# Not sure if BLS question, but how do you check the neurological status of a person?



## patzyboi (May 22, 2013)

Other than the AVPU/A and O times __ and checking pupils/tracking eyes
Also GCS and just asking them to do simple tasks.


----------



## Handsome Robb (May 22, 2013)

Can they reiterate what's going on? If they can answer A&O questions but can't explain to me what's happening to them then they aren't awake alert and oriented.


----------



## JPINFV (May 22, 2013)

http://www.med-ed.virginia.edu/courses/pom1/pexams/NeurologicExam/


----------



## teedubbyaw (May 22, 2013)

Neuro exams are very in depth. As a basic, stick to what you know, IMO.


----------



## Ewok Jerky (May 22, 2013)

very generally, in addition to the tests they give you in class:

Is your Pt able to carry on a normal conversation? understand what you are saying and respond appropriately?  If not, document specifically what deficit the Pt has.  

As others have pointed out, a full neuro exam is very detailed and not necessary or practical prehospital.  It involves testing not just mental status but all 12 cranial nerves, dermatomes, reflexes, cerebellar and gait functions.

that being said, if you are interested you should totally find out more for your own education.  PM if i can help more in depth.


----------



## Akulahawk (May 23, 2013)

patzyboi said:


> Other than the AVPU/A and O times __ and checking pupils/tracking eyes
> Also GCS and just asking them to do simple tasks.


As others have said, in addition to the A&O questions, does their conversation make sense? Is it appropriate for the situation? Repetitive statements? Can the patient verbalize a coherent plan of self-care? Can the patient  count backwards from 100 by 7's (serial 7's) or spell world backwards? 

My neighbor's dad "sounds" OK at first blush. Unfortunately, he doesn't remember things well and if you talk with him for a while, you'll notice that he's got some statements and questions that he uses to try to cover for the fact that he doesn't remember meeting or talking with you just 2 minutes ago or the two minutes before that. 

There's a lot to doing a full-on neuro exam, but these are the things I do as a quick & dirty screen. It's not meant to be accurate or diagnostic. It's meant as a "something's wrong in the CPU" screen that takes less than a couple minutes that I can do during my physical exam.


----------



## Carlos Danger (May 23, 2013)

Robb said:


> Can they reiterate what's going on? If they can answer A&O questions but can't explain to me what's happening to them then they aren't awake alert and oriented.



Being able to verbalize what is happening to them isn't part of the generally accepted criteria for being "alert and oriented". 

A&O just requires that they follow simple commands, converse appropriately, and are oriented to person, place, and time.

The problem with requiring that they "verbalize what is happening" is that it's too subjective. I mean, there's subjectivity in this exam anyway, but it should be kept to a minimum.

I think the right way to approach a situation where someone answers A&O questions appropriately, but just doesn't seem "with it", is to document exactly that.

"Pt is alert, converses normally, and is oriented to person, place, and time, but seems confused because [write exactly what the pt said or did that makes it seem to you as though they aren't all there]."

It's so much easier and quicker to chart this stuff on computers than it was on handwritten reports.


----------



## Aidey (May 23, 2013)

I think whether being able to understand what is happening is part of A&O scale depends on if you are in the half of the country that uses X3 or X4. In the X4 version that is one of the criteria.


----------



## MountainMedic (May 24, 2013)

teedubbyaw said:


> Neuro exams are very in depth. As a basic, stick to what you know, IMO.



Wow, this is terrible advice. Most EMTs and even medics suck at neuro exams. When you suck at something, you should get better at it, no matter your cert level. Every full neuro exam should include the following: 

GCS (includes A&Ox whatever)
CSM x 4
Cranial nerves (this is where it gets complex, but takes literally 10 seconds)
Stroke screen (for the most part a narrow cranial nerve exam) 
Deep tendon reflexes (we don't do this and it's seldom important)
Ataxia? Tongue fasciculations? 

There's a lot of research lately about quick cranial nerve adjustments and cerebellotonsillar strokes. Google HINTS cerebellotonsillar stroke if interested. 

As for tracking eyes, you're testing 2 cranial nerves. Out of 12. If you track your pt's eyes upwards as well, that's 3 (CN3, 4, and 6). Can they see (CN2)? Smell (CN1)? Have a pt puff their cheeks (CN7, impaired in Bell's palsy), Wiggle their tongue from side to side (CN12), shrug their shoulders (CN11), test their ability to turn head from side to side without dizziness (vestibular branch of CN8). CN5 is sensory to the face. CN9 is mostly sensory except for motor to the muscle that lifts the larynx when you swallow. 

