Presentation on theme: "Slumping, Slurring and Slipping Away: Stroke Assessment"— Presentation transcript:
1Slumping, Slurring and Slipping Away: Stroke Assessment Laurie A. Romig, MD, FACEPMedical DirectorPinellas County (FL) EMS
2This 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.
3Prehospital Stroke Care MYTH: It doesn’t make a differenceFACT: It does! (as with AMI)Better field management can help to limit stroke deficitRapid transport to the right facility is an important component of the overall treatment strategyCHALLENGE: Not all areas have the appropriate infrastructure in place (i.e., Stroke Centers)
4Prehospital Stroke Care Use the FAST-G# exam and history to determine hospital destinationUse the MEND* checklist to refine field impressionEvaluation 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)
6Stroke in the United States Affects > 700,000 persons per year1/3 die, 1/3 become disabled, 1/3 recoverThird leading cause of deathLeading cause of long-term disabilityCosts $50 billion per year
7Change in Terminology: Acute Brain Attack (Not “CVA”) Term aids public education effortsIdentifies the brain as the organ involvedImplies appropriate sense of urgencyLikens event to heart attackCVA = cerebrovascular accidentBad term because stroke is preventable and treatable
8Stroke Definition and Types General DefinitionSudden brain dysfunction due to blood vessel problemIschemic stroke (80%)decreased blood supply to a focal area of brainmostly thromboembolism (blood clot)Hemorrhagic stroke (20%)blood vessel rupture within skull not due to traumaintracerebral (inside the brain tissue) or subarachnoid (under the coverings of the brain)
9Ischemic Stroke Most common cause: thromboembolism CLOTINFARCTMost common cause: thromboembolismPossible sources of clot:HeartLarge artery (to brain)Small artery (in brain)Strokes associated with clots in small brain arteries are called “lacunar”Clot occluding artery
10Intracerebral Hemorrhage Most common cause:chronic hypertensionOther causes:Vessel malformationTumor, bleeding abnormalitiesBleeding into brain
11Subarachnoid Hemorrhage Most common cause:aneurysm ruptureOther causes:Vessel malformationTumor, bleeding abnormalitiesBleeding around brain
12Transient Ischemic Attack (TIA) Reversible focal dysfunction present for minutes to less than 1 hourAmong TIA patients who go the ED:5% have stroke in next 2 days10% have stroke in next 3 months25% have a recurrent event (TIA or stroke) within 3 monthsStroke risk can be decreased with proper therapyDo not enable patients to disregard the importance of a TIA, even if they have had them before and know what they are!
13Ischemic Stroke: Nonmodifiable Risk Factors Advanced ageMale genderFamily history of early stroke or MINonmodifiable basically means that you can’t influence or change these risk factors. They just are what they are.
14Ischemic Stroke: Modifiable Risk Factors Hypertension (systolic and diastolic)Cigarette smokingPrior stroke/ TIAHeart diseaseDiabetes mellitus, hyperlipidemiaHypercoagulable statesCarotid bruitCocaine, excess alcoholCould this be you?Remind everybody to take a look at these risk factors for THEIR OWN health purposes!
15Time is Brain: Save the Penumbra!! The Stroke Battle CryTime is Brain: Save the Penumbra!!
16Time 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
17Time is Brain: Save the Penumbra Patient symptoms are due to both the infarcted core and the ischemic penumbraOne cannot determine by exam how much brain can still be savedTherefore, the full extent of the damage is not immediately clear. Deficits could get worse or could get betterTreatment aims to salvage the circulation to the penumbraIf treated early enough, all of the brain tissue could be salvageable
18Time is Brain: Save the Penumbra 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 scanwithin 3 hours of onset (the sooner, the better)age 18 or olderno other absolute contraindicationsThrombolytic 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.
