of last year until April there were (3) new articles that came out in regards to stroke care, specifically neurointervention type care (similar to the heart cath).  Since that time another (2) articles have come out that again confirm the first (3) trials (Mr Clean, Extend IA and Escape).

 

In review of these articles (unlike January 2014 that showed no benefit at all and potential harm to patients) the neurointervionlist are able to show that a specific subset of patients do better with the advanced therapy.   In the study 89% of the patients received tPA, from that point, 81.5 % (233 patients) received the clot removal device.   Of that 32.6 % of the patients had favorable outcome (versus 19.1% in the control group).  This means that for every 1 in 7 patients that the neurointerventionlist help with the clot retrieval device … we see a good outcome. 

 

Where does the RACE score come into place.   In the prehospital setting it is almost next to impossible to complete a true NIH stroke scale (time consuming and not everyone hits all the parts).  A group of physicians from Barcelona developed the Scoring system to help ease the process, but still have validity.

 

The Score is comprised from the face, arm, leg, head / gaze deviation and then depending on right or left side weakness either aphasia or agnosia.  Total possible value is 9 with a RACE score greater than 5 concerning for large vessel disease and these individuals should be transported to a Comprehensive Stroke Center.  The RACE score helps the process because ultimately at the CSC these patients would receive advanced type of imaging (cerebral perfusion scans) that would determine if there was salvageable brain penumbra.   If there was … then the patient would be taken to the lab, if not then the patient would receive rectal aspirin (unless tPA given) and admitted to the neuro ICU for monitoring.

 

Rapid Arterial Occlusion Evaluation Scale (RACE SCORE)

Facial palsy

Ask the patient to show teeth

Absent

Mild

Moderate to severe

Symmetrical movement

Slightly asymmetrical

Completely asymmetrical

0

1

2

Arm motor function

Extending the arm of the patient 90 degrees (if sitting) or 45 degrees (if supine)

Normal to mild Moderate

Severe

Limb upheld more than 10 seconds

Limb upheld less than 10 seconds

Patient do not raise the arm against gravity

0

1

2

Leg motor function

Extending the leg of the patient 30 degrees (in supine)

Normal to mild Moderate

Severe

Limb upheld more than 5 seconds

Limb upheld less than 5 seconds

Patient do not raise the leg against gravity

0

1

2

Head and gaze deviation

Observe eyes and cephalic

deviation to one side

 

Absent

 

Present

Eye movements to both sides were possible and no cephalic deviation was observed

Eyes and cephalic deviation to one side was observed

0

 

1

If right hemiparesis

(Aphasia)

Ask the patient two verbal orders

·         Close your eyes

·         Make a fist

Normal

Moderate

Severe

Performs both tasks correctly

Performs one task correctly

Performs neither task

0

1

2

If left hemiparesis

(Agnosia)

 

Ask:

Asomatognosia

Whose arm is this? (while showing him/her the paretic arm)

Anosognosia

How well can you move this arm?

Normal

Moderate

Severe

No asomatognosia or anosognosia

Asomatognosia or anosognosia

Both of them present

0

1

2

Score Total (0 – 9)

 

 

So where do we come into the mix of all of this?  The biggest part is working with our prehospital colleagues to ensure that they understand the RACE score and stroke assessment.  From that point ensuring that the patient gets the optimal therapies for blood pressure, keeping the head of bed elevated above 30 degrees, intubating the patient if necessary (all of the standard stroke type stuff).

 

Still working on a neuro lecture with the RACE score … once completed will let you know.

 

Keep up the good work … and remember “Share the Care; Work as a Team” and what you do really does matter