What’s the Scoop on Expanding Neurologic · neurologic tests •High specificity testing •Low...

What’s the Scoop on Expanding Neurologic

AssessmentBob Matoba M.Ed., EMT-P

Lead Instructor St. Anthony Paramedic [email protected], 303-358-7640

What’s the Scoop on Expanding Neurologic Assessment

Overview

• Playing the game of EMS.

• Stroke scales.

• Specificity vs. sensitivity

of medical tests.

• Components of an

expanded neurologic

assessment.

• Practice an expanded

neurologic assessment.

The Game of EMS

Playing the game of EMS

• Managing patients within EMS is not

about WINNING the game…

– The game of EMS, is more about

playing so you don’t lose.

The Game of EMS

What are the few situations when we land a “WIN” within EMS?

• Child birth with healthy mom and baby.• Staunching a controllable hemorrhage.• Administer dextrose in hypoglycemia.• Clearing an obstructed airway in a conscious

patient.• Initiate a cardiac alert for an MI patient.• Initiate a stroke alert for a patient with

appropriate CVA criteria.• Identify & report an actual abusive situation.

Leveling Out thePlaying Field…

What are potential game changers for

leveling out the EMS playing field?

• 12 lead ECG monitoring

• Capnography

• CPAP

What game changer is available to all

levels of EMS providers?

• An expanded neurologic assessment.

Pre-Hospital Stroke Scales

An expanded neurologic assessment

starts with performing a stroke scale.

• Cincinnati Prehospital Stroke Scale

(CPSS)

• FAST Stroke Scale

Cincinnati Stroke Scale

Developed in 1997 by the University of

Cincinnati Medical Center.

• Elements of a Cincinnati Prehospital

Stroke Scale (CPSS)

–Unilateral facial droop.

–Unilateral arm drift.

–Slurred speech.- “The sky is always

blue in Cincinnati.”

- “You can’t teach an

old dog new tricks.”

FAST Stroke Scale

Developed in the United Kingdom in

1998 for training ambulance staff.

• Elements of a FAST Stroke Scale

– F

– A

– S

– T- In the presence of symptom/s, TIME is

of the essence.

- Time to call 911 (999) immediately.

acial drooping

rm weakness

peech difficulties

ime

Stroke Scales

Sensitivity vs. Specificity

• Stroke scales

– Highly sensitive testing.

– Low specificity testing.

How do these levels of sensitivity

and specificity correlate to the

development of a working

differential diagnosis?

Sensitivity and Specificity

Sensitivity

• Relates to the test's ability to correctly detect ill patients who have the condition (True Positive).

– Increasing:

– Decreasing:

=

More people will have a “true positive” result, with less accuracy.

Less people will have a “true positive” result, with more accuracy.

• High sensitivity

– Increases the number of people who test “true positive” for the disease.

3 with disease: 7 without disease:

Sensitivity – Detecting

Trade off:Increases the number of healthy people who FALSELY get identified as having the condition.

Testing to Detect Disease

• Low sensitivity

– Increases the accuracy of people who test “true positive” for the disease.


Sensitivity – Detecting

Trade off:Increases the number of diseased people who DON’T get identified as having the condition.

Testing to Detect Disease


Specificity

• Relates to the test's ability to correctly reject healthy patients without the condition (True Negative).

– Increasing:

– Decreasing:

=

More people will have a “true negative” result, with less accuracy.

Less people will have a “true negative” result, with more accuracy.

• High specificity

– Increases the number of people who test “true negative” for the disease.


Specificity – Rejecting

Trade off:Increases the number of diseased people who get FALSELY cleared from having the condition.

Testing to Reject Disease

Testing to Reject Disease

• Low specificity

– Increases the accuracy of people who test “true negative” for the disease.


Specificity – Rejecting

Trade off:Increases the number of healthy people who fall outside the test’s ability to clear them from the condition.


• Correlation between sensitivity and specificity.

– Manipulating one will affect the other.

– The diagnostic power of any test is determined by balancing both it’s sensitivity and it’s specificity.

Testing to Detect Disease Testing to Reject Disease

Stroke ScaleA Highly Sensitive Test

The good news!!!• Patients failing any aspect of a stroke

scale are probably experiencing a stroke, and/or an abnormal neurologic condition.

The bad news!!!• Passing a stroke scale doesn’t mean

you are not having a stroke.• Most patients will pass a stroke scale.

Neurological Assessment

• Components of a “COMPREHENSIVE”


– Stroke Scale

testing.

– Mental status (MS).

– Cranial nerves (CN).