19Time is Brain: Save the Penumbra Other interventions such as intraarterial thrombolytics and clot retrieval devices are being used in facilities with specialized capabilities for some stroke patientsTreatment windows are expanding to 6 to 8 hours or more as facilities gain more experience with new devicesThe Penumbra is damaged by seizure, hypotension, hyperglycemia, fever, acidosisThis has implications for what we need to evaluate, monitor and treat in the field
20Time is Brain: Determine Cause In ED: define likelihood of ischemic strokeFull evaluation may take days and requires admission to the hospitalDifferential diagnosis is not extensiveIschemia vs. hemorrhageMimics include: tumor, trauma, seizure, migraine, hypoglycemia, overdose
21Stroke MimicsThese conditions can result in focal cerebral dysfunction and mimic a stroke:hypoglycemia improves w/D50seizure w/postictal state staring/limb shaking at onsetmigraine previous similar eventstumor onset over weeks to monthsabscess onset over weeks to monthssubdural hematoma posttrauma
23Cincinnati 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 laterFacial droopArm driftSpeechTime patient was last seen or known to be normalThis is a BLS level evaluation tool!More detail on each element to follow
25Facial Droop You may have to encourage the patient to try Even in unresponsive patients, facial droop may be obviousIt’s common also to see drooling from the affected sideLeft facial droopThis patient actually has Bell’s Palsy, but the facial droop appearance is the same for our purposesFacial 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.
27Arm DriftNormal finding is for both arms not to move once extended or to move togetherIf patient is unable to obey commands, look for spontaneous movement or movement in response to verbal/painful stimulusIf patient is unresponsive and not moving at all DO NOT mark this as abnormal. You just don’t know the answer.
28Speech: 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 deficitSlurred words (dysarthria)Caused by cranial nerve deficit
29Time 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
30You 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.
31What difference would the determination of “last seen or known normal” make? The actual time of onset of symptoms is unknownIf 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 neighborThis is similar to the situation of a patient waking up with deficits—we don’t truly know when the symptoms started
32FAST-G Adaptation (Pinellas County) Adds field determination of blood glucose in order to rule out hypoglycemia as a reversible cause of stroke-like symptomsThis is a high priority assessment tool, especially in diabetic patients or those with other potential reasons to be hypoglycemicYou’d be surprised at how many hypoglycemia patients present with stroke symptoms, so don’t think that this is a rare occurrence!
33PLEASE 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 changesIntoxication/overdoseSepsisMetabolic problemsHead injuryEtc.
35Important History Elements Help to pin down symptoms and last known normal timeHelp to determine risk factors and underlying causes as well as potential for stroke imitatorsAssist in differentiating ischemic from hemorrhagic strokeAssist in determining appropriate out-of-hospital and in-hospital treatmentA Brain Attack form can prompt you for appropriate historyThis is a State of Florida requirementWhy specific bits of patient history are important.
36Importance of Witness Documentation Witnesses can be your only source of historyWe need to document specific witness testimony AND provide the hospital with witness contact information if they are not going to the hospitalHospital staff may need to ask for additional informationNotify hospital staff if witness is coming to hospital and who to look forRecord witness information on Brain Attack form or run report
37Important History Elements: HPI Potential symptoms to questionExtremity weaknessGeneral weakness (i.e., nonfocal)Vision changesSlurred or inappropriate speechNausea/VomitingSyncope/Near-syncope
38Important History Elements: HPI More potential symptoms to questionDizziness/VertigoAltered 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
39Relevance of specific symptoms Severe or unusual headache, especially combined with nausea/vomiting and/or altered LOC most typical of hemorrhagic strokeMay indicate transport to a Neurosurgery capable facility.Dizziness/vertigo, lack of coordination possible cerebellar strokeDysarthria (slurred speech) rather than aphasia (wrong words or none) possible brainstem stroke
40Past Medical History (Risk Factor Assessment) Dysrhythmias (particularly acute or chronic a. fib.)DiabetesCurrent 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)
41Past Medical History (Risk Factor Assessment) Chronic hypertensionCoronary artery disease or other vascular atherosclerosisRecent systemic cancer (common cause of pediatric stroke)Resuscitation status (prehospital DNR?)And our other routine past history questioning
42A 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 daysYou may be in the best position to determine from witnesses or the patient what is NORMAL FOR THEMDocument all deficits on the run report and try to make clear which are old, new or worse than usual
43Fibrinolytic Screening Not all positive responses are ABSOLUTE contraindications for fibrinolyticsCriteria are dynamically changing with new modes of therapyRisk is balanced against potential benefitNOTE: Age is NOT a primary factor!
44Fibrinolytic Screening Head trauma at onset of symptomsWhich 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?
