Slumping, Slurring and Slipping Away: Stroke Assessment

Slumping, Slurring and Slipping Away: Stroke Assessment
Laurie A. Romig, MD, FACEP Medical Director Pinellas County (FL) EMS

This discussion relates only to nontraumatic neurological problems!
Caution! This discussion relates only to nontraumatic neurological problems! Assessment is the same, but treatment and destination decisions may be different.

Prehospital Stroke Care
MYTH: It doesn’t make a difference FACT: It does! (as with AMI) Better field management can help to limit stroke deficit Rapid transport to the right facility is an important component of the overall treatment strategy CHALLENGE: Not all areas have the appropriate infrastructure in place (i.e., Stroke Centers)

Prehospital Stroke Care
Use the FAST-G# exam and history to determine hospital destination Use the MEND* checklist to refine field impression Evaluation and treatment criteria are based on latest AHA/ASA guidelines # Pinellas County adaptation of Cincinnati Stroke Scale *Miami Emergency Neurologic Deficit (includes Cincinnati Stroke Scale elements)

Stroke Facts and Rationale for Acute Care

Stroke in the United States
Affects > 700,000 persons per year 1/3 die, 1/3 become disabled, 1/3 recover Third leading cause of death Leading cause of long-term disability Costs $50 billion per year

Change in Terminology: Acute Brain Attack (Not “CVA”)
Term aids public education efforts Identifies the brain as the organ involved Implies appropriate sense of urgency Likens event to heart attack CVA = cerebrovascular accident Bad term because stroke is preventable and treatable

Stroke Definition and Types
General Definition Sudden brain dysfunction due to blood vessel problem Ischemic stroke (80%) decreased blood supply to a focal area of brain mostly thromboembolism (blood clot) Hemorrhagic stroke (20%) blood vessel rupture within skull not due to trauma intracerebral (inside the brain tissue) or subarachnoid (under the coverings of the brain)

Ischemic Stroke Most common cause: thromboembolism
CLOT INFARCT Most common cause: thromboembolism Possible sources of clot: Heart Large artery (to brain) Small artery (in brain) Strokes associated with clots in small brain arteries are called “lacunar” Clot occluding artery

Intracerebral Hemorrhage
Most common cause: chronic hypertension Other causes: Vessel malformation Tumor, bleeding abnormalities Bleeding into brain

Subarachnoid Hemorrhage
Most common cause: aneurysm rupture Other causes: Vessel malformation Tumor, bleeding abnormalities Bleeding around brain

Transient Ischemic Attack (TIA)
Reversible focal dysfunction present for minutes to less than 1 hour Among TIA patients who go the ED: 5% have stroke in next 2 days 10% have stroke in next 3 months 25% have a recurrent event (TIA or stroke) within 3 months Stroke risk can be decreased with proper therapy Do not enable patients to disregard the importance of a TIA, even if they have had them before and know what they are!

Ischemic Stroke: Nonmodifiable Risk Factors
Advanced age Male gender Family history of early stroke or MI Nonmodifiable basically means that you can’t influence or change these risk factors. They just are what they are.

Ischemic Stroke: Modifiable Risk Factors
Hypertension (systolic and diastolic) Cigarette smoking Prior stroke/ TIA Heart disease Diabetes mellitus, hyperlipidemia Hypercoagulable states Carotid bruit Cocaine, excess alcohol Could this be you? Remind everybody to take a look at these risk factors for THEIR OWN health purposes!

Time is Brain: Save the Penumbra!!
The Stroke Battle Cry Time is Brain: Save the Penumbra!!

Time Is Brain: Save The Penumbra
(DEAD) The penumbra is a zone of reversible ischemia around a core of irreversible infarction. This area of brain is salvageable in the first few hours after onset of acute ischemic stroke symptoms. Clot in Artery

Time is Brain: Save the Penumbra
Patient symptoms are due to both the infarcted core and the ischemic penumbra One cannot determine by exam how much brain can still be saved Therefore, the full extent of the damage is not immediately clear. Deficits could get worse or could get better Treatment aims to salvage the circulation to the penumbra If treated early enough, all of the brain tissue could be salvageable

Thrombolytic agent t-PA can limit brain damage safely if given within 3 hours—it reduces risk of disability due to ischemic stroke by 30% t-PA is currently administered only if: clinical diagnosis (no hemorrhage) confirmed by CT scan within 3 hours of onset (the sooner, the better) age 18 or older no other absolute contraindications Thrombolytic therapy is not without its own risks, but those risks can be minimized by careful selection. Currently, only a relatively small percentage of stroke patients are eligible for this therapy.

Other interventions such as intraarterial thrombolytics and clot retrieval devices are being used in facilities with specialized capabilities for some stroke patients Treatment windows are expanding to 6 to 8 hours or more as facilities gain more experience with new devices The Penumbra is damaged by seizure, hypotension, hyperglycemia, fever, acidosis This has implications for what we need to evaluate, monitor and treat in the field

Time is Brain: Determine Cause
In ED: define likelihood of ischemic stroke Full evaluation may take days and requires admission to the hospital Differential diagnosis is not extensive Ischemia vs. hemorrhage Mimics include: tumor, trauma, seizure, migraine, hypoglycemia, overdose

Stroke Mimics These conditions can result in focal cerebral dysfunction and mimic a stroke: hypoglycemia improves w/D50 seizure w/postictal state staring/limb shaking at onset migraine previous similar events tumor onset over weeks to months abscess onset over weeks to months subdural hematoma posttrauma

The Stroke “Primary Survey”: The FAST-G Exam

Cincinnati Prehospital Stroke Scale “FAST”
Perform as part of Primary Survey under “D” for “Disability” Also incorporated in the FAST stroke primary evaluation tool and the MEND stroke secondary evaluation tool that you’ll hear about later Facial droop Arm drift Speech Time patient was last seen or known to be normal This is a BLS level evaluation tool! More detail on each element to follow

Facial Droop (Cranial Nerves): Show Teeth or Smile
Abnormal: One side of face does not move as well as the other side Right-sided droop © AHA 1997

Facial Droop You may have to encourage the patient to try
Even in unresponsive patients, facial droop may be obvious It’s common also to see drooling from the affected side Left facial droop This patient actually has Bell’s Palsy, but the facial droop appearance is the same for our purposes Facial droop can be caused by other disorders as well (such as Bell’s Palsy), so a complete detailed stroke examination is VERY important. If ONLY cranial nerve function is disrupted, stroke is less likely.

Arm Drift (Motor): Hold arms out, palms down and close eyes
Abnormal: One arm cannot be lifted or drifts down Right-sided drift © AHA 1997

Arm Drift Normal finding is for both arms not to move once extended or to move together If patient is unable to obey commands, look for spontaneous movement or movement in response to verbal/painful stimulus If patient is unresponsive and not moving at all DO NOT mark this as abnormal. You just don’t know the answer.

Speech: Repeat Phrase “You can’t teach an old dog new tricks.”
Abnormal: Wrong or inappropriate words or unable to speak (aphasia) Caused by left hemispheric deficit Slurred words (dysarthria) Caused by cranial nerve deficit

Time last seen or known normal
Forget the concept of “time of symptom onset” and change to “time last seen or known normal” This is CRUCIAL because time is the major determinant in what interventions may be effective “Time of onset” is often difficult to determine, so we default to the level of “time last normal” This also accounts for patients with previous deficits, because we’re asking about normality for that patient

You are called to a 76 year old female found on the floor in her apartment with obvious right-sided weakness and aphasia. She can’t give you history of when the symptoms started, but the neighbor is able to tell you that she last spoke with the patient the previous evening, when she was acting normally. The patient’s son shows up and says that he talked to her on the telephone just one hour ago, and she was normal at that time.

What difference would the determination of “last seen or known normal” make?
The actual time of onset of symptoms is unknown If the son had not known that the patient was normal one hour prior, we would have had to assume that the stroke symptoms began outside of the several hour window for intervention because we would have had to default to the last time she was contacted by the neighbor This is similar to the situation of a patient waking up with deficits—we don’t truly know when the symptoms started

FAST-G Adaptation (Pinellas County)
Adds field determination of blood glucose in order to rule out hypoglycemia as a reversible cause of stroke-like symptoms This is a high priority assessment tool, especially in diabetic patients or those with other potential reasons to be hypoglycemic You’d be surprised at how many hypoglycemia patients present with stroke symptoms, so don’t think that this is a rare occurrence!

PLEASE NOTE!!! ALTERED MENTAL STATUS without focal neurological findings as evaluated in the FAST-G and MEND exams should NOT be attributed by default to stroke. Other medical problems are far more common causes of isolated mental status changes Intoxication/overdose Sepsis Metabolic problems Head injury Etc.

Important Supplemental Medical History

Important History Elements
Help to pin down symptoms and last known normal time Help to determine risk factors and underlying causes as well as potential for stroke imitators Assist in differentiating ischemic from hemorrhagic stroke Assist in determining appropriate out-of-hospital and in-hospital treatment A Brain Attack form can prompt you for appropriate history This is a State of Florida requirement Why specific bits of patient history are important.

Importance of Witness Documentation
Witnesses can be your only source of history We need to document specific witness testimony AND provide the hospital with witness contact information if they are not going to the hospital Hospital staff may need to ask for additional information Notify hospital staff if witness is coming to hospital and who to look for Record witness information on Brain Attack form or run report

Important History Elements: HPI
Potential symptoms to question Extremity weakness General weakness (i.e., nonfocal) Vision changes Slurred or inappropriate speech Nausea/Vomiting Syncope/Near-syncope

Important History Elements: HPI
More potential symptoms to question Dizziness/Vertigo Altered sensation (dull, increased, pins and needles, etc.) Altered level of consciousness* Severe or otherwise unusual headache* Stiff/painful neck* Symptoms resolved? TIA rather than stroke * Potential hemorrhagic stroke indicators

Relevance of specific symptoms
Severe or unusual headache, especially combined with nausea/vomiting and/or altered LOC  most typical of hemorrhagic stroke May indicate transport to a Neurosurgery capable facility. Dizziness/vertigo, lack of coordination  possible cerebellar stroke Dysarthria (slurred speech) rather than aphasia (wrong words or none)  possible brainstem stroke

Past Medical History (Risk Factor Assessment)
Dysrhythmias (particularly acute or chronic a. fib.) Diabetes Current or very recent pregnancy (within days) Sickle cell disease (common cause of stroke in younger patients) Previous stroke (and whether ischemic or hemorrhagic, if known)

Past Medical History (Risk Factor Assessment)
Chronic hypertension Coronary artery disease or other vascular atherosclerosis Recent systemic cancer (common cause of pediatric stroke) Resuscitation status (prehospital DNR?) And our other routine past history questioning

A Word About Old Deficits
Patients with old strokes or other neurological deficits may, of course, have abnormal findings on the FAST or MEND exams even on their best days You may be in the best position to determine from witnesses or the patient what is NORMAL FOR THEM Document all deficits on the run report and try to make clear which are old, new or worse than usual

Fibrinolytic Screening
Not all positive responses are ABSOLUTE contraindications for fibrinolytics Criteria are dynamically changing with new modes of therapy Risk is balanced against potential benefit NOTE: Age is NOT a primary factor!

Head trauma at onset of symptoms Which came first? Seizure at onset? Could symptoms be Todd’s Paralysis (postictal paralysis) due to the seizure or did a stroke cause the seizure? Symptoms consistent with cerebral bleed?

Patient on Coumadin or Warfarin? Aspirin or NSAIDs do NOT have the same effect, but note these separately History of bleeding or clotting disorder? Previous hemorrhagic stroke? Increased likelihood of recurrence rather than new ischemic stroke

Current pregnancy or very recent delivery? Pregnant women can be hypercoagulable and fibrinolytics can be contraindicated at very early stages of pregnancy or in first few days after delivery Surgery or significant hemorrhage within the last 3 months? GI, vascular, thoracic, orthopedic, cranial surgery GI bleed, variceal bleed, intracerebral bleed, major traumatic hemorrhage

The Stroke Secondary Survey: The Miami Emergency Neurologic Deficit (MEND) Exam

MEND Exam: Stroke Secondary Survey
Perform en route unless awaiting transport May be able to detect strokes NOT evident from FAST exam Helps to define the specific stroke syndrome Helps to document severity of stroke, which may enter into hospital treatment recommendations Establishes detailed baseline for later comparison Can be accomplished in less than 5 minutes This is also a BLS assessment; it just takes a little more knowledge of physiology to interpret

MEND Exam: Mental Status Section
Level of consciousness: AVPU Remember that this is supposed to reflect the patient’s highest level of mental function, so be sure to stimulate adequately

MEND Exam: Mental Status Section: Speech
Speech: Repeat “You can’t teach an old dog new tricks” Use this phrase specifically rather than just judging from spontaneous speech Listen for aphasia or dysarthria

Aphasia An impairment in understanding (receptive aphasia) and/or formulating complex, meaningful elements of language (expressive aphasia) Doesn’t always mean unable to speak at all, but may include inappropriate words or word order or difficulty with word finding (could also be considered “dysphasia”) Reflects a temporal or frontal lobe problem Patients often appear frustrated that they can’t get the words out or that you can’t understand them

Dysarthria (“dys” = abnormal, “arthria” = articulation) Slow, slurred, weak, imprecise or uncoordinated speech Caused by weakness or incoordination of speech muscles Words are usually appropriate Both aphasia and dysarthria are recorded as abnormal If patient isn’t speaking at all because they are unconscious, you can’t evaluate speech

MEND Exam: Mental Status Section: Questions
Ask patient for their age and what month it is If patient is aphasic or unable to follow commands you just can’t evaluate this element. Don’t assume that they would not be oriented if they could respond.

MEND Exam: Mental Status Section: Commands
Ask patient to open their eyes wide and then close them tightly (or vice versa) This is more sensitive than hand squeezing because eye opening motor function is affected less often by motor deficits than hand muscle function The patient is less likely to have problems because they physically can’t do the task You may think that you can assume the answer to this question by the patient’s response to the speech test, but follow the systematic approach

MEND Exam: Cranial Nerve Section: Facial Droop
Cranial nerves affect speech (through facial muscles), vision (through eye muscles and the optic nerve), facial movement, facial sensation, hearing, and swallowing Ask patient to “give me a big smile” or “show me your teeth” Both sides of the mouth should move equally Facial droop without other neurological deficits may actually be caused by isolated nerve problems such as Bell’s Palsy rather than stroke

If the patient pulls his false teeth out of his pocket at this point, at least you’ve got evidence of ability to follow commands!

MEND Exam: Cranial Nerve Section: Visual Fields
Definition: the area in which objects can be seen in peripheral vision while focusing straight ahead Usually broken into left and right upper and lower quadrants We’ll test all four quadrants, but record abnormalities only as left or right

Have patient look straight at your nose Hold your hands about 18 inches in front of the patient, fingers bent at the palm and facing each other If YOU can’t see your fingers wiggling in YOUR peripheral vision, your hands are too far apart!

Tell the patient to point to where they see wiggling fingers (if they do) If they don’t see your fingers at first, move your hands toward the patient’s nose a little to make sure that you’re within their normal field of vision Obviously, if a patient can’t follow commands, you can’t do this test

Wiggle your fingers in each of the four quadrants, but try not to make the pattern predictable to the patient Report any abnormalities only by “right” or “left” (don’t have to specify upper or lower)

MEND Exam: Cranial Nerve Section: Horizontal Gaze
This basically tests eye muscle function, which is governed by cranial nerves 3, 4 and 6 in the brainstem, though the cortex can also affect eye muscle function Have the patient look straight ahead at you to start with. Instruct them to follow your finger with their eyes, but not to move their head. You may need to touch their chin to remind them not to move. Check to see if the patient has any prosthetic eyes!

Using a polite finger , start with your finger in the midline and have the patient follow the finger to each side The object is to “bury the sclera”, or get the patient to look ALL the way to the side You may have to hold an eye open if lid droop is present

Examples of possible deficits

If the patient is unable to comply with commands to do the horizontal gaze assessment, simply observe spontaneous eye movement (if present) If you see a deviated gaze, the deficit is actually recorded as THE DIRECTION IN WHICH THE EYE WILL NOT MOVE (right or left) Gaze deviated to left is recorded as a right gaze deficit The eye muscles that allow the eye to track to the right are not functioning, therefore the eye is being pulled to the left

MEND Exam: Cranial Nerve Section: Horizontal Gaze: Advanced Physiology
Eye deviation at REST is technically called GAZE PREFERENCE. The eye muscles CAN move in all directions, but they “prefer” not to This is usually a result of a cerebral hemispheric stroke Example: Eyes that seem to “prefer” to be looking to the left actually represent a left hemispheric stroke and would be recorded as an abnormal horizontal gaze to the right (won’t look to the right) on the BAT form But it would also be called a left gaze preference Don’t get too wound up or carried away with this!!!!! Tell anyone that gets confused by this and the next slide to DISREGARD and just go by the instructions on the previous slide.

MEND Exam: Cranial Nerve Section: Horizontal: Advanced Physiology
A real inability of the eye to follow past the midline is true GAZE PALSY, and is usually the result of a brainstem problem or direct injury to the eye muscles. In these injuries, the eyes appear to look AWAY from the affected side of the brainstem. For our purposes, don’t get too tied up in trying to figure out where the stroke is by the gaze deficit. Other symptoms will probably help you to discriminate better

MEND Exam: Limb Section: Arm Drift
This is simply a repeat of the arm drift assessment done in the FAST exam Please DO repeat the test rather than assuming that the results will be the same as during the FAST Eyes should be closed for the arm drift test, but do not have to be for the leg drift test Palms should face down for the arm drift test (sleepwalker position) Arms are held out simultaneously, not separately The key to look for is whether the sides are symmetrical or not, not how high the lift is Exam can be done on a supine or seated patient

MEND Exam: Limb Section: Leg Drift
Legs are tested separately Can be done with a seated or supine patient Eyes do not need to be closed Have patient attempt to lift the whole leg, not just kick out or up with the lower leg Again, symmetry is the most important factor to observe Having the patient hold the limb up for a second or two rather than just kicking up once may better reveal a subtle weakness on one side compared to the other

A note about patients who can’t follow commands for arm and leg drift
Observe spontaneous movement and document accordingly; do the best you can Remember, symmetry is really the most important observation

MEND Exam: Limb Section: Abnormal Sensory Section
Have the patient uncross arms and legs for these tests Crossed arms and legs can lead to confusion for the brain Have the patient close their eyes Test arms and legs separately, having patient tell you or point to the side they feel a touch on (if they do) Even aphasic patients may be able to accurately indicate results this way After testing each side separately, ask if the sensation is the same on both sides

MEND Exam: Limb Section: Abnormal Sensory Section
Touch on the back of the hands and the top of the foot or on the shin Test the same location on each side Note absence of sensation as abnormal, but also note alteration in sensation (pins and needles, decreased sensation, etc) as abnormal Again, symmetry is the key A person with chronic peripheral vascular disease or neuropathy may have decreased or altered distal sensation all the time, but it will usually be symmetrical

MEND Exam: Limb Section: Abnormal Coordination Section
This section tests the cerebellum, which supplies coordination of muscle movements The test for the upper extremities is called the Finger to Nose test The test for the lower extremities is called the Heel to Shin test

Abnormal Coordination Section
If the test cannot be performed because of extremity weakness, don’t assume that coordination is abnormal This is one reason to do the coordination testing AFTER motor testing Name the abnormality for the side that is actively moving (finger or heel) as part of the test, not the stationary nose or shin

MEND Exam: Limb Section: Finger to Nose Test
Hold your finger upright in the midline in front of the patient’s face (about 8 to 10 inches away to start) Tell the patient to touch your finger with one finger of one hand, then to touch their nose, then back to your finger You can demonstrate if needed

MEND Exam: Limb Section: Finger to Nose Test
Once they get the idea, pull your finger far enough away from them that they have to stretch a bit This uncovers more subtle ataxia or incoordination Have them repeat the motion several times, then switch sides Abnormal findings are missing your finger or their own nose or having a tremor during the motion In doing full neuro exams, we usually move the examiner’s finger around to force the patient to catch a moving target, but we don’t need to do that at the EMS level

MEND Exam: Limb Section: Heel to Shin Test
Have the patient slide the heel of one foot straight down the top of the shin of the other leg, from the knee down to the foot Repeat on the other side Look for inability to place or keep the foot on the shin Remember that the abnormal side is named for the foot, not the shin Remember that inability to do this test because of muscle weakness does NOT mean that you mark the results abnormal

A note about tremors Tremors that appear at rest are not usually due to stroke, but are more often due to disorders such as Parkinson’s disease and other CNS disorders These tremors usually disappear when performing a specific motor task Intention tremor, or a tremor that begins or worsens when performing a motor task is more commonly due to stroke

Bonus Content. Download this presentation from www. jumpstarttriage
Bonus Content!!!!!! Download this presentation from or go to and click on the “The Other Dr. Romig” page You’ll find extra sections on Prehospital Treatment for Strokes, the Five Major Stroke Syndromes, and practice scenarios that we just don’t have time for.

Summary Stroke has joined Acute Myocardial Infarction as a very time-sensitive prehospital disorder

Summary Rapid and basic assessment on scene with expedited transport is, in effect, therapy for these patients Basic stroke assessment is a BLS skill. More advanced assessment can improve your understanding of the disorder and facilitate clear communication with Stroke Teams at Stroke Centers

Questions? Don’t forget the Bonus Content 

Bonus Content!!

Prehospital Stroke Management

Basic Principles of Prehospital Stroke Care
First do no harm avoid giving glucose unless absolutely indicated avoid treating hypertension avoid causing aspiration pneumonia Report to ED details of symptom onset neurologic exam witness information

Avoid Giving Glucose THE RULE: Do NOT give glucose-containing solutions to acute stroke patients THE REASON: Hyperglycemia causes lactic acidosis and damages the penumbra THE EXCEPTIONS: Hypoglycemic patients with known history of hypoglycemic episodes (such as insulin dependent diabetics) should still be treated as usual. The symptoms may be due to the low blood sugar. Patients without a REASON to be hypoglycemic should only treated if their blood sugar is < 50 gm/dl

Avoid Treating Hypertension
THE RULE: EMS should not treat hypertension in acute stroke patients THE REASONS: HTN is commonly caused by the stroke It may be required for penumbra perfusion It often subsides without treatment

Avoid Causing Aspiration Pneumonia
THE RULES: Keep 100% NPO Elevate head 30o (no higher) unless hypotensive This is actually a recommendation that is being debated by some neurologists If vomiting, use left lateral recumbent position THE REASON: Most stroke patients have trouble swallowing & aspiration is a major cause of morbidity & mortality

On Scene Care Summary Complete FAST-G Priority interventions
Maintain SpO2 of at least 95% No benefit to maintaining higher SpO2 Keep head straight, elevate head of stretcher to no more than 30 degrees unless hypotensive Left lateral recumbent position if nauseated or vomiting Of course, the usual ABC priorities apply as well.

On Scene Care Summary Priority interventions (cont.)
Maintain systolic BP of at least 90 mm Hg DO NOT treat hypertension Treat blood glucose if < 50 mg/dl (< 40 mg/dl for neonate) and no history of hypoglycemia Treat patients with known hypoglycemia history as usual Make destination decision based on exam and history Get at least HPI and witness information on scene

On Scene Care Summary IV insertion can be delayed until during transport if it is not needed for a priority intervention Same for cardiac monitor and 12 lead ECG Key is to minimize scene time in order to maximize window for definitive treatment

En Route Care Summary Document thoroughly
Treat clinical complications as they arise Perform MEND exam as a secondary assessment tool DO NOT DELAY to do this on scene Contact receiving facility as soon as possible to give them time to prepare for the patient

Quick Radio Report Template
Patient age and gender Symptoms and FAST-G results Make sure to include time last seen normal and blood glucose Most PERTINENT history (history of previous bleed or ischemic stroke, pregnant?) Vital signs, cardiac rhythm if available Interventions performed Fibrinolytic screening negative, positive for possible contraindications, or in progress (don’t necessarily need details over the radio) MEND exam results/stroke syndrome suspected if available ETA I’ve intentionally put this on one slide in spite of it being very busy so that it can be used as a template for a work aid. We might even want to create some wallet card/clipboard size cheat sheets similar to the Miami card

How does a good radio report help the ED?
Clear a bed for the patient if necessary and prep to receive patient report on arrival Notify CT and reshuffle other patients waiting for same Notify Stroke Team so that they can be present or en route when you arrive Prep their registration processes so that tests can be ordered more quickly In general, get everybody into the same kind of mindset a Trauma Team or STEMI Team has

Example of ED Report 64-year-old man, last known to be without symptoms at 0130 today, with a chief complaint of right-sided weakness. He was found by his wife at 0300; she is with us. There was no observed trauma or seizure activity observed. His glucose is 140 and his BP is 168/105. Fibrinolytic screening is negative for contraindications

Example of ED Report He is alert with mild dysarthria, no aphasia, normal visual fields, & moderate weakness of the right face, arm, & leg. (MEND exam) Monitor shows atrial fibrillation with a ventricular response rate of lead shows no signs of ischemia. He has maintained a pulse ox of 96% on 2 liters of O2 by cannula and we’ve performed no other interventions. Our ETA is approximately 10 minutes.

The Major Stroke Syndromes

Brain: Major Divisions
Note: Cerebrum = R and L hemispheres = cortex and subcortex Cerebral Cortex gray matter “computer center” Cerebral Subcortex deep white matter “wires” connecting cortex and brainstem Brainstem connects cerebrum and spinal cord (“funnel” of the brain) contains nerves to face/head Cerebellum coordination center

Functional areas of the cerebral cortex
A stroke in these particular areas will likely affect the functions shown for that area.

Major Stroke Syndromes
1. Left Hemisphere 2. Right Hemisphere 3. Brainstem 4. Cerebellum Hemorrhagic Stroke syndromes are named for the location of the injured area of the brain. HEMORRHAGIC stroke is separated out because of its potential importance in destination and treatment decision making, but it can occur in any area of the brain.

Right and Left Hemispheric Strokes
Motor and sensory deficits are found on the side OPPOSITE to the affected side of the brain Visual field deficits are also found on the side OPPOSITE to the affected side of the brain Horizontal gaze is also affected in the direction OPPOSITE to the affected side of the brain Because the eye can’t move to the opposite side, it actually appears to be looking AT the affected side of the brain in hemispheric strokes

Hemiparesis: weakness or partial paralysis Hemiplegia: paralysis
Left (Dominant) Hemisphere Typical Signs: Right Side Weakness and Aphasia Right Visual Field Deficit Aphasia Left Gaze Preference (in hemispheric stroke, looks TOWARD the side of the injury) Right Hemiparesis Right Hemisensory Loss Hemiparesis: weakness or partial paralysis Hemiplegia: paralysis

Aphasia In right hand dominant people, the speech center of the brain is found in the left hemisphere So left hemispheric stroke is the most likely cause of aphasia in most people HOWEVER, some left hand dominant people have their speech centers on the right side of the brain, so they may present with right hemispheric stroke symptoms and aphasia

Right (Nondominant) Hemisphere Typical Signs: Left Side Weakness
Left Hemi-inattention (Neglect) Left Visual Field Deficit Right Gaze Preference (in hemispheric stroke, looks TOWARD the side of the injury) Left Hemiparesis Left Hemisensory Loss

Hemi-inattention or “Neglect”
Patients with neglect tend not to acknowledge (i.e., they “neglect”) anything about the affected side of their body “People who experience damage to the right parietal lobe sometimes show a fascinating condition called hemi-inattention. When this occurs, the person is unable to attend to the left side of the body and the world. A person with hemi-inattention may shave or apply makeup only to the right side of the face. While dressing, he or she may put a shirt on the right arm but leave the left side of the shirt hanging behind the body. The person may eat from only the right side of the plate, not noticing the food on the left side. This condition is not due to visual problems or the loss of sensation on the left side of the body, but is a deficit in the ability to direct attention to the left side of the body and the world.” (Psychobiology, Salem Press)

Hemi-inattention or “Neglect”
The most common form of neglect is neglect of the left side of the body due to a right hemispheric lesion, but neglect can affect other areas as well If a patient appears not to acknowledge your presence from one side of the body, try changing sides to rule out the presence of hemi-inattention (neglect) Patients can often eventually totally recover from hemi-inattention deficits

Brainstem Typical Signs: Bilateral Abnormalities
Crossed Signs (1 side of face and contralateral body) Quadriparesis Sensory Loss in All 4 Limbs Hemiparesis Hemisensory Loss

Brainstem Typical Signs: Cranial Nerve and Other Deficits
Decreased LOC Nausea, Vomiting Hiccups, Abnormal Respirations Vertigo, Tinnitus Eye Movement Abnormalities: Diplopia Dysconjugate Gaze Gaze Palsy (horizontal gaze deficit or gaze preference) Oropharyngeal Weakness: Dysarthria (speaking), Dysphagia (swallowing)

Cerebellum Typical Signs: Lack of Coordination
Ipsilateral (same side) Limb Ataxia (dyscoordination) Truncal or Gait Ataxia (imbalance) Tremors, or Limb Ataxia, result from lack of coordination of opposing muscle groups (flexors vs. extensors), causing the muscle groups to fight each other

Hemorrhage and the Brain Coverings
Cranium (skull): hard container enclosing brain Meninges: 3-layered cloth-like covering of brain and spinal cord Hemorrhagic stroke suddenly increases intracranial pressure Subarachnoid hemorrhage irritates the meninges

Symptoms Suggestive of Hemorrhage
Both Subarachnoid and Intracerebral Hemorrhage: Headache Nausea, Vomiting Decreased LOC (not always present) Subarachnoid Hemorrhage: Intolerance to Light Neck Stiffness / Pain Intracerebral Hemorrhage: Focal Signs Such as Hemiparesis None of these signs are DIAGNOSTIC of hemorrhage; hemorrhage may be totally indistinguishable from ischemic stroke without imaging studies

Other potentially distinguishing characteristics of hemorrhagic stroke
New onset of seizures is more common with hemorrhagic than ischemic strokes Altered mental status is more commonly associated with hemorrhagic strokes Remember that isolated altered mental status is NOT very likely to be due to stroke Most hemorrhagic strokes will have some combination of the listed symptoms and signs, not just one abnormal finding

Hemorrhagic Stroke You may NOT be able to detect a hemorrhagic stroke merely by doing the FAST-G exam History questions are extremely important to focus you on further findings!! The MEND exam may be the only exam that reveals physical signs of a hemorrhagic stroke A minority of strokes are hemorrhagic and the minority of hemorrhagic stroke patients end up going to surgery Know your local protocols about transport destinations for possible hemorrhagic stroke patients

Noncontrast CT Scans: Ischemic Stroke
R Hours L Initial CT scans of ischemic stroke patients may be NORMAL or may only show signs of cerebral edema You can see the sulci and gyri on the right side of the brain, but the same area is more blurry on the left side Gyrus (a fold of cortex) Subtle blurring and compression of sulci Sulcus (space between gyri)

Noncontrast CT Scans: Ischemic Stroke
R Days L The CT scan usually later develops the more typical dark changes of ischemic infarction Quick Quiz: What neurological findings would you expect this patient to have? (Answer is in speaker’s notes for presentation) This is a left hemispheric infarct; therefore, you would expect to find aphasia and right sided weakness/paralysis and/or sensory deficits along with a possible left horizontal gaze deficit (= right gaze preference) and right visual field deficits Obvious dark changes of infarction

Noncontrast CT Scan: Hemorrhagic Strokes
Intracerebral Hemorrhage Subarachnoid Hemorrhage “Ball” of white blood in thalamus White blood in cisterns & 4th ventricle

Quick Summary of Major Stroke Syndromes

Major Syndrome Deficits
LEFT HEMISPHERE 1 Speech–Aphasia Right Body–Visual Motor, Sensory 1 2 5 RIGHT HEMISPHERE 2 Left Body–Neglect, Visual, Motor, Sensory 4 BRAINSTEM 3 Right and/or Left Motor, Sensory Eye Movements Speech/Swallowing Dizziness/Nausea â Consciousness 3 POSSIBLE HEMORRHAGE 5 Headache Neck Pain/Stiffness Light Intolerance Nausea/Vomiting â Consciousness + Focal Findings CEREBELLUM 4 Imbalance Dyscoordination

5 Major Syndromes: Typical Signs
FOCAL DEFICITS LEFT HEMISPHERE RIGHT HEMISPHERE BRAINSTEM CEREBELLUM HEMORRHAGE * + SPEECH Aphasia– wrong or inappropriate words Says correctly Dysarthria– slurring Says correctly Says correctly but slowly (often sleepy) FACIAL DROOP Right facial droop Left facial droop May have bilateral droop No droop No droop ARM DRIFT Right arm drift (weakness) Left arm drift (weakness) May have bilateral drift (weakness) No drift No drift * Finger-to-nose and/or heel-to-shin testing typically abnormal Decreased level of consciousness with headache and stiff neck are typical; this syndrome without associated focal neurologic deficits is most consistent with subarachnoid hemorrhage. With intracerebral hemorrhage, focal deficits may occur. +

Practice Scenarios: Stroke Syndromes and the MEND

Practice Case #1 You are dispatched to a 74 year old male patient complaining of “dizziness”. On arrival, you find an alert patient sitting in a chair. Click on whatever you want to do next. Hx of Present Illness FAST-G Transport Now Past History Vital Signs Fibrinolytic Screening MEND

Practice Case #1: FAST-G (left click to obtain information, then click on arrow)
Left facial droop A Right arm drift S Speech slurred, but appropriate words T 20 minutes (witnessed) G 104

Practice Case #1: Fibrinolytic Screening (left click to obtain information, then click on arrow)
No head trauma at onset No seizure at onset No previous hemorrhagic stroke + nausea without headache or neck stiffness Not on Coumadin (takes one aspirin a day) No history of bleeding/clotting disorder Not pregnant No recent surgery or hemorrhage

Practice Case # 1: Past History (click on arrow to proceed)
+ HTN + CAD + TIA’s + COPD - DM Otherwise negative

Practice Case #1: Hx of Present Illness (left click to obtain information, then click on arrow)
Sudden onset of severe vertigo with nausea, no vomiting Weakness of right arm and leg No syncope, numbness/paresthesias, headache, neck pain/stiffness, shaking/tremor, seizure activity, trauma + double vision + slurred speech Other history= chest pain/pressure, palpitations, racing pulse, SOB, cough, etc

Practice Case #1: Vital Signs (left click to obtain information, then click on arrow)
BP 186/96 HR 112, regular RR 18 SaO2 95% on room air Sinus rhythm

Practice Case #1: MEND (click on arrow to proceed)
Your ambulance is here. Are you sure you want to do this now? (The MEND should be delayed until en route if transport is available.)

You are transporting… (left click to obtain information, then left click to go to next case)
Brain Attack Alert (persistent deficits and within thrombolytic window)? YES At risk for hemorrhagic stroke? Probably not Appropriate destination? Closest Stroke Center If you can’t answer these questions, go back to start of case

What’s your initial guess as to which stroke syndrome this patient is experiencing?
Right hemispheric? Left hemispheric? Cerebellar? Brainstem?

MEND Exam Cranial Nerves Mental Status Limbs Left facial droop Alert
Visual fields normal Right gaze palsy (won’t look to right) Mental Status Alert Abnormal (slurred) speech Answers both questions appropriately Follows commands, though weakly with right side Limbs + right arm and leg drift Normal sensation Right arm and leg too weak to perform coordination testing. Left side normal.

Practice Case # 1 Which stroke syndrome does this appear to be?
Brainstem Presence of crossed motor signs, vertigo, speech deficit and gaze palsy indicate Brainstem origin Is this patient a fibrinolytic candidate? YES!

Practice Case # 2 You are dispatched to a 54 year old female with altered mental status. You find her in her bed at the nursing home. Click on whatever you want to do next. Hx of Present Illness FAST-G Transport Now Past History Vital Signs Fibrinolytic Screening MEND

Practice Case # 2: FAST-G
Right facial droop A Not moving left arm at all but moving other extremities restlessly (weakly on right) S Not speaking at all T Last seen normal for her 5 hours ago G 66

Practice Case # 2: Fibrinolytic Screening
No head trauma at onset No seizure at onset No previous hemorrhagic stroke + vomiting Takes Coumadin No history of bleeding/clotting disorder Not pregnant No recent surgery or hemorrhage

Practice Case # 2: Past History
+ atrial fibrillation + CAD + previous ischemic stroke with residual aphasia and mild right sided weakness - DM + HTN with recent medication change

Practice Case # 2: Hx of Present Illness
Found on nursing rounds; normally awake and alert with aphasia and mild right sided weakness No known head trauma or seizure activity No previous bleed or bleeding/clotting disorders Unknown complaints before symptom onset No recent surgery or hemorrhage Other history= chest pain/pressure, palpitations, racing pulse, SOB, cough, etc

Practice Case # 2: Vital Signs
BP 230/130 HR 98, irregular, a. fib on monitor RR 12 SaO2 92% on room air

Your ambulance is here. Are you sure you want to do this now?
Practice Case #2: MEND Your ambulance is here. Are you sure you want to do this now?

While you’re loading up…
YES (due to altered mental status without alternate explanation, patient on Coumadin, high BP, vomiting, unknown headache) At risk for hemorrhagic stroke? YES (due to suspected hemorrhagic origin, time since last known normal not as important) Brain Attack Alert? Appropriate destination? Consider Neurosurgical facility Left click to proceed

MEND Exam Mental Status Cranial Nerves Limbs Right facial droop
Unable to test visual fields Unable to test horizontal gaze, but no gaze preference Mental Status Responds to pain (withdraws) No speech Unable to test response to questions Does not follow commands Limbs Left arm not moving, right side weak on spontaneous motion No response to pain with right arm, otherwise withdraws from pain Unable to do coordination testing

Practice Case # 2 Which stroke syndrome does this appear to be?
Hemorrhagic right cerebral hemisphere Is this patient a fibrinolytic candidate? NO! NO! (due to lack of specific reason to be hypoglycemic and BS > 50) Treat blood sugar? Treat blood pressure? NO! Left click to proceed to next slide

Practice Case # 3 You are dispatched to the sidewalk outside of a bar for a 70 year old male found down on the sidewalk. He appears to be asleep but rouses to verbal stimulation and stays awake. There is a definite odor of EtOH on his breath. Click on whatever you want to do next. Hx of Present Illness FAST-G Transport Now Past History Vital Signs Fibrinolytic Screening MEND

Practice Case # 3: FAST-G (left click to obtain information, then click on arrow)
No facial droop A No arm drift S Slurred speech but appropriate words T Bartender inside says he saw the patient walk into the bar normally about an hour ago G 180

Practice Case # 3: Fibrinolytic Screening (left click to obtain information, then click on arrow)
No signs of head trauma No seizure at onset Patient states he has never had a stroke Neck hurts “like usual” from arthritis Does not take Coumadin No history of bleeding/clotting disorder Not pregnant No recent surgery or hemorrhage

Practice Case # 3: Past History (click on arrow to proceed)
“I drink a little more than I should” + DM, on oral meds Denies other past history

Practice Case # 3: Hx of Present Illness (left click to obtain information, then click on arrow)
States he only had “two beers” today Denies focal or general weakness, vision change, nausea or vomiting, syncope/near syncope, dizziness, paresthesias (“I got a buzz on, does that count?”), headache, seizure activity Other history= Oral intake, compliance with meds, recent trauma

Practice Case # 3: Vital Signs (left click to obtain information, then click on arrow)
BP 110/74 HR 88, regular RR 12 SaO2 96% on room air Sinus rhythm on monitor

Practice Case # 3: What now?
“But I don’t need to go to the hospital. I want to go home!”

How do we answer this question??
Is this man just drunk, or might he have something more serious going on? How do we answer this question?? Left click to proceed

Which stroke syndrome could mimic alcohol intoxication?
Right hemispheric Left hemispheric Brainstem Cerebellar  Left click to see correct answer

How might we distinguish between intoxication (alcohol +/- other drugs) and cerebellar stroke?
Ask about drinking habits How much did you drink compared to normal for you? Do you feel more drunk than usual for what you drank? Ask bartender or friends about patient’s behavior compared to normal Left click to proceed

How might we distinguish between intoxication (alcohol +/- other drugs) and cerebellar stroke?
Look for evidence of FOCAL signs Isolated intoxication should affect the patient equally on both sides Unilateral abnormalities or a marked difference in degree of impairment between sides should be suggestive of a stroke Would still need to try to distinguish ischemic from hemorrhagic etiology What tool do we have to help with this? The MEND exam Left click to proceed

In this case… (left click to see info, then left click to proceed)
The patient does admit to feeling more drunk than he should after just two beers. The bartender verifies that he’s only had two “normal sized” beers. On the MEND exam: Mental status exam is normal except for slurred speech Cranial nerve exam is normal Strength and sensation are normal The patient is a bit ataxic even while sitting and has abnormal finger to nose and heel to shin tests bilaterally, but MUCH worse on the left side than the right

Disposition? Explain risks to the patient. If he continues to refuse treatment and transport, follow your usual refusal protocol. Remember that this is a high risk situation. Remember that intoxicated patients get sick too! Left click to proceed

At risk for hemorrhagic stroke? Appropriate destination?
You’ve talked the patient into transport. Now, while you’re loading up… (left click for answers, then left click to proceed) At risk for hemorrhagic stroke? Probably NOT Brain Attack Alert? YES (due to last known normal time of about an hour ago with positive neuro findings) Appropriate destination? Closest Stroke Center

Congratulations. You’ve finished
Congratulations! You’ve finished! If you haven’t already done so, download and check out the Pinellas County EMS Brain Attack Form.

Thanks for playing. (Please contact me at drromig@medcontrol
Thanks for playing! (Please contact me at with any feedback or errors)

Slumping, Slurring and Slipping Away: Stroke Assessment

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Slumping, Slurring and Slipping Away: Stroke Assessment

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