# Neuro assessment



## Brandon O (Jun 8, 2015)

I just had a reader request an article for my site discussing field neuro exams. Anybody have any specific questions, confusions, or issues they'd be interested in seeing addressed regarding this?


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## Flying (Jun 8, 2015)

Ideas:
Knowing all about the pupillary light reflex and its clinical implications would be a fine way to recap various physio/pharmacological effects in more detail. It's definitely possible to go beyond flashing a penlight and saying "yep, they're dilated".

Common chronic and acute conditions (pain caused by ischemia, neuropathy, sciatica/nerve compression). 

The "baseline" and what it should mean to you. Many talk about finding it, and just as many don't know the basics of why a person has chronic pain as indicated by their history, or why he/she cannot move their appendages through their full range of motion.

seizures eyes nerves reflexes pain aging traumatic brain injury group homes


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## ERDoc (Jun 8, 2015)

Anisocoria doesn't always mean life threatening issues.


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## Flying (Jun 8, 2015)

I submit to your expertise ERDoc.


If one wants a decent picture of a person's neurological health, what _exactly_ are we looking for?
When we put together any combination of the past history, LOC, general demeanor, reflexes, gross motor/sensory function, scoring scale xyz, etc., what do know/want to know based on the presentation and why? What is clinically significant and what isn't?

Ultimately I'm interested in improving upon my limited education and most godawful initial EMT training and being alerted to the basics of which I don't know. I would love to see the general neuro exam and common myths and misconceptions addressed, but I know I am probably better served with textbooks for that matter.

Cool finding abc remains a tempting topic. The different degrees of responsiveness fascinate me, ranging from classic drunkenness to one only being able to answer yes/no questions via simple motor response.


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## ERDoc (Jun 9, 2015)

There is no way to fully answer your question in a forum post.  I think it may be more useful to say what I have seen as more common problems in prehospital providers.  My experience is very biased as I have only worked in two different locations, so it may be limited to the areas that I work and not indicitive of a global issue.

First, understand what the terms you are using means.  I won't define them (consider it your homework assignment, lol) but know what the different levels of consciousness mean, including obtunded and lethargic truly mean.  Understand the limited utility of the GCS and when it is appropriate to use and when it is not (hint, if the pt has nontraumatic abd pain, it's a useless scale.  Personal rant, I hate any scale that gives a dead person or a loaf of bread a score of more than 0).

Understand why anisocoria in an awake and talking head injury pt is not as concerning as it is made out to be in EMT class.  To help understand this, understand what the cranial nerves are.

This is a start.  Please understand I am not trying to dodge your question but what you ask is something akin to asking me to explain the cardiac cycle and arrythmias in a brief forum post.  If you really want to understand what you are looking at and when it is abnormal, start by gaining a good understand of how the nervous system works and then read about when happens when things don't work right.


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## Flying (Jun 9, 2015)

My question was leaning towards replying to Brandon's original post, but thank you for answering to the extent that you did.


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## ERDoc (Jun 9, 2015)

Sorry, lol.


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## RedAirplane (Jun 9, 2015)

I might have to read this post, since I have no clue what you guys are talking about. 

(Aside, I do think I could explain cardiac cycle and arrhythmias in a short post, but maybe not at the level you had in mind)


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## Aprz (Jun 9, 2015)

Ishan said:


> I might have to read this post, since I have no clue what you guys are talking about.


What don't you understand?


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## RedAirplane (Jun 9, 2015)

Aprz said:


> What don't you understand?



We could begin with, what is a neuro assessment?


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## Aprz (Jun 9, 2015)

Ishan said:


> We could begin with, what is a neuro assessment?


The name should give it away. Assessing the patient's neurological status. You probably do a basic neuro assessment on most calls, falls, traumas, strokes, and altered mental status calls.

AVPU is part of your neurological assessment. A problem with the central nervous system could be why their level of consciousness is decreased.

AO questions such as asking person, place, time, and event is part of your neurological assessment. A problem with the central nervous system could be why they are disoriented.

Glasgow coma scale (GCS) is part of your neurological assessment. MDCalc, The EMT Spot

The FAST exam for stroke is a basic neurological assessment.

F - Facial droop
A - Arm drift
S - Speech
T - Time last seen normal / Transport

Checking the patient's distal CSM before and after spinal immobilization is a neurological assessment. A problem with their central or peripheral nervous system could cause this to be abnormal.

If you are working on an ambulance, you probably do some of these daily.

Pretty much anything you ask or physically exam that pertains to their neurological status is a neuro assessment.

Check out the Miami Emergency Neurologic Deficit (MEND) exam.

*This link will attempt to download a PDF.* Facing Cranial Nerve Assessment. If that link doesn't work, try this and click on the PDF button as instructed in the article so you can see the visual that the author is referring to. You can read the article without the visual if you don't want to download the PDF.

Not something I'd expect an regular ambulance crew to do, but it might be good to at least know of the NIHSS. The MEND exam is like a trimmed down version of this. If you do IFT, you might read or be told this number when transport to or from a facility that specializes in neurological care. Wikipedia

You might find some good information on the Facebook group Neurology and Neuroscience. There hasn't been any recent activity in it, but I am sure there is a lot of good information in there that you can browse through or you can ask a question. I am sure most members are like me and are ready to answer your questions when you ask it in that group.

Hope that helps!


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## RedAirplane (Jun 9, 2015)

I figured it had to do with neurological status, but I guess I didn't know what specifically you guys meant.

One thing that would be really helpful in my role would be to know whether a bonk on the head needs to be transported, referred to urgent care by POV for concussion evaluation, or released to self as a minor laceration.


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## NomadicMedic (Jun 9, 2015)

Ishan said:


> I figured it had to do with neurological status, but I guess I didn't know what specifically you guys meant.
> 
> One thing that would be really helpful in my role would be to know whether a bonk on the head needs to be transported, referred to urgent care by POV for concussion evaluation, or released to self as a minor laceration.




Much of that depends on the results of the neuro exam.


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## Aprz (Jun 9, 2015)

It's really gonna vary by provider, their training, area, and agency. Their area and agency will likely have protocols and policies that cover that.


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## EastCoast42 (Jun 10, 2015)

When in doubt, always suggest transport just to cover yourself. It's better to be safe then sorry with head injuries. You should also watch for any type of AMS, because then your free game (at least here) to require the PT to be transported, no exceptions.


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## Carlos Danger (Jun 10, 2015)

EastCoast42 said:


> You should also watch for any type of AMS, because then your free game (at least here) to require the PT to be transported, no exceptions.



Does altered always = incompetent?


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## Chewy20 (Jun 10, 2015)

EastCoast42 said:


> When in doubt, always suggest transport just to cover yourself. It's better to be safe then sorry with head injuries. You should also watch for any type of AMS, because then your free game (at least here) to require the PT to be transported, no exceptions.



Highly doubt AMS means automatic transport in your area. Not every drunk gets transported right?

Like @Remi said, learn the differences.


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## climberslacker (Jun 10, 2015)

Remi said:


> Does altered always = incompetent?



I assume you asked the question for discussion so, Short answer? No.

Competence has everything to do with the patient's ability to understand and accept the risks of refusing transport to the hospital by ambulance. HINT: they can do this without the term "seizure, coma, death" that people love to throw around for every refusal.


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## EastCoast42 (Jun 11, 2015)

Aprz said:


> It's really gonna vary by provider, their training, area, and agency. Their area and agency will likely have protocols and policies that cover that.





Chewy20 said:


> Highly doubt AMS means automatic transport in your area. Not every drunk gets transported right?
> 
> Like @Remi said, learn the differences.



All AMS within my state = automatic transport for BLS units unless the PT requests ROS. At that time, you contact med control and let them decide what to do... I don't necessarily agree with it, but it is what it is..


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## Underoath87 (Jun 13, 2015)

EastCoast42 said:


> All AMS within my state = automatic transport for BLS units unless the PT requests ROS. At that time, you contact med control and let them decide what to do... I don't necessarily agree with it, but it is what it is..



ROS?


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## NomadicMedic (Jun 13, 2015)

Refusal of service.


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## RedAirplane (Jun 13, 2015)

Aprz said:


> It's really gonna vary by provider, their training, area, and agency. Their area and agency will likely have protocols and policies that cover that.



If your best friend just got whacked with a heavy object at close range, what symptoms would make you call EMS? What symptoms would make you drive him to urgent care? What symptoms would make you tell him to get checked out by his personal MD?


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## EastCoast42 (Jun 13, 2015)

Underoath87 said:


> ROS?


In this context, ROS= Refusal of Services.


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## NomadicMedic (Jun 13, 2015)

Ishan said:


> If your best friend just got whacked with a heavy object at close range, what symptoms would make you call EMS? What symptoms would make you drive him to urgent care? What symptoms would make you tell him to get checked out by his personal MD?



Ambulance: Unconscious. Serious bleeding that I can't control. Brain matter on the floor. A repeated AMS assessment that shows they're STILL altered. Acute neuro deficits. In other words, an EMERGENCY. 

A POV To the ED: any worsening symptoms. Severe pain with no AMS or Neuro deficits. 

PCP exam: in any acute case, this is rather pointless. How many PCP have immediate access to CT and have any recent experience in assessing traumatic head injuries? Mostly zero. (ProTip: they'd send you straight to the ED. Very likely by ambulance! No Bueno.)

If they're dying, they need a medic and an expeditious trip to the ED.  

If they're not actively dying, they can get a ride to the ED in the car.


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