45Fibrinolytic Screening Patient on Coumadin or Warfarin?Aspirin or NSAIDs do NOT have the same effect, but note these separatelyHistory of bleeding or clotting disorder?Previous hemorrhagic stroke?Increased likelihood of recurrence rather than new ischemic stroke
46Fibrinolytic Screening 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 deliverySurgery or significant hemorrhage within the last 3 months?GI, vascular, thoracic, orthopedic, cranial surgeryGI bleed, variceal bleed, intracerebral bleed, major traumatic hemorrhage
48MEND Exam: Stroke Secondary Survey Perform en route unless awaiting transportMay be able to detect strokes NOT evident from FAST examHelps to define the specific stroke syndromeHelps to document severity of stroke, which may enter into hospital treatment recommendationsEstablishes detailed baseline for later comparisonCan be accomplished in less than 5 minutesThis is also a BLS assessment; it just takes a little more knowledge of physiology to interpret
49MEND Exam: Mental Status Section Level of consciousness: AVPURemember that this is supposed to reflect the patient’s highest level of mental function, so be sure to stimulate adequately
50MEND 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 speechListen for aphasia or dysarthria
51MEND Exam: Mental Status Section: Speech AphasiaAn 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 problemPatients often appear frustrated that they can’t get the words out or that you can’t understand them
52MEND Exam: Mental Status Section: Speech Dysarthria (“dys” = abnormal, “arthria” = articulation)Slow, slurred, weak, imprecise or uncoordinated speechCaused by weakness or incoordination of speech musclesWords are usually appropriateBoth aphasia and dysarthria are recorded as abnormalIf patient isn’t speaking at all because they are unconscious, you can’t evaluate speech
53MEND Exam: Mental Status Section: Questions Ask patient for their age and what month it isIf 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.
54MEND 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 functionThe patient is less likely to have problems because they physically can’t do the taskYou 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
55MEND 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 swallowingAsk patient to “give me a big smile” or “show me your teeth”Both sides of the mouth should move equallyFacial droop without other neurological deficits may actually be caused by isolated nerve problems such as Bell’s Palsy rather than stroke
56If the patient pulls his false teeth out of his pocket at this point, at least you’ve got evidence of ability to follow commands!
57MEND Exam: Cranial Nerve Section: Visual Fields Definition: the area in which objects can be seen in peripheral vision while focusing straight aheadUsually broken into left and right upper and lower quadrantsWe’ll test all four quadrants, but record abnormalities only as left or right
58MEND Exam: Cranial Nerve Section: Visual Fields Have patient look straight at your noseHold your hands about 18 inches in front of the patient, fingers bent at the palm and facing each otherIf YOU can’t see your fingers wiggling in YOUR peripheral vision, your hands are too far apart!
59MEND Exam: Cranial Nerve Section: Visual Fields 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 visionObviously, if a patient can’t follow commands, you can’t do this test
60MEND Exam: Cranial Nerve Section: Visual Fields Wiggle your fingers in each of the four quadrants, but try not to make the pattern predictable to the patientReport any abnormalities only by “right” or “left” (don’t have to specify upper or lower)
61MEND 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 functionHave 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!
62MEND Exam: Cranial Nerve Section: Horizontal Gaze Using a polite finger , start with your finger in the midline and have the patient follow the finger to each sideThe object is to “bury the sclera”, or get the patient to look ALL the way to the sideYou may have to hold an eye open if lid droop is present
63MEND Exam: Cranial Nerve Section: Horizontal Gaze Examples of possible deficits
64MEND Exam: Cranial Nerve Section: Horizontal Gaze 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 deficitThe eye muscles that allow the eye to track to the right are not functioning, therefore the eye is being pulled to the left
65MEND 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 toThis is usually a result of a cerebral hemispheric strokeExample: 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 formBut it would also be called a left gaze preferenceDon’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.