– Coordination (CO).

– Sensory function (SF).

– Gait (GA).

Neurological Assessment

Goal for an expanded

neurological assessment

• Bridge the gap between

stroke scales and a comprehensive

neurological assessment.

• Needs to be:

– Time sensitive.

– Practical for integration into existing

EMS practices.

Expanded Neurological Assessment

Steps for an “expanded” neurologic assessment1. Perform stroke scale2. Visual acuity3. Eye movement4. Peripheral vision5. Fingers then nose6. Pupil reactions7. Facial sensation8. Raise eyebrows9. Forced eyebrows10. Puff cheeks11. Clinch teeth

12. Tongue out13. Tongue to roof of

mouth14. Say “ahh…”15. Swallow16. Bilateral hearing17. Pull/Push arms/legs18. Shoulders & Head19. Heels to shins20. Heels to toes21. Rhomberg Test

Stroke Scale1. Facial droop

2. Arm drift

3. Abnormal speech

– Patient slurs words, uses wrong

words, or is unable to speak.

72% - 89% probability of a stroke

or a neurologic problem

with abnormal

indicator/s.

Expanded Neurologic Assessment Testing

Sensitivity vs. specificity of expanded neurologic tests

• High specificity testing

• Low sensitivity testing

How does this clinically relate?

• Failure of a test doesn’t specifically tell you what is wrong.

• Failing tells you there is a non-specified neurologic problem or abnormality.

Cranial Nerves

I. Olfactory (Smell)II. Optic (Vision)III. Oculomotor (Eyelid, eyeball, pupils)IV. Trochlear (Eyeball movement)V. Trigeminal (Facial sensation)VI. Abducens (Eyeball movement)VII. Facial (Taste, tears, & facial expression)VIII.Vestibulocochlear (Auditory)IX. Glossopharyngeal (Swallowing of throat)X. Vagus (Swallowing, cough, & speech)XI. Accessory (Movement head & shoulders)XII. Hypoglossal (Tongue, speech)

Visual Acuity (CN II)

Ability to read words.

Pass

• Patient is able to read common words.

Fail

• Patient is unable to read common

words.

What if you suspect the patient is

illiterate?

• Use your fingers for counting.

Planes of ReferenceDuring the Assessment

Frontal Plane Mid-Line Plane

Eye Movement (CN III, IV, VI)

Ability to visually track “H” branches

& inward/outward while keeping

head in a fixed

mid-line position.Pass

• Patient is able to smoothly track without

moving head.

Fail

• Patient is unable to track, or has to move

head while tracking.

Peripheral Vision (CN II, III)

Ability to identify peripheral

movement within close proximity of

the frontal plane.

Pass

• Patient is able to discern peripheral

movement without moving head.

Fail

• Patient is unable to discern peripheral

movement, or have to move outside the

frontal plane to discern movement.

Fingers then Nose (CO)

Ability to touch index finger to index

finger, then back to patient’s nose.

Pass

• From multiple locations, patient is able

to coordinate finger to finger, then to

nose.

Fail

• Patient is unable to coordinate finger to

finger, then to nose.

Assessing Pupils

Directing light vs. shining light

• Directing light =

• Shining light =

A deliberate angle, as

well as a deliberate direction.

Pointing in the general

direction.

Directing light Shining light

Assessing Pupils• The goal for assessing pupils is to direct

light “onto,” NOT into the cornea.

• You DON’T have to shine the light

from the front of eye.

• “Easier” on the patient to direct light

from the side close to the frontal plane.

Assessing Pupils• Light positioned near or inside the

frontal plane.Direct constriction• Reaction from light directed onto cornea.Accommodation• Reaction in the opposite eye.

Direct

Constriction

Accommodation

http://www.google.com/url?sa=i&rct=j&q=&esrc=s&source=images&cd=&cad=rja&uact=8&ved=2ahUKEwilkuHH8ZLeAhUF3lMKHR_TArcQjRx6BAgBEAU&url=http://designatprinting.com/eye-clipart/cute-eyes-clipart-32-16-eye/&psig=AOvVaw19sO7jsPSUfWx2MT_LXaPl&ust=1540051622868324

Pupil Reactions (CN III)

Observe for appropriate pupillary

reaction, as well as accommodation.

Pass

• Pupils directly react, as

well as accommodate.

Fail

• Pupils do not react, and/or do not

accommodate.

Facial Sensation (SF, CN V)

Ability to sense bilateral touch along

the forehead, zygoma, chin, and

mandible on 2 passes.Pass

• Patient bilaterally and

equally senses touch

along all areas.