Checking cranial nerves will increase your chance of catching strokes (although Cincinnati Stroke Scale is 90something% sensitive), and may also be beneficial in catching carious nerve palsies from infections or neurologic disorders. It's a lot of info, but I find it useful surprisingly frequently. THAT SAID, IT HARDLY EVER CHANGES MY TREATMENT. 

You don't know the value of the information you don't know until you know it.


----------



## teedubbyaw (May 24, 2013)

What are you talking about? Who said anything about "sucking"?

A basic has no need to do a full neuro exam. And I can't say I've heard of any basics being taught how to do a full neuro in school.


----------



## chaz90 (May 24, 2013)

teedubbyaw said:


> What are you talking about? Who said anything about "sucking"?
> 
> A basic has no need to do a full neuro exam. And I can't say I've heard of any basics being taught how to do a full neuro in school.



Assessment skills aren't limited by scope or level. EMTs aren't taught a comprehensive neuro assessment in school, but there's no reason they can't learn it on their own and do it. Quality assessments are one area that really tell me how much the person cares about improving their skills. Just because education has failed many providers doesn't mean they can't take it upon themselves to improve their skills. 

Not needing a full neuro assessment? How frequently do we see patients with neuro complaints? We spend 30-45 minutes with a patient, and the ED doc might spend 5 minutes in contact with him. If we find something small and subtle that we can pass along, that represents valuable information that may have otherwise been missed.


----------



## teedubbyaw (May 24, 2013)

I completely agree, but again, it's not something taught, however, if a basic knows how to do it, and you trust that they know how to do it well, then that's a different story. 

If your average basic says they did a full neuro, not knowing them, you'd probably raise an eyebrow, or think that their definition of a full neuro is doing the Cincinnati screen.


----------



## Flight-LP (May 27, 2013)

MountainMedic said:


> Wow, this is terrible advice. Most EMTs and even medics suck at neuro exams. When you suck at something, you should get better at it, no matter your cert level. Every full neuro exam should include the following:
> 
> GCS (includes A&Ox whatever)
> CSM x 4
> ...




Good info in your post about CN testing!

I'm curious though as to why you'd say that DTRs are seldom important and not done. In the case of an OB patient, they are an absolute must.


----------



## JPINFV (May 27, 2013)

Flight-LP said:


> Good info in your post about CN testing!
> 
> I'm curious though as to why you'd say that DTRs are seldom important and not done. In the case of an OB patient, they are an absolute must.


How many ambulances have reflex hammers? Sure, you can go the absolute ghetto route and use the stethoscope or karate chop, but it's not the best. 

If the OP is serious about neuro checks and wants to get good DTRs, invest the $7-8 for a Queen's Square hammer. They're infinitely better than the traditional tomahawk hammer, and only a couple dollars more.


----------



## Glucatron (Jun 22, 2013)

One thing my partner taught me is to ask the pt to remember three things like banana, tree and dog. Then ask what they are in 3-5 minutes. However, this is only to test short term memory. MountainMedic, thanks for your informational post!


----------



## TheLocalMedic (Jun 27, 2013)

I like what whomever said about the "remember what I just said" thing.  

Had a patient recently who fell, little old lady (not on a blood thinner) and she seemed perfectly normal besides a small bruise just above her left eye.  Everything I asked she gave perfect answers to, and all the nuero exams were normal, but something seemed off.  

I told her, "I'm going to ask you to remember a number.  The number is 1."  She repeated the number back to me appropriately.  I waited about 30 seconds and asked her what number I had asked her to remember and she had no idea.  

Turns out she had significant hemorrhage...  Seemed normal at first though...


----------



## eonefireemt3 (Jul 13, 2013)

AVPU is the start of your Neuro assessment. Then you would go on to assessing the pupils, then throw in a good stroke scale assessment for good measure.


----------



## JPINFV (Jul 14, 2013)

eonefireemt3 said:


> AVPU is the start of your Neuro assessment. Then you would go on to assessing the pupils, then throw in a good stroke scale assessment for good measure.



That's a really really limited neuro exam.


----------



## VFlutter (Jul 14, 2013)

JPINFV said:


> That's a really really limited neuro exam.



Unless that "good stroke scale" is a full NIHSS.


----------