66MEND 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
67MEND Exam: Limb Section: Arm Drift This is simply a repeat of the arm drift assessment done in the FAST examPlease DO repeat the test rather than assuming that the results will be the same as during the FASTEyes should be closed for the arm drift test, but do not have to be for the leg drift testPalms should face down for the arm drift test (sleepwalker position)Arms are held out simultaneously, not separatelyThe key to look for is whether the sides are symmetrical or not, not how high the lift isExam can be done on a supine or seated patient
68MEND Exam: Limb Section: Leg Drift Legs are tested separatelyCan be done with a seated or supine patientEyes do not need to be closedHave patient attempt to lift the whole leg, not just kick out or up with the lower legAgain, symmetry is the most important factor to observeHaving 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
69A note about patients who can’t follow commands for arm and leg drift Observe spontaneous movement and document accordingly; do the best you canRemember, symmetry is really the most important observation
70MEND Exam: Limb Section: Abnormal Sensory Section Have the patient uncross arms and legs for these testsCrossed arms and legs can lead to confusion for the brainHave the patient close their eyesTest 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 wayAfter testing each side separately, ask if the sensation is the same on both sides
71MEND Exam: Limb Section: Abnormal Sensory Section Touch on the back of the hands and the top of the foot or on the shinTest the same location on each sideNote absence of sensation as abnormal, but also note alteration in sensation (pins and needles, decreased sensation, etc) as abnormalAgain, symmetry is the keyA person with chronic peripheral vascular disease or neuropathy may have decreased or altered distal sensation all the time, but it will usually be symmetrical
72MEND Exam: Limb Section: Abnormal Coordination Section This section tests the cerebellum, which supplies coordination of muscle movementsThe test for the upper extremities is called the Finger to Nose testThe test for the lower extremities is called the Heel to Shin test
73Abnormal Coordination Section If the test cannot be performed because of extremity weakness, don’t assume that coordination is abnormalThis is one reason to do the coordination testing AFTER motor testingName the abnormality for the side that is actively moving (finger or heel) as part of the test, not the stationary nose or shin
74MEND 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 fingerYou can demonstrate if needed
75MEND 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 bitThis uncovers more subtle ataxia or incoordinationHave them repeat the motion several times, then switch sidesAbnormal findings are missing your finger or their own nose or having a tremor during the motionIn 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
76MEND 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 footRepeat on the other sideLook for inability to place or keep the foot on the shinRemember that the abnormal side is named for the foot, not the shinRemember that inability to do this test because of muscle weakness does NOT mean that you mark the results abnormal
77A note about tremorsTremors 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 disordersThese tremors usually disappear when performing a specific motor taskIntention tremor, or a tremor that begins or worsens when performing a motor task is more commonly due to stroke
78Bonus 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.
79SummaryStroke has joined Acute Myocardial Infarction as a very time-sensitive prehospital disorder
80SummaryRapid and basic assessment on scene with expedited transport is, in effect, therapy for these patientsBasic 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
84Basic Principles of Prehospital Stroke Care First do no harmavoid giving glucose unless absolutely indicatedavoid treating hypertensionavoid causing aspiration pneumoniaReport to EDdetails of symptom onsetneurologic examwitness information
85Avoid Giving GlucoseTHE RULE: Do NOT give glucose-containing solutions to acute stroke patientsTHE REASON: Hyperglycemia causes lactic acidosis and damages the penumbraTHE 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
86Avoid Treating Hypertension THE RULE: EMS should not treat hypertension in acute stroke patientsTHE REASONS:HTN is commonly caused by the strokeIt may be required for penumbra perfusionIt often subsides without treatment
87Avoid Causing Aspiration Pneumonia THE RULES:Keep 100% NPOElevate head 30o (no higher) unless hypotensiveThis is actually a recommendation that is being debated by some neurologistsIf vomiting, use left lateral recumbent positionTHE REASON: Most stroke patients have trouble swallowing & aspiration is a major cause of morbidity & mortality
88On Scene Care Summary Complete FAST-G Priority interventions Maintain SpO2 of at least 95%No benefit to maintaining higher SpO2Keep head straight, elevate head of stretcher to no more than 30 degrees unless hypotensiveLeft lateral recumbent position if nauseated or vomitingOf course, the usual ABC priorities apply as well.
89On Scene Care Summary Priority interventions (cont.) Maintain systolic BP of at least 90 mm HgDO NOT treat hypertensionTreat blood glucose if < 50 mg/dl (< 40 mg/dl for neonate) and no history of hypoglycemiaTreat patients with known hypoglycemia history as usualMake destination decision based on exam and historyGet at least HPI and witness information on scene
90On Scene Care SummaryIV insertion can be delayed until during transport if it is not needed for a priority interventionSame for cardiac monitor and 12 lead ECGKey is to minimize scene time in order to maximize window for definitive treatment
91En Route Care Summary Document thoroughly Treat clinical complications as they arisePerform MEND exam as a secondary assessment toolDO NOT DELAY to do this on sceneContact receiving facility as soon as possible to give them time to prepare for the patient
92Quick Radio Report Template Patient age and genderSymptoms and FAST-G resultsMake sure to include time last seen normal and blood glucoseMost PERTINENT history (history of previous bleed or ischemic stroke, pregnant?)Vital signs, cardiac rhythm if availableInterventions performedFibrinolytic screening negative, positive for possible contraindications, or in progress (don’t necessarily need details over the radio)MEND exam results/stroke syndrome suspected if availableETAI’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
93How does a good radio report help the ED? Clear a bed for the patient if necessary and prep to receive patient report on arrivalNotify CT and reshuffle other patients waiting for sameNotify Stroke Team so that they can be present or en route when you arrivePrep their registration processes so that tests can be ordered more quicklyIn general, get everybody into the same kind of mindset a Trauma Team or STEMI Team has
94Example of ED Report64-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
95Example of ED ReportHe 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.
97Brain: Major Divisions Note: Cerebrum= R and L hemispheres= cortex and subcortexCerebral Cortexgray matter“computer center”Cerebral Subcortexdeep white matter“wires” connecting cortex and brainstemBrainstemconnects cerebrum and spinal cord (“funnel” of the brain)contains nerves to face/headCerebellumcoordination center
98Functional areas of the cerebral cortex A stroke in these particular areas will likely affect the functions shown for that area.
99Major Stroke Syndromes 1. Left Hemisphere2. Right Hemisphere3. Brainstem4. CerebellumHemorrhagicStroke 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.
100Right and Left Hemispheric Strokes Motor and sensory deficits are found on the side OPPOSITE to the affected side of the brainVisual field deficits are also found on the side OPPOSITE to the affected side of the brainHorizontal gaze is also affected in the direction OPPOSITE to the affected side of the brainBecause 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
101Hemiparesis: weakness or partial paralysis Hemiplegia: paralysis Left (Dominant) Hemisphere Typical Signs: Right Side Weakness and AphasiaRight Visual Field DeficitAphasiaLeft Gaze Preference(in hemispheric stroke, looks TOWARD the side of the injury)Right HemiparesisRight Hemisensory LossHemiparesis: weakness or partial paralysisHemiplegia: paralysis
102AphasiaIn right hand dominant people, the speech center of the brain is found in the left hemisphereSo left hemispheric stroke is the most likely cause of aphasia in most peopleHOWEVER, 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
103Right (Nondominant) Hemisphere Typical Signs: Left Side Weakness Left Hemi-inattention (Neglect)Left Visual Field DeficitRight Gaze Preference(in hemispheric stroke, looks TOWARD the side of the injury)Left HemiparesisLeft Hemisensory Loss
104Hemi-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)
105Hemi-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 wellIf 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
106Brainstem Typical Signs: Bilateral Abnormalities Crossed Signs (1 side of face and contralateral body)QuadriparesisSensory Loss in All 4 LimbsHemiparesis Hemisensory Loss
107Brainstem Typical Signs: Cranial Nerve and Other Deficits Decreased LOCNausea, VomitingHiccups, Abnormal RespirationsVertigo, TinnitusEye Movement Abnormalities:DiplopiaDysconjugate GazeGaze Palsy (horizontal gaze deficit or gaze preference)Oropharyngeal Weakness:Dysarthria (speaking), Dysphagia (swallowing)
108Cerebellum Typical Signs: Lack of Coordination Ipsilateral (same side) Limb Ataxia (dyscoordination)Truncal or GaitAtaxia (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
109Hemorrhage and the Brain Coverings Cranium (skull): hard container enclosing brainMeninges: 3-layered cloth-like covering of brain and spinal cordHemorrhagic stroke suddenly increases intracranial pressureSubarachnoid hemorrhage irritates the meninges
110Symptoms Suggestive of Hemorrhage Both Subarachnoid and Intracerebral Hemorrhage:HeadacheNausea, VomitingDecreased LOC (not always present)Subarachnoid Hemorrhage:Intolerance to LightNeck Stiffness / PainIntracerebral Hemorrhage:Focal Signs Such as HemiparesisNone of these signs are DIAGNOSTIC of hemorrhage; hemorrhage may be totally indistinguishable from ischemic stroke without imaging studies
111Other potentially distinguishing characteristics of hemorrhagic stroke New onset of seizures is more common with hemorrhagic than ischemic strokesAltered mental status is more commonly associated with hemorrhagic strokesRemember that isolated altered mental status is NOT very likely to be due to strokeMost hemorrhagic strokes will have some combination of the listed symptoms and signs, not just one abnormal finding
112Hemorrhagic StrokeYou may NOT be able to detect a hemorrhagic stroke merely by doing the FAST-G examHistory 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 strokeA minority of strokes are hemorrhagic and the minority of hemorrhagic stroke patients end up going to surgeryKnow your local protocols about transport destinations for possible hemorrhagic stroke patients