Fail

• Patient unable to bilaterally sense touch

along all areas.

During the second pass, deliberately

avoid touching one area.

Raise Eyebrows (CN VII)

Ability to raise eyebrows.

Pass

• Patient able to bilaterally, and

symmetrically raise eyebrows.

Fail

• Patient unable to raise eyebrows and/or

asymmetrical eyebrow control.

Forced Eyebrows (CN VII)

Ability to raise eyebrows against

gentle pressure.

Pass

• Patient able to bilaterally raise eyebrows

against gentle pressure.

Fail

• Patient unable to raise eyebrows, and/or

asymmetrical eyebrow control.

Clinch Teeth (CN VII)

Ability to symmetrically open mouth

while actively

clinching teeth

together.Pass

• Patient able to symmetrically open

mouth while clinching teeth together.

Fail

• Patient unable to symmetrically open

mouth while clinching teeth together.

Puff Cheeks (CN VII)

Ability to symmetrically puff cheeks

while holding lips

tightly closed.

Pass

• Patient able to symmetrically puff

cheeks with lips tightly closed.

Fail

• Patient unable to symmetrically puff

cheeks without lips tightly closed.

Tongue Out (CN XII)

Ability to stick tongue straight out

along the mid-line plane.

Pass

• Patient able to symmetrically stick out

tongue along the mid-line plane.

Fail

• Patient unable to symmetrically stick

out tongue along the mid-line plane.

Tongue to Roof of Mouth (CN XII)

Ability to symmetrically stick tongue

to roof of mouth.

Pass

• Patient able to symmetrically stick

tongue to roof of mouth.

Fail

• Patient unable to symmetrically stick

tongue to roof of mouth.

Say Ah… (CN XII)

Ability to open mouth

while saying ahh...

Pass

• Patient able to open mouth, and you

notice the tongue dropping inferiorly.

Fail

• Patient able to open mouth, and/or you

notice the tongue does not drop

inferiorly.

https://www.google.com/url?sa=i&rct=j&q=&esrc=s&source=images&cd=&cad=rja&uact=8&ved=2ahUKEwjG1vrDopPeAhXC61MKHcACDKwQjRx6BAgBEAU&url=https://www.biocodexmicrobiotainstitute.com/en/publications/open-wide-and-say-ah-new-diagnostic-test-autism&psig=AOvVaw3l8oNpuLDUWthK4BXOyCsU&ust=1540064641522257

Swallow (CN IX, X)

Ability to swallow without

difficulty.

Pass

• Patient able to swallow without

difficulty.

Fail

• Patient unable to swallow, and/or

swallows with difficulty.

Bilateral Hearing (CN VIII)

Ability to hear while non-assessed

ear is simultaneously distracted.

Pass

• Patient able to equally and bilaterally

hear in both ears.

Fail

• Patient unable to equally and bilaterally

hear in both ears.

=

https://www.google.com/url?sa=i&rct=j&q=&esrc=s&source=images&cd=&cad=rja&uact=8&ved=&url=https://www.audicus.com/hearing-loss-sounds-you-are-missing/&psig=AOvVaw2TOze8yVzYEPE3C_ZCAlk6&ust=1540066329715889

https://www.google.com/url?sa=i&rct=j&q=&esrc=s&source=images&cd=&cad=rja&uact=8&ved=&url=https://www.audicus.com/hearing-loss-sounds-you-are-missing/&psig=AOvVaw2TOze8yVzYEPE3C_ZCAlk6&ust=1540066329715889

Pull/Push Arms & Legs (CO)

Ability to resist pulling and pushing

forces in arms

and legs.

Pass

• Patient able to equally and bilaterally hold

arms and legs against pulling/pushing force.

Fail

• Patient unable to equally and bilaterally

hold arms and legs against pulling/pushing

force.

Shoulders & Head (CN XI)

Ability to shrug shoulders then turn

head right and left against resistance.

Pass

• Patient able to shrug shoulders and turn

head with equal resistance.

Fail

• Patient unable to shrug shoulders and turn

head without equal resistance.

Heel to Shin (CO, GA, CN VIII)

Ability to lift and draw foot in a

straight up and down

movement.

Pass

• Patient able to move foot in a straight up

and down movement.

Fail

• Patient unable to move foot in a straight

up and down movement.

Heels to Toes (CO, GA, CN VIII)

Ability to walk heel to toe.

Pass

• Patient able to walk heel to toe without

assistance.

Fail

• Patient unable to walk heel to toe, or

requires a large amount of assistance.

