Laurie A. Romig, MD, FACEP
Medical Director
Pinellas County (FL) EMS

• 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)

• 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)

• 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

• 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

• 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)

INFARCT
CLOT
Clot occluding artery
Most common cause: thromboembolism
Possible sources of clot:
• Heart
• Large artery (to brain)
• Small artery (in brain)

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

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

• 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!

• Advanced age
• Male gender
• Family history of early stroke or
MI

• 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?

Clot in
Artery
(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.

• 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

• 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

• 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

• 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
– tumor previous similar events onset over weeks to months
– abscess
– subdural hematoma onset over weeks to months posttrauma

• 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!

• Abnormal:
– One side of face does not move as well as the other side
Right-sided droop
© AHA 1997

• 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
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.

A
• Abnormal:
– One arm cannot be lifted or drifts down
Right-sided drift
© AHA 1997

• 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.

• “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

• 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

• 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!

• 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.

• 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

• 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

• Potential symptoms to question
– Extremity weakness
– General weakness (i.e., nonfocal)
– Vision changes
– Slurred or inappropriate speech
– Nausea/Vomiting
– Syncope/Near-syncope

• 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

• 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

• 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)

• 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

• 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

• 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

• 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

• 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

• 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

• 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.

• 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

• 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!

• 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)

• 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

• 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

• 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

• 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

• 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

• Observe spontaneous movement and document accordingly; do the best you can
– Remember, symmetry is really the most important observation

• 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

• 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

• 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

• 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

• 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

• 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

• 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

• 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

www.jumpstarttriage.com/The_Other_Dr.php
or go to www.jumpstarttriage 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.

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

• 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

Don’t forget the Bonus Content 

• 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

• 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

• 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

• THE RULES:
– Keep 100% NPO
– Elevate head 30 o (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

• 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

• 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

• 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

• 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

• 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

• 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

• 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

• 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 86. 12 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.

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

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

1. Left Hemisphere
2. Right Hemisphere
3. Brainstem
4. Cerebellum
5. 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.

• 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

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

• 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

• 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)

• 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

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

Decreased LOC
Nausea, Vomiting
Hiccups, Abnormal
Respirations
Oropharyngeal
Weakness:
Dysarthria
(speaking), Dysphagia
(swallowing)
Vertigo, Tinnitus
Eye Movement
Abnormalities:
Diplopia
Dysconjugate Gaze
Gaze Palsy
(horizontal gaze deficit or gaze preference)

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

• 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

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

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

• 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

• 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
R 4 Hours
Gyrus (a fold of cortex)
L
Sulcus
(space between gyri)
Subtle blurring and compression of sulci

R 4 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)
Obvious dark changes of infarction

Intracerebral Hemorrhage Subarachnoid Hemorrhage
“Ball” of white blood in thalamus
White blood in cisterns & 4th ventricle

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

FOCAL
DEFICITS
S PEECH
LEFT
HEMISPHERE
Aphasia
– wrong or inappropriate words
RIGHT
HEMISPHERE
Says correctly
BRAINSTEM CEREBELLUM HEMORRHAGE
* +
Dysarthria
– slurring
Says correctly
Says correctly but slowly
(often sleepy)
F ACIAL
DROOP
Right facial droop
Left facial droop
May have bilateral droop
No droop No droop
A RM
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.

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.
FAST-G
Past History
Fibrinolytic
Screening
Hx of Present
Illness
Vital Signs
MEND
Transport
Now

F
A
S
T
G
(left click to obtain information, then click on arrow)
Left facial droop
Right arm drift
Speech slurred, but appropriate words
20 minutes (witnessed)
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

(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

(left click to obtain information, then click on arrow)
• BP 186/96
• HR 112, regular
• RR 18
• SaO2 95% on room air
• Sinus rhythm

(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.)

(left click to obtain information, then left click to go to next case)
Brain Attack Alert
(persistent deficits and within thrombolytic window)?
At risk for hemorrhagic stroke?
Appropriate destination?
YES
Probably not
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?

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

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

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.
FAST-G
Past History
Fibrinolytic
Screening
Hx of Present
Illness
Vital Signs
MEND
Transport
Now

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

• 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

• + atrial fibrillation
• + CAD
• + previous ischemic stroke with residual aphasia and mild right sided weakness
• - DM
• + HTN with recent medication change

• 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

• 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?

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

• Mental
Status
– Responds to pain
(withdraws)
– No speech
– Unable to test response to questions
– Does not follow commands
• Cranial Nerves
– Right facial droop
– Unable to test visual fields
– Unable to test horizontal gaze, but no gaze preference
• 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

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

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.
FAST-G
Hx of Present
Illness
Transport
Now
Past History
Vital Signs
Fibrinolytic
Screening
MEND

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

• “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

(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

“But I don’t need to go to the hospital. I want to go home!”

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





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

(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

• 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

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

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