Neurological Assessment

[mycrofft]

I love watching posters get personal and kick each other in the shins.

:glare:
Learn and follow your local protocols. If you need to learn more to meet them, do it. No point in not learning to do something better, including better than the protocols, but meet them with maximum efficiency first.

If you take a map of the US, stick a pin in it for each designated CVA-specialty receiving facility, you will still have one hell of a lot of territory without pins.

If the facility near you is also a busy ER, factor in potential for diversion and delay once there.

 

[ki4mus]

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...

My class did.

 

[daedalus]

My class did.

Doesn't matter, its not in DOT which means that most EMTs do not learn about it in their initial education, its not tested on, and it is not the standard or care for an EMT.

JP, I am speaking about EMT education, not what you learn outside of class.

 

[JPINFV]

JP, I am speaking about EMT education, not what you learn outside of class.

I never said you weren't. One of my contentions, though, is the concept that you can't or shouldn't incorporate outside education to the practice of EMS at any level (provided you stay within your scope of practice).

 

[daedalus]

I never said you weren't. One of my contentions, though, is the concept that you can't or shouldn't incorporate outside education to the practice of EMS at any level (provided you stay within your scope of practice).

and I agree. However it is a sad state of affair when our EMTs are not told about the CNs and many other things in class. I for one use a lot of things that I was never told about in EMT school while at work. However, these things are not the standard of care I am held to nor tested on. Continuing education makes a better provider but does nothing to promote the minimum which needs to be higher, and I know you agree with that.

You can baffle your stupid EMT supervisors now that you are a medical student anyways

 

[JPINFV]

Choir. You're preaching to it.

 

[46Young]

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

Simple solution to that - call the intended receiving hospital, advise them of your findings, and let THEM decide if they want to activate the stroke team. You're covering your tail while acting in the best interests of the pt. If the hosp doesn't want to do a stroke workup on your pt, then it's on them.

With our current education/scope being what is is, our main role in the prehospital environment is to gather information for the ED based on our assessment/diagnostics, make a PRESUMPTIVE (not definitive) Dx, and treat the pt accordingly using our education and training, while utilizing our protocols as guidelines.

If there's even a slight suspicion on my part that the pt may be experiencing a CVA, I'm going to uptriage and let the ED decide how to manage the pt. If the closest hosp isn't a stroke center, I'll tell them what I have and then ask them if they would prefer that I divert to a stroke center. This isn't really that difficult to do. You're all blowing this way out of proportion.

When either giving a report to the ED, or writing my PCR, I never state "R/O MI, R/O CVA, R/O asthma exac", although it may be fairly obvious that's what's going on with the pt. Using a R/O MI for an example, I'll advise of dyspnea exertional or otherwise, retrosternal Cx pain, 12 lead changes, any changes with O2/NTG/morphine/fentanyl, etc. I'm not advising a Dx (I'm not an MD), but treating the pt based on my findings and reaction to interventions.

 

[daedalus]

When either giving a report to the ED, or writing my PCR, I never state "R/O MI, R/O CVA, R/O asthma exac", although it may be fairly obvious that's what's going on with the pt. Using a R/O MI for an example, I'll advise of dyspnea exertional or otherwise, retrosternal Cx pain, 12 lead changes, any changes with O2/NTG/morphine/fentanyl, etc. I'm not advising a Dx (I'm not an MD), but treating the pt based on my findings and reaction to interventions.

That is kind of strange because it is expected of us to develop a field diagnosis. Around here, stating "we are treating the patient for probable acute coronary syndrome", or "We have a CVA vs TIA" is not uncommon.

 

[46Young]

That is kind of strange because it is expected of us to develop a field diagnosis. Around here, stating "we are treating the patient for probable acute coronary syndrome", or "We have a CVA vs TIA" is not uncommon.

Yes, we can make a "presumptive Dx". By presumptive I mean that we are treating for what we think the probable cause is. The way that I relate my findings and subsequent treatments makes obvious my thought process and rationale for Tx. I don't like putting my actual "diagnosis" in writing, although I usually say what I believe to be happening during my verbal report.

In court, the best thing to say is "the pt was found to be alert and answering questions appropriately, able to follow commands, denies Cx pain, H/A, dizziness or nausea, had bibasilar rales, elevated BP/pulse/RR, c/o DOE and orthopnea as well, neg 12 lead changes evident, little improvement with high flow O2 per the pt and our reassessment. We treated this pt based on our findings with CPAP, NTG, and morphine. All is documented on the PCR". No Dx was given, but the rationale and thought processfor our Tx is clear.

Not stating a Dx is legal judo as far as I'm concerned.

 

[Dwindlin]

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.

Facial nerve does not have to be all or nothing. You could have any number of manifestations. There is no tell tale sign for Bell's. Bell's by its definition is idiopathic and can only be diagnosed by ruling everything else out. There is research that shows Bell's is likely the result of inflammation (but this has yet to be proven). Honestly anytime you are presented with a patient showing ANY kind of unilateral weakness you should be thinking stroke (unless of course they tell you it's not new) because unless you carry a lab and advanced imaging on your truck you cannot rule out any of the differentials. The one exception I'll say is a TIA, but even then, if you have someone who is currently having symptoms you still can't say its a TIA because the only thing that differentiates a TIA from CVA is time.