Rhomberg Test (CO, CN VIII)

With feet together and

head faced upward,

ability to stand upright

without assistance.Pass

• Patient able to maintain position with

eyes open and eyes closed.

Fail

• Patient unable to maintain position with

eyes open and/or eyes closed.

Expanded Neurological

Assessment


Assessment

Any failure of an expanded neurological assessment test

warrants a recommendation for transport and further medical

assessment.

Expanded Neurologic Assessment

This “expanded” assessment is

NOT a comprehensive

neurological assessment.




mouth14. Say “ahh…”15. Swallow16. Bilateral hearing17. Pull/Push arms/legs18. Shoulders & Head19. Heels to shins20. Heels to toes21. Rhomberg Test


Assessment

• Break into pairs.

• One person plays the patient.

• One person plays the medical provider.

Let’s work through the expanded

neurological assessment as a

DIRECTED group.

• Smile

• Arms out palms

facing up with eyes

closed and hold for

at least 10 seconds

• “You can’t teach an


Steps for an “expanded” neurologic assessment1. Perform stroke scale


Steps for an “expanded” neurologic assessment1. Perform stroke scale2. Visual acuity

• Have the patient

read some text.

• Count fingers if you

suspect illiteracy.


Steps for an “expanded” neurologic assessment1. Perform stroke scale2. Visual acuity3. Eye movement

Center start point – head straight forward

• Right lateral “H” branch / up then down

• Back to center…

• Left lateral “H” branch / up then down


• Inward then outward


Steps for an “expanded” neurologic assessment1. Perform stroke scale2. Visual acuity3. Eye movement4. Peripheral vision

• Independent right perspective

• Independent left perspective

• Simultaneous bilateral perspectives


Steps for an “expanded” neurologic assessment1. Perform stroke scale2. Visual acuity3. Eye movement4. Peripheral vision5. Fingers then nose


• 2 different locations on right

• 2 different locations on left

Steps for an “expanded” neurologic assessment1. Perform stroke scale2. Visual acuity3. Eye movement4. Peripheral vision5. Fingers then nose6. Pupil reactions


• Direct R pupil reaction

• L pupil accommodation

• Direct L pupil reaction

• R pupil accommodation

Steps for an “expanded” neurologic assessment1. Perform stroke scale2. Visual acuity3. Eye movement4. Peripheral vision5. Fingers then nose6. Pupil reactions7. Facial sensation


• Bilateral forehead, zygoma, chin and

mandible

• Repeat with a deliberate exclusion

Steps for an “expanded” neurologic assessment1. Perform stroke scale2. Visual acuity3. Eye movement4. Peripheral vision5. Fingers then nose6. Pupil reactions7. Facial sensation8. Raise eyebrows


Steps for an “expanded” neurologic assessment1. Perform stroke scale2. Visual acuity3. Eye movement4. Peripheral vision5. Fingers then nose6. Pupil reactions7. Facial sensation8. Raise eyebrows9. Forced eyebrows


• Thumbs creating resistance on eyebrows

Steps for an “expanded” neurologic assessment1. Perform stroke scale2. Visual acuity3. Eye movement4. Peripheral vision5. Fingers then nose6. Pupil reactions7. Facial sensation8. Raise eyebrows9. Forced eyebrows10. Puff cheeks




12. Tongue out




mouth




mouth14. Say “ahh…”




mouth14. Say “Ahh…”15. Swallow




mouth14. Say “Ahh…”15. Swallow16. Bilateral hearing

• Speak into right ear while distracting left ear

• Speak into left ear while distracting right ear




mouth14. Say “Ahh…”15. Swallow16. Bilateral hearing17. Push/pull arms/legs

• Separately compare R

arm then L arm


knee then L knee

1. Perform stroke scale2. Visual acuity3. Eye movement4. Peripheral vision5. Fingers then nose6. Pupil reactions7. Facial sensation8. Raise eyebrows9. Forced eyebrows10. Puff cheeks11. Clinch teeth12. Tongue out


13. Tongue to roof of mouth

14. Say “Ahh…”15. Swallow16. Bilateral hearing17. Push/pull arms/legs18. Shoulders & Head

• Shoulders against resistance

• Head R against resistance

• Head L against resistance

Steps for an “expanded” neurologic assessment




14. Say “Ahh…”15. Swallow16. Bilateral hearing17. Push/pull arms/legs18. Shoulders & Head19. Heel to shin

• Right heel to shin

• Left heel to shin


Steps for an “expanded” neurologic assessment1. Perform stroke scale2. Visual acuity3. Eye movement4. Peripheral vision5. Fingers then nose6. Pupil reactions7. Facial sensation8. Raise eyebrows9. Forced eyebrows10. Puff cheeks11. Clinch teeth12. Tongue out



