Neurological Assessment

[rhan101277]

On every stroke call, that seems to you to be a stroke when you arrive, do you always do a entire nuero assessment. Check all 12 cranial nerves, visual acuity, fine motor control etc.?

Our instructor wants us to be able to do a differential field diagnosis for left, right or cerebellar stroke.

I have been on just one stroke call with a paramedic, the only test he did was arm drift. He didn't even ask the pt to recite, "you can't teach an old dog new tricks".

A proper stroke assessment shouldn't take more than 1 minute or 2 at most, but if you are wrong then that is an extra 1 or 2 minutes you could have had.

I also think it is neat, how if someone can't move their arm due to stroke, that when you ask them to move it, they think they are moving it and don't realize they are not.

Its getting harder in class :wacko:

 

[ResTech]

Rhan... I know many will disagree... but care of a CVA in the field is mainly supportive. We don't do neuro surgery in the field.... so nothing that we can do except supportive care. Even the AHA recommends no to only little oxygen.

As far as your question, I use the Cincinnati pre-hospital stroke assessment. Arm drift, speech, and facial droop. And also assess grip strength, headache, visual disturbances, paresthesia, weakness, ataxic gait, nausea, and pupillary changes.

Differential diagnosis is key to being a good provider especially with resp and cardiac issues. But as long as you know your patient is having a stroke, why do you need to know where in the brain it is occuring? Is it gonna make you do ne thing any different in the back of your ambulance?

 

[Ridryder911]

Rhan... I know many will disagree... but care of a CVA in the field is mainly supportive. We don't do neuro surgery in the field.... so nothing that we can do except supportive care. Even the AHA recommends no to only little oxygen.

As far as your question, I use the Cincinnati pre-hospital stroke assessment. Arm drift, speech, and facial droop. And also assess grip strength, headache, visual disturbances, paresthesia, weakness, ataxic gait, nausea, and pupillary changes.

Differential diagnosis is key to being a good provider especially with resp and cardiac issues. But as long as you know your patient is having a stroke, why do you need to know where in the brain it is occuring? Is it gonna make you do ne thing any different in the back of your ambulance?

Surely, your not suggesting to be that ignorant. Sorry let's call it like it is. You want to drive real fast and load and go? Be an ambulance driver. Want to go into EMS to treat then know what the hell you are doing or ... get out.

First the Cincinnati Stroke Scale was NEVER designed to differentiate if a person is having a stroke or not as it is ONLY a statistical measurement with predictability. There are far better assessments that are faster and better detailed and conclusive.

I highly suggest before giving any more advice on Advanced or even maybe basic EMS treatments you might want obtain a grasp of the why's and how's of emergency medicine. Sorry, such courses as ASLS and many others can teach you the importance of differentiating between types of strokes and acute hemorrhages. The recognition is much importance of findings for different types of Brain Attacks has different time sensitive tests and treatments while others do not.

Again, opinions are one thing but lack of knowledge is another.


http://www.asls.net/introduction.html
R/r 911

 

[ResTech]

hmmm... it's funny how many protocols list the Cincinnati Pre-hospital Stroke assessment as primary method for assessing for stroke. I have yet to see any that mentions cranial nerve assessment.

Again Rid... you are in the back of the unit.... how are you gonna treat your stroke patient any different then I would treat mine?

I forgot to mention to make sure to check blood glucose level as part of the differential. I had a patient once that was VERY convincing to be stroking out and instead was hypoglycemia.

First the Cincinnati Stroke Scale was NEVER designed to differentiate if a person is having a stroke or not

This study seems to highly support its use and high predictive value.... the only thing that is going to definitively dx a CVA is use of imagery.

From http://www.ncbi.nlm.nih.gov/pubmed/10092713

The Cincinnati Prehospital Stroke Scale (CPSS) is a 3-item scale based on a simplification of the National Institutes of Health (NIH) Stroke Scale. When performed by a physician, it has a high sensitivity and specificity in identifying patients with stroke who are candidates for thrombolysis.

CONCLUSION: The CPSS has excellent reproducibility among prehospital personnel and physicians. It has good validity in identifying patients with stroke who are candidates for thrombolytic therapy, especially those with anterior circulation stroke.

You want to drive real fast and load and go? Be an ambulance driver.

What are you even talking about? I specifically mentioned about doing a specific ASSESSMENT and differential. Did I say don't assess? I didn't think so.

The reality is we are limited with what we can do in the field for a CVA. Unless the patient starts to have severe neurological effects that cause respiratory or other hemodynamic effects (usually more with hemorragic etiology)... all we are gonna do is O2, ECG, IV and supportive care by reassuring and taking to appropriate facility. Do you disagree with this management? And in some systems, they may have to fill out a checklist for thrombolytics.

You do this nice cranial nerve assessment... and still what does it change pre-hospital? treatment doesn't change... destination facility doesn't change, report to the ED doesn't change (ie coming in with a CVA patient). Am I wrong?

 

[MSDeltaFlt]

On every stroke call, that seems to you to be a stroke when you arrive, do you always do a entire nuero assessment. Check all 12 cranial nerves, visual acuity, fine motor control etc.?

Our instructor wants us to be able to do a differential field diagnosis for left, right or cerebellar stroke.

I have been on just one stroke call with a paramedic, the only test he did was arm drift. He didn't even ask the pt to recite, "you can't teach an old dog new tricks".

A proper stroke assessment shouldn't take more than 1 minute or 2 at most, but if you are wrong then that is an extra 1 or 2 minutes you could have had.

I also think it is neat, how if someone can't move their arm due to stroke, that when you ask them to move it, they think they are moving it and don't realize they are not.

Its getting harder in class :wacko:

Doing an entire neuro assessment takes practice. You'll take a while at first, but you'll get faster and faster the more you do it. And doing the assessment will let you and your MD know where the stroke is happening, and if it is ischemic or hemorrhagic or something else entirely. And that can change the treatment dramatically.

You see most EMS-er's do not get stuck so much on airway or circulation. That is because we are trained and trained and trained again with our focus being on "getting that tube" or "converting this or that rhythm". We are not trained nearly as much on breathing or disability. and these two areas get medics hung up like crazy quite frequently. Just look at the threads on this and other forums and you'll see.

Also, 1-2 minutes is not that long, and you can probably do some of it if not all of it enroute. Keep practicing. You'll do fine.

 

[Ridryder911]

hmmm... it's funny how many protocols list the Cincinnati Pre-hospital Stroke assessment as primary method for assessing for stroke. I have yet to see
You do this nice cranial nerve assessment... and still what does it change pre-hospital? treatment doesn't change... destination facility doesn't change, report to the ED doesn't change (ie coming in with a CVA patient). Am I wrong?

Yes.

Not all hospitals are recognized as "Stroke Centers"; those that can perform emergency CT and differentiation for neuroradiology. As well, many may still not perform any aggressive treatment after the window of 3 hours have passed; where as others can perform such procedures as the "Mercy" technique way past that with success. Again, yes initial assessment is crucial to determine the type and possible location of the stroke so determination of proper care can be followed up.

If you attend such course as ASLS, they will quickly inform you the initial assessment is crucial in determination of stroke and possible outcomes. One of the major emphasis placed is to be able to have the Paramedic to be able to discuss assessment as per proper medical terminology and respectable knowledge of proper assessment capabilities. Many of those physicians (which were part of the developers) will quickly correct you that the Cincinnati Scale should had never been introduced as a diagnosis aid; that it was only designed to be used as a marker for statistical studies, never an assessment tool.

Part of the problem that was recognized by neuro physicians was the inability of Paramedic to properly perform an assessment that was needed; far more than the Cincinnati Stroke Scale provided. Part of but not detailed enough for a diagnosis; i.e. Bell's Palsy vs CVA, etc..

Protocols should only be suggestions and should never have to include assessment techniques. Many still use the Coma Cocktail too... but hopefully most have realized over the past 20 years that it is foolish. So let's not base treatment based upon generalization of poor EMS protocols.

EMS is a division of emergency medicine, not a dilution of it.

R/r 911

 

[ki4mus]

Even as basics we are expected to do a basic nero-assessment, and basics with any expeirance are expeced to do a complete assessment with all 12 cranial nerves and dermatone sensation... And even though I am weak at it our paramedic instuctor is training us to know where in the brain the stroke occured.

I just say that "our treatment is only suportive, so I'm not gonna bother doing my job" is plain lazy. Those people suffering from "Lazy Medic Syndrome" are the largest part of the reason that para-medicine has trouble gaining the respect of the "Higher-ups" in the medical comunity, as-well-as why in some area's medics are losing skills/prtocols to preform the skills....

 

[ki4mus]

[/QUOTE]
You do this nice cranial nerve assessment... and still what does it change pre-hospital? treatment doesn't change... destination facility doesn't change, report to the ED doesn't change (ie coming in with a CVA patient). Am I wrong?[/QUOTE]

It does change the destination. I'm not sure about how your area does it, but we have designated Stroke Centers that we go to if we belive that our Pt has had a CVA, and if our report is good enough we completly by-pass the ER.

That is why you do a complete assessment on all Pt's

 

[Shishkabob]

I think you guys are missing what Res was stating completely, yet somehow bash him as being wrong. I'm going to five him the benefit if the doubt and say he knows what a stroke center is.


He was saying that once a stroke is confirmed, they'll be taken to a stroke center anyway, no matter if it's ischemic or hemmorhagic in nature. Even if we are confident that it's one type or the other, the ED is still going to scan the head regardless for possible tPA.



Now, READ amd comprehend in what I just wrote. I dint want you coming back calling me lazy for nit doing a full neuro assessment or anything, because I never stated such.

 

[Akulahawk]

First off: I know what a Stroke Center is...

What is needed in the field is a screening tool that is highly sensitive and specific for detecting a stroke. The CPSS is such a tool... While it will not tell you if the CVA is ischemic or hemorrhagic, it will help the provider determine whether or not to do a "Stroke Alert" and head towards a designated Stroke Center. Since "Time is Brain"... you want to minimize time spent on scene and in transit. Do your neuro exam while en-route... If you're en-route and you're able to determine hemorrhagic/ischemic and location of the CVA, and you're heading towards a Stroke Center... what's changed on your end, therapy wise? Not much. For the patient? You've managed to establish a baseline status... and given the Stroke Center a bit more info to chew on, which might get a Stroke Team better primed for the incoming patient.

If you have time on-scene while you're waiting for transport to arrive... do the neuro exam. Sure you already knew you were headed for a Stroke Center... but getting that baseline exam is important.

Oh, and I did note that the CPSS is included in the exam taught by the ASLS... which means it's not exactly there for statistical purposes... It's there as a quick screening tool...

 

[daedalus]

Basics are not taught to do cranial nerve examination...
In fact the class does note even teach the names of the cranial nerves so how can the assess something they do not even know exists...

 

[JPINFV]

Basics are not taught to do cranial nerve examination...
In fact the class does note even teach the names of the cranial nerves so how can the assess something they do not even know exists...

The basic class doesn't touch on lab values, but I took a glance at my patient's labs when they were available, especially on abn labs patients. It's not like basic class is the end all, be all of prehospital education.

 

[ResTech]

Part of but not detailed enough for a diagnosis; i.e. Bell's Palsy vs CVA,

It's not a Paramedic's job to make a definitive diagnosis in the field. Providers who like to get all fancy and try to diagnose like a physician many times walk into the ED looking like dumb ***'s cause they are totally wrong and it's so obvious they are trying to appear more then they are. It's impossible for us in the field to always have ALL the facts on what is going on with our patients. If a patient test positive on the CPSS and has other associated S/S and other differentials ruled out, then go with the CVA and monitor and treat for such.

If we alert the Stroke team and it turns out to be something other than... is it really a big deal? Especially when the patient is exhibiting S/S of a neurological event?

 

[Dwindlin]

It's not a Paramedic's job to make a definitive diagnosis in the field. Providers who like to get all fancy and try to diagnose like a physician many times walk into the ED looking like dumb ***'s cause they are totally wrong and it's so obvious they are trying to appear more then they are. It's impossible for us in the field to always have ALL the facts on what is going on with our patients. If a patient test positive on the CPSS and has other associated S/S and other differentials ruled out, then go with the CVA and monitor and treat for such.

If we alert the Stroke team and it turns out to be something other than... is it really a big deal? Especially when the patient is exhibiting S/S of a neurological event?

Agree. Considering Bell's Palsy is a diagnosis of exclusion even the ER/Neuro team is going (or should be) treating unilateral facial weakness as a stroke until it has been completely ruled out. I know personally if I have someone exhibiting s/s that appear to Bell's then I'm treating it as a stroke, and I think EMS providers (any provider for that matter) would folly to do otherwise. Just my humble opinion of course.

 

[Ridryder911]

It's not a Paramedic's job to make a definitive diagnosis in the field. Providers who like to get all fancy and try to diagnose like a physician many times walk into the ED looking like dumb ***'s cause they are totally wrong and it's so obvious they are trying to appear more then they are. It's impossible for us in the field to always have ALL the facts on what is going on with our patients. If a patient test positive on the CPSS and has other associated S/S and other differentials ruled out, then go with the CVA and monitor and treat for such.

If we alert the Stroke team and it turns out to be something other than... is it really a big deal? Especially when the patient is exhibiting S/S of a neurological event?

You better believe it is a big deal. Apparently, you are not aware what occurs when a stroke team is activated. One should know how to assess properly or get out of the profession. Sorry, I am proud of my diagnostic skills alike my other peers (yes, we TQI to verify accuracy) and as well as a professional to make such diagnosis based upon the findings and ruling out we can perform. (i.e if you knew your cranial nerves then you would know the differential of Bell's Palsy and a CVA)

Again, if one wants to be an ambulance driver .... so be it. Cook book medicine is really not that hard.. just memorize s/s and follow a protocol... no thinking required.

R/r 911

 

[Flight-LP]

I'm surprised no one has touched on the Los Angeles Pre-Hospital Stroke Screen; an evaluation that has much higher sensitivity and specificity to accurately analyze CVA potential. CPSS is a nice bare bones baseline to work off of, but come on, when you have to include pictures of the evaluation (thanks for dumbing that one even more AHA!), thats a little too baseline for the professional provider.

http://www.ncbi.nlm.nih.gov/pubmed/10625718?dopt=Abstract

Something else to consider for those interested in looking at the Bell's Palsy possibility is that BP is a dysfunction of just CN VII, the facial nerve. It is usually self limiting with no extremity involvement. However, a really good way to look deeper is to watch the pts. forehead. When you get them to smile and check for droop, if their forehead wrinkles, it is has cerebral involvement. The forehead muscles are innervated by both sides of the brain, therefore a bleed or clot on one side will not prevent muscle activity in the forehead, even though it causes facial droop. However, the facial nerve itself is all or nothing. If it is a facial nerve issue, all nerve activity is lost. Just another little tidbit to consider while assessing your neuro folks.

A thorough neuro (hey that rhyme's!) assessment is an absolute for several reasons. Of course the most obvious is for appropriate destination with capabilities of diagnostics and access to neurological or neurosurgical care. Another reason in recent years is the associated cost of misutilization and activation of stroke teams. Remember, not all team are in house, sometimes they are on call. It is quite costly to activate these folks after hours. Use the best tools in your box to make the best decisions................

 

[rhan101277]

Having excellent pre hospital diagnosis skills go a long way in earning your respect in the various ER's you visit. Not only that but people take notice and it can have an effect on others, who do not take their job seriously. One of the adjunct instructors has only been a paramedic for three years and he calls med control all the time because he thinks this medication will be better than protocol and he almost always gets the go ahead because physicians know he is a excellent paramedic.

Consistently coming in the ER with proper diagnosis can make a big difference in patient mortality. Why you ask, because they are confident in you and prepare everything all the machines are warmed up and ready.

I am doing the best I can, because I want to be a skilled clinical paramedic. Not a cook book paramedic.

While I realize it will take a long time to get the appropriate experience to get good. I don't want to be good, I want to be the best.

 

[Dwindlin]

You better believe it is a big deal. Apparently, you are not aware what occurs when a stroke team is activated. One should know how to assess properly or get out of the profession. Sorry, I am proud of my diagnostic skills alike my other peers (yes, we TQI to verify accuracy) and as well as a professional to make such diagnosis based upon the findings and ruling out we can perform. (i.e if you knew your cranial nerves then you would know the differential of Bell's Palsy and a CVA)

Again, if one wants to be an ambulance driver .... so be it. Cook book medicine is really not that hard.. just memorize s/s and follow a protocol... no thinking required.

R/r 911

I'm confused by the boded part. Can you tell me how you can distinguish pre-hospital Bell's from a CVA barring the patient already having a diagnosis? As far as I am aware Bell's is (as I said in a previous post) a diagnosis by exclusion, and is actually considered an idiopathic process (though recent thought is inflammation of CN VII leads to compression as the nerve exits at the stylomastoid foramen).

By its definition you cannot be diagnosed with Bell's unless EVERYTHING else it could possibly be is negative. And honestly the differential isn't that large. CVA, TIA, neoplasm, infectious/inflammatory process none of which you can r/o prehospital.

While I am not saying diagnostic skills are not important, honestly this is one area where frankly it should not matter. A stroke team should be activated on a positive CPSS or LAPSS. No matter what you tell them from your assessment they should be fully working up the patient even IF they have a Bell's diagnosis (or any cranial nerve dysfunction for that matter) as there is no positive test for many of them.

 

[Flight-LP]

See my above post for part of your answer...................

Should the patient be fully evaluated at a neuro receiving facility for a neurological deficit? Absolutely!

Should a stroke team be activiated based on a LAPSS?
Sure!

A positive CPSS?
In my humble opinion no. But then again, I have a stroke center on every street corner, most with in house teams. Individual mileage will vary.

Yes, a Bell's patient could have associated extremity deficits, but again, a tell tale sign is the ability to control the frontalis muscle. Cranial nerve deficit = loss of voluntary control.
unihemispheral CVA = intact control due to bilateral nerve innervation.

 

[Aidey]

On every stroke call, that seems to you to be a stroke when you arrive, do you always do a entire nuero assessment. Check all 12 cranial nerves, visual acuity, fine motor control etc.?

Our instructor wants us to be able to do a differential field diagnosis for left, right or cerebellar stroke.

I have been on just one stroke call with a paramedic, the only test he did was arm drift. He didn't even ask the pt to recite, "you can't teach an old dog new tricks".

For me the extent of my assessment is going to depend on several things, the main one being how "sick" the pt appears.

For example, if I get there and the pt can't tell me their name (but is alert and able to nod, or otherwise respond), I'm not going to ask them to recite "you can't teach a old dog new tricks" because I already know their speech is impaired.

Another example is the pt who is slumped over in a chair, and has no movement on one side. I'm not going to make that person try stand up so I can assess their gait or balance. 1. I already have a very strong suspicion it's impaired and I have a strong index of suspicion that the pt won't be able to bear their weight which leads to number 2. There is a big risk of the patient falling which is just about the last thing you want to happen.

If the patient can't speak that also complicates your assessment to a degree and may mean you can't conduct a full assessment. I've conducted an assessment on a totally aphasic stroke patient by asking yes and no questions and having them squeeze my hand for yes. I was able to get some important information, but it took about 3 times longer than a normal assessment, and there are some things that are very difficult to assess that way like "What were you doing when the symptoms started?"

So basically what I'm saying is that as a paramedic it's not only important to do a proper assessment, but it is also important to know when not to do something, or when it's not going to be possible to do part of the assessment. Sometimes you are also going to have to prioritize what parts of an assessment you do in a short transport. You may not have time to do a LAPHSS, then a NIH Stroke scale, Cranial nerve exam, gait assessment, IV, EKG, Blood glucose, etc etc etc.

I know that it is important to be more than just "ambulance drivers", but in my opinion sometimes delaying transport to do a bunch of stuff is doing the patient more harm then good. (This is a longstanding, on going argument also). Over time you will develop your assessment skills, and you will be able to see when your pt is in bad shape and needs to get moving now and you do what you can enroute.

So the short answer is no, I don't always do all 800 parts of the assessment we can do, but it's not out of being lazy, or feeling that 'oh the CSS was positive, that is enough". It's because in the real world it just doesn't always happen because you are busy doing other things.

I also think it is neat, how if someone can't move their arm due to stroke, that when you ask them to move it, they think they are moving it and don't realize they are not.

While this is physiologically an interesting thing, be aware that when the pt realizes that they aren't moving that limb it can cause them A LOT of anxiety and panic.