 

[Akulahawk]

Facial nerve does not have to be all or nothing. You could have any number of manifestations. There is no tell tale sign for Bell's. Bell's by its definition is idiopathic and can only be diagnosed by ruling everything else out. There is research that shows Bell's is likely the result of inflammation (but this has yet to be proven). Honestly anytime you are presented with a patient showing ANY kind of unilateral weakness you should be thinking stroke (unless of course they tell you it's not new) because unless you carry a lab and advanced imaging on your truck you cannot rule out any of the differentials. The one exception I'll say is a TIA, but even then, if you have someone who is currently having symptoms you still can't say its a TIA because the only thing that differentiates a TIA from CVA is resolution of symptoms in a short time.

As we all (should) know, TIA is by definition, transient. The effects disappear and no permanent damage is done. They can not be differentiated from a CVA in the field. We're not going to, because if we're wrong...

Bell's Palsy does affect the facial nerve... resulting in paralysis of the musculature that the nerve innervates. A CVA/TIA that affects all of the facial nerve on one side of the face will have the same appearance as Bell's Palsy... As I believe JP and others have said, Bell's Palsy is a diagnosis of exclusion. EVERYTHING ELSE HAS TO BE RULED OUT.

 

[Dwindlin]

As we all (should) know, TIA is by definition, transient. The effects disappear and no permanent damage is done. They can not be differentiated from a CVA in the field. We're not going to, because if we're wrong...

Bell's Palsy does affect the facial nerve... resulting in paralysis of the musculature that the nerve innervates. A CVA/TIA that affects all of the facial nerve on one side of the face will have the same appearance as Bell's Palsy... As I believe JP and others have said, Bell's Palsy is a diagnosis of exclusion. EVERYTHING ELSE HAS TO BE RULED OUT.

I'm confused are you agreeing with me?

This is exactly what I have been saying. The TIA comment would be more along the lines if you pick a pt who is telling you they had a deficit that is now gone, but again I clarified by saying if you have a pt currently showing symptoms nothing can ruled out prehospital and thus any deficit should be considered a CVA.

 

[Akulahawk]

I'm confused are you agreeing with me?

This is exactly what I have been saying. The TIA comment would be more along the lines if you pick a pt who is telling you they had a deficit that is now gone, but again I clarified by saying if you have a pt currently showing symptoms nothing can ruled out prehospital and thus any deficit should be considered a CVA.

Actually, agreeing and clarifying...

 

[46Young]

+1 on posts #'s 30 and 31.

If you think that you're training/education is good enough to downtriage pts without the benefits of in-hospital diagnostics (and a medical degree!) just remember that pride comes before a fall. I'm directing this comment in part to post # 15. It takes only one pt to have a poor outcome due to your negligence, by not directing txp to the appropriate facility, to lose your home, job, cert, your means of living in court.

One should always maintain a high degree of suspicion, until proved otherwise, and uptriage/manage the pt accordingly. Failure to do so by either complacency or delusions of educational grandeur is playing with fire.

And yes, if I'm thinking possible CVA in the least U/A, I AM going to load and go. I'll do everything that I can for the pt with respect to time while enroute to the hospital. We can't provide definitive care for a possible CVA in the prehospital environment, only prophylactics and diagnostics within our scope. I don't see how that's cookbook medicine. Suspected CVA's, much like traumas, need definitive in-hospital care as quickly as possible.

 

[Flight-LP]

Facial nerve does not have to be all or nothing. You could have any number of manifestations. There is no tell tale sign for Bell's. Bell's by its definition is idiopathic and can only be diagnosed by ruling everything else out. There is research that shows Bell's is likely the result of inflammation (but this has yet to be proven). Honestly anytime you are presented with a patient showing ANY kind of unilateral weakness you should be thinking stroke (unless of course they tell you it's not new) because unless you carry a lab and advanced imaging on your truck you cannot rule out any of the differentials. The one exception I'll say is a TIA, but even then, if you have someone who is currently having symptoms you still can't say its a TIA because the only thing that differentiates a TIA from CVA is time.

As I said, you can have other presentating symptoms, however if the patient cannot voluntarily control the frontalis muscle, it IS a CN VII issue. This was an added tidbit of info that I thought some may found useful. Take it as you wish.

 

[46Young]

As I said, you can have other presentating symptoms, however if the patient cannot voluntarily control the frontalis muscle, it IS a CN VII issue. This was an added tidbit of info that I thought some may found useful. Take it as you wish.

Much appreciated tidbit of information. Like I said earlier, I would relate that info to the receiving facility and let them decide if they want to activate the stroke team or not.

 

[Dwindlin]

As I said, you can have other presentating symptoms, however if the patient cannot voluntarily control the frontalis muscle, it IS a CN VII issue. This was an added tidbit of info that I thought some may found useful. Take it as you wish.

You're right it is. However this doesn't mean Bell's. Losing the frontalis muscle can be the result of anything on the differential for muscle deficit. You could have a tumor putting just enough pressure on the facial nerve to affect only the temporal/posterior auricular fibers, or a stroke to motor nucleus that feeds those same fibers. And in all reality it may not be neurologically impaired, the muscle itself could be damaged. While the tidbit on the frontalis muscle being controlled by CN VII is valid information, saying CN VII is "all or nothing" is not.

 

[redcrossemt]

I pose the following:

While a positive CPHSS may lead you to believe a stroke is occurring; does a negative CPHSS mean a stroke is not occurring?

This is where additional assessment comes in. Pre-hospital providers should consider classes like ASLS to learn further assessment skills, such as those included in the NIH stroke scale, and should take the time to review their cranial innervations, as well as neurological assessment techniques.

I know we don't have time in all cases, and that not all patients need a full neurological assessment. However, assuming the patient's issue is not a stroke based solely on a negative CPHSS is a bad idea.