14. Say “Ahh…”15. Swallow16. Bilateral hearing17. Push/pull arms/legs18. Shoulders & Head19. Heel to shins20. Heels to toes




14. Say “Ahh…”15. Swallow16. Bilateral hearing17. Push/pull arms/legs18. Shoulders & Head19. Heel to shins20. Heels to toes21. Rhomberg test

• Open eyed• Eyes closed

Expanded Neurologic

Assessment

• Switch roles and start back at the beginning…

• Smile

• Arms out palms

facing up with eyes

closed and hold for

at least 10 seconds

• “You can’t teach an


Steps for an “expanded” neurologic assessment1. Perform stroke scale


Steps for an “expanded” neurologic assessment1. Perform stroke scale2. Visual acuity

• Have the patient

read some text.

• Count fingers if you

suspect illiteracy.


Steps for an “expanded” neurologic assessment1. Perform stroke scale2. Visual acuity3. Eye movement

Center start point – head straight forward

• Right lateral “H” branch / up then down


• Left lateral “H” branch / up then down


• Inward then outward


Steps for an “expanded” neurologic assessment1. Perform stroke scale2. Visual acuity3. Eye movement4. Peripheral vision

• Independent right perspective

• Independent left perspective

• Simultaneous bilateral perspectives


Steps for an “expanded” neurologic assessment1. Perform stroke scale2. Visual acuity3. Eye movement4. Peripheral vision5. Fingers then nose


• 2 different locations on right

• 2 different locations on left

Steps for an “expanded” neurologic assessment1. Perform stroke scale2. Visual acuity3. Eye movement4. Peripheral vision5. Fingers then nose6. Pupil reactions


• Direct R pupil reaction

• L pupil accommodation

• Direct L pupil reaction

• R pupil accommodation

Steps for an “expanded” neurologic assessment1. Perform stroke scale2. Visual acuity3. Eye movement4. Peripheral vision5. Fingers then nose6. Pupil reactions7. Facial sensation


• Bilateral forehead, zygoma, chin and

mandible

• Repeat with a deliberate exclusion

Steps for an “expanded” neurologic assessment1. Perform stroke scale2. Visual acuity3. Eye movement4. Peripheral vision5. Fingers then nose6. Pupil reactions7. Facial sensation8. Raise eyebrows


Steps for an “expanded” neurologic assessment1. Perform stroke scale2. Visual acuity3. Eye movement4. Peripheral vision5. Fingers then nose6. Pupil reactions7. Facial sensation8. Raise eyebrows9. Forced eyebrows


• Thumbs creating resistance on eyebrows

Steps for an “expanded” neurologic assessment1. Perform stroke scale2. Visual acuity3. Eye movement4. Peripheral vision5. Fingers then nose6. Pupil reactions7. Facial sensation8. Raise eyebrows9. Forced eyebrows10. Puff cheeks




12. Tongue out




mouth




mouth14. Say “ahh…”




mouth14. Say “Ahh…”15. Swallow




mouth14. Say “Ahh…”15. Swallow16. Bilateral hearing

• Speak into right ear while distracting left ear

• Speak into left ear while distracting right ear




mouth14. Say “Ahh…”15. Swallow16. Bilateral hearing17. Push/pull arms/legs


arm then L arm


knee then L knee




14. Say “Ahh…”15. Swallow16. Bilateral hearing17. Push/pull arms/legs18. Shoulders & Head

• Shoulders against resistance

• Head R against resistance

• Head L against resistance





14. Say “Ahh…”15. Swallow16. Bilateral hearing17. Push/pull arms/legs18. Shoulders & Head19. Heel to shin

• Right heel to shin

• Left heel to shin





14. Say “Ahh…”15. Swallow16. Bilateral hearing17. Push/pull arms/legs18. Shoulders & Head19. Heel to shins20. Heels to toes




14. Say “Ahh…”15. Swallow16. Bilateral hearing17. Push/pull arms/legs18. Shoulders & Head19. Heel to shins20. Heels to toes21. Rhomberg test

• Open eyed• Eyes closed


What type of patient complaints might it

be beneficial to acquire this amount of

information?


What type of patient complaints might it

be beneficial to acquire this amount of

information?

• Syncope

• Near syncope

• General weakness

• Dizziness

• Altered LOC

• Headache

• Vision disturbances

• Falