Brandon O
Puzzled by facies
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Love love love it, Local. Hope you don't mind if I pick your brain a bit.
What is your test? And what do you mean by "verify"?
My "thorough" peripheral strength test is bilateral wrist flexion/extension; bilateral finger abduction; bilateral grips; and bilateral ankle flexion/extension. Then of course sensation, for which I usually do a bilateral pinch and ask if it feels the same; if I'm feeling very thorough I might do a poke (pen point) for sharp and stroke for dull.
For us non-neuroscientists in the audience, could you briefly remark on what the Babinski indicates to you about the nature and location of the lesion?
Currently what I've been doing as a balance between feasibility and sensitivity is: check equality, check response to light; have them track in the four major directions (looking for nystagmus or paralysis, although I'll be honest and say that I'm not always great at distinguishing normal tracking saccades from true nystagmus); and check visual fields by having them look at my nose and putting a hand in the four major quadrants (usually with both eyes open; should I really be testing each eye separately?).
What does the "circle" tracking add?
How useful is checking for accommodation/convergence (other than letting you legitimately write PERRLA on your paperwork!)? Is there a serious possibility of a clinically significant lesion that would impact this but not be revealed elsewhere? Same question for consensual constriction and the "swinging flashlight." And do you find that these sort of tests are still useful in the older patients whose pupils are often small and poorly reactive to begin with?
I like the double vision test, but is it plausible that an otherwise competent patient would not have noticed this on their own?
I had understood doll's eyes to be a fairly late-stage and severe sign; could you really encounter this in someone who otherwise presents well?
There is some good stuff on tests for posterior stroke here http://emcrit.org/podcasts/posterior-stroke/ although I find the head impulse test rather finicky and the test of skew only somewhat less so (I will occasionally do the latter).
So double vision in each eye suggests a neurological etiology?
Is this sort of thing something you find feasible for a field assessment?
Do you have a way of differentiating between acute causes of confusion here vs. chronic dementia? (I already KNOW that most of my patients are confused; I want to know if they're also having a stroke!)
Do you find an explicit question-response test of comprehension and dysarthria useful if you're otherwise performing a full assessment? I gave up the "repeat after me" part of the Cincinatti Stroke Scale a long time ago, simply because the patient is answering lots of my questions anyway, and I should easily notice any speech or comprehension problems without needing any additional tests.
Never tried this but I know it's an old standby. Do you find that the baseline-dementia folks are usually fairly able to comply with this sort of task in a reasonably timely manner? (i.e. versus five minutes on scene trying to get them to hold a pen and understand what you're yelling at them)
I have a couple copies of the Mini-mental in my bag; I've never busted it out, but one of these days with a high-risk refusal I'm going to give it to the patient and see how that goes. But that's mostly just buffing the report; if we're at that point, my pretest probability is low enough that I can't imagine going, "He scored a 23 -- helo to the comprehensive stroke center!"
To be clear, you're saying that if someone strokes in the left hemisphere causing widespread hemiparesis, we would expect (for instance) the RIGHT arm to be weak, but the LEFT lower face?
What's bury/hide the eyelashes entail?
Do you get much more out of a sequence like this than from a simple big smile ("show me your teeth" as I say)?
My understanding was that the forehead is double innervated from both hemispheres; thus paralysis there is not really consistent with a neurological event, (versus something like Bell's) unless very widespread (bilateral involvement). True/false?
Can you say a bit more on this? Are you saying there can be isolated damage that causes a partial but not total paralysis of the muscles in the tongue?
Although I see these tests somewhat frequently, I tend not to use them as I'm never sure how to interpret them clinically, and it often seems like getting compliance in tasks like this can be tough. I have thought that I might throw in a finger-to-nose if I suspected an isolated cerebellar lesion. As far as the fold-the-paper I would have the same previous question as far as dementia vs. an acute process.
Okay, that's all I got! To summarize, I'm mainly concerned with the role of neuro evaluations like this in the field -- are they feasible for an EMT to both perform and interpret, are they appropriate for our patient demographic, and most of all to what extent are they likely to affect our decisions. In general I find that the more in-depth you get with the assessment, the more it becomes relevant mainly to the patient who wants to refuse transport and needs a magnifying glass run over them to ensure you're not missing something -- but of course, the smaller the particles you're looking at, the less significant any pathology hiding there is going to be, so at some point anything we find might not be very meaningful.
Thanks a ton for your input! We're lucky to have such an expert resource here.
What is your test? And what do you mean by "verify"?
My "thorough" peripheral strength test is bilateral wrist flexion/extension; bilateral finger abduction; bilateral grips; and bilateral ankle flexion/extension. Then of course sensation, for which I usually do a bilateral pinch and ask if it feels the same; if I'm feeling very thorough I might do a poke (pen point) for sharp and stroke for dull.
For us non-neuroscientists in the audience, could you briefly remark on what the Babinski indicates to you about the nature and location of the lesion?
Currently what I've been doing as a balance between feasibility and sensitivity is: check equality, check response to light; have them track in the four major directions (looking for nystagmus or paralysis, although I'll be honest and say that I'm not always great at distinguishing normal tracking saccades from true nystagmus); and check visual fields by having them look at my nose and putting a hand in the four major quadrants (usually with both eyes open; should I really be testing each eye separately?).
What does the "circle" tracking add?
How useful is checking for accommodation/convergence (other than letting you legitimately write PERRLA on your paperwork!)? Is there a serious possibility of a clinically significant lesion that would impact this but not be revealed elsewhere? Same question for consensual constriction and the "swinging flashlight." And do you find that these sort of tests are still useful in the older patients whose pupils are often small and poorly reactive to begin with?
I like the double vision test, but is it plausible that an otherwise competent patient would not have noticed this on their own?
I had understood doll's eyes to be a fairly late-stage and severe sign; could you really encounter this in someone who otherwise presents well?
There is some good stuff on tests for posterior stroke here http://emcrit.org/podcasts/posterior-stroke/ although I find the head impulse test rather finicky and the test of skew only somewhat less so (I will occasionally do the latter).
So double vision in each eye suggests a neurological etiology?
Is this sort of thing something you find feasible for a field assessment?
Do you have a way of differentiating between acute causes of confusion here vs. chronic dementia? (I already KNOW that most of my patients are confused; I want to know if they're also having a stroke!)
Do you find an explicit question-response test of comprehension and dysarthria useful if you're otherwise performing a full assessment? I gave up the "repeat after me" part of the Cincinatti Stroke Scale a long time ago, simply because the patient is answering lots of my questions anyway, and I should easily notice any speech or comprehension problems without needing any additional tests.
Never tried this but I know it's an old standby. Do you find that the baseline-dementia folks are usually fairly able to comply with this sort of task in a reasonably timely manner? (i.e. versus five minutes on scene trying to get them to hold a pen and understand what you're yelling at them)
I have a couple copies of the Mini-mental in my bag; I've never busted it out, but one of these days with a high-risk refusal I'm going to give it to the patient and see how that goes. But that's mostly just buffing the report; if we're at that point, my pretest probability is low enough that I can't imagine going, "He scored a 23 -- helo to the comprehensive stroke center!"
To be clear, you're saying that if someone strokes in the left hemisphere causing widespread hemiparesis, we would expect (for instance) the RIGHT arm to be weak, but the LEFT lower face?
What's bury/hide the eyelashes entail?
Do you get much more out of a sequence like this than from a simple big smile ("show me your teeth" as I say)?
My understanding was that the forehead is double innervated from both hemispheres; thus paralysis there is not really consistent with a neurological event, (versus something like Bell's) unless very widespread (bilateral involvement). True/false?
Can you say a bit more on this? Are you saying there can be isolated damage that causes a partial but not total paralysis of the muscles in the tongue?
Although I see these tests somewhat frequently, I tend not to use them as I'm never sure how to interpret them clinically, and it often seems like getting compliance in tasks like this can be tough. I have thought that I might throw in a finger-to-nose if I suspected an isolated cerebellar lesion. As far as the fold-the-paper I would have the same previous question as far as dementia vs. an acute process.
Okay, that's all I got! To summarize, I'm mainly concerned with the role of neuro evaluations like this in the field -- are they feasible for an EMT to both perform and interpret, are they appropriate for our patient demographic, and most of all to what extent are they likely to affect our decisions. In general I find that the more in-depth you get with the assessment, the more it becomes relevant mainly to the patient who wants to refuse transport and needs a magnifying glass run over them to ensure you're not missing something -- but of course, the smaller the particles you're looking at, the less significant any pathology hiding there is going to be, so at some point anything we find might not be very meaningful.
Thanks a ton for your input! We're lucky to have such an expert resource here.