113Noncontrast CT Scans: Ischemic Stroke R Hours LInitial CT scans of ischemic stroke patients may be NORMAL or may only show signs of cerebral edemaYou can see the sulci and gyri on the right side of the brain, but the same area is more blurry on the left sideGyrus (a foldof cortex)Subtle blurring and compression of sulciSulcus (space between gyri)
114Noncontrast CT Scans: Ischemic Stroke R Days LThe CT scan usually later develops the more typical dark changes of ischemic infarctionQuick 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 deficitsObvious dark changes of infarction
115Noncontrast CT Scan: Hemorrhagic Strokes Intracerebral HemorrhageSubarachnoid Hemorrhage“Ball” of whiteblood in thalamusWhite blood incisterns & 4th ventricle
1185 Major Syndromes: Typical Signs FOCALDEFICITSLEFTHEMISPHERERIGHTHEMISPHEREBRAINSTEMCEREBELLUMHEMORRHAGE*+SPEECHAphasia–wrong orinappropriatewordsSays correctlyDysarthria–slurringSays correctlySays correctlybut slowly(often sleepy)FACIALDROOPRight facialdroopLeft facialdroopMay havebilateral droopNo droopNo droopARMDRIFTRight arm drift(weakness)Left arm drift(weakness)May havebilateral drift(weakness)No driftNo drift*Finger-to-nose and/or heel-to-shin testing typically abnormalDecreased level of consciousness with headache and stiff neck are typical; this syndromewithout associated focal neurologic deficits is most consistent with subarachnoid hemorrhage.With intracerebral hemorrhage, focal deficits may occur.+
119Practice Scenarios: Stroke Syndromes and the MEND
120Fibrinolytic Screening Practice Case #1You 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 IllnessFAST-GTransport NowPast HistoryVital SignsFibrinolytic ScreeningMEND
121Practice Case #1: FAST-G (left click to obtain information, then click on arrow) Left facial droopARight arm driftSSpeech slurred, but appropriate wordsT20 minutes (witnessed)G104
122Practice Case #1: Fibrinolytic Screening (left click to obtain information, then click on arrow) No head trauma at onsetNo seizure at onsetNo previous hemorrhagic stroke+ nausea without headache or neck stiffnessNot on Coumadin (takes one aspirin a day)No history of bleeding/clotting disorderNot pregnantNo recent surgery or hemorrhage
123Practice Case # 1: Past History (click on arrow to proceed) + HTN+ CAD+ TIA’s+ COPD- DMOtherwise negative
124Practice Case #1: Hx of Present Illness (left click to obtain information, then click on arrow) Sudden onset of severe vertigo with nausea, no vomitingWeakness of right arm and legNo syncope, numbness/paresthesias, headache, neck pain/stiffness, shaking/tremor, seizure activity, trauma+ double vision+ slurred speechOther history= chest pain/pressure, palpitations, racing pulse, SOB, cough, etc
125Practice Case #1: Vital Signs (left click to obtain information, then click on arrow) BP 186/96HR 112, regularRR 18SaO2 95% on room airSinus rhythm
126Practice 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.)
127You are transporting… (left click to obtain information, then left click to go to next case) Brain Attack Alert(persistent deficits and within thrombolytic window)?YESAt risk for hemorrhagic stroke?Probably notAppropriate destination?Closest Stroke CenterIf you can’t answer these questions, go back to start of case
128What’s your initial guess as to which stroke syndrome this patient is experiencing? Right hemispheric?Left hemispheric?Cerebellar?Brainstem?
129MEND Exam Cranial Nerves Mental Status Limbs Left facial droop Alert Visual fields normalRight gaze palsy (won’t look to right)Mental StatusAlertAbnormal (slurred) speechAnswers both questions appropriatelyFollows commands, though weakly with right sideLimbs+ right arm and leg driftNormal sensationRight arm and leg too weak to perform coordination testing. Left side normal.
130Practice Case # 1 Which stroke syndrome does this appear to be? BrainstemPresence of crossed motor signs, vertigo, speech deficit and gaze palsy indicate Brainstem originIs this patient a fibrinolytic candidate?YES!
131Fibrinolytic Screening Practice Case # 2You 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 IllnessFAST-GTransport NowPast HistoryVital SignsFibrinolytic ScreeningMEND
132Practice Case # 2: FAST-G Right facial droopANot moving left arm at all but moving other extremities restlessly (weakly on right)SNot speaking at allTLast seen normal for her 5 hours agoG66
133Practice Case # 2: Fibrinolytic Screening No head trauma at onsetNo seizure at onsetNo previous hemorrhagic stroke+ vomitingTakes CoumadinNo history of bleeding/clotting disorderNot pregnantNo recent surgery or hemorrhage
134Practice Case # 2: Past History + atrial fibrillation+ CAD+ previous ischemic stroke with residual aphasia and mild right sided weakness- DM+ HTN with recent medication change
135Practice Case # 2: Hx of Present Illness Found on nursing rounds; normally awake and alert with aphasia and mild right sided weaknessNo known head trauma or seizure activityNo previous bleed or bleeding/clotting disordersUnknown complaints before symptom onsetNo recent surgery or hemorrhageOther history= chest pain/pressure, palpitations, racing pulse, SOB, cough, etc
136Practice Case # 2: Vital Signs BP 230/130HR 98, irregular, a. fib on monitorRR 12SaO2 92% on room air
137Your ambulance is here. Are you sure you want to do this now? Practice Case #2: MENDYour ambulance is here. Are you sure you want to do this now?
138While 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 facilityLeft click to proceed
139MEND Exam Mental Status Cranial Nerves Limbs Right facial droop Unable to test visual fieldsUnable to test horizontal gaze, but no gaze preferenceMental StatusResponds to pain (withdraws)No speechUnable to test response to questionsDoes not follow commandsLimbsLeft arm not moving, right side weak on spontaneous motionNo response to pain with right arm, otherwise withdraws from painUnable to do coordination testing
140Practice Case # 2 Which stroke syndrome does this appear to be? Hemorrhagic right cerebral hemisphereIs 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
141Fibrinolytic Screening Practice Case # 3You 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 IllnessFAST-GTransport NowPast HistoryVital SignsFibrinolytic ScreeningMEND
142Practice Case # 3: FAST-G (left click to obtain information, then click on arrow) No facial droopANo arm driftSSlurred speech but appropriate wordsTBartender inside says he saw the patient walk into the bar normally about an hour agoG180
143Practice Case # 3: Fibrinolytic Screening (left click to obtain information, then click on arrow) No signs of head traumaNo seizure at onsetPatient states he has never had a strokeNeck hurts “like usual” from arthritisDoes not take CoumadinNo history of bleeding/clotting disorderNot pregnantNo recent surgery or hemorrhage
144Practice Case # 3: Past History (click on arrow to proceed) “I drink a little more than I should”+ DM, on oral medsDenies other past history
145Practice Case # 3: Hx of Present Illness (left click to obtain information, then click on arrow) States he only had “two beers” todayDenies focal or general weakness, vision change, nausea or vomiting, syncope/near syncope, dizziness, paresthesias (“I got a buzz on, does that count?”), headache, seizure activityOther history= Oral intake, compliance with meds, recent trauma
146Practice Case # 3: Vital Signs (left click to obtain information, then click on arrow) BP 110/74HR 88, regularRR 12SaO2 96% on room airSinus rhythm on monitor
147Practice Case # 3: What now? “But I don’t need to go to the hospital. I want to go home!”
148How 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
149Which stroke syndrome could mimic alcohol intoxication? Right hemisphericLeft hemisphericBrainstemCerebellarLeft click to see correct answer
150How might we distinguish between intoxication (alcohol +/- other drugs) and cerebellar stroke? Ask about drinking habitsHow 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 normalLeft click to proceed
151How might we distinguish between intoxication (alcohol +/- other drugs) and cerebellar stroke? Look for evidence of FOCAL signsIsolated intoxication should affect the patient equally on both sidesUnilateral abnormalities or a marked difference in degree of impairment between sides should be suggestive of a strokeWould still need to try to distinguish ischemic from hemorrhagic etiologyWhat tool do we have to help with this?The MEND examLeft click to proceed
152In 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 speechCranial nerve exam is normalStrength and sensation are normalThe 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
153Disposition?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
154At 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 NOTBrain Attack Alert?YES(due to last known normal time of about an hour ago with positive neuro findings)Appropriate destination?Closest Stroke Center
155Congratulations. 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.
156Thanks for playing. (Please contact me at drromig@medcontrol Thanks for playing! (Please contact me at with any feedback or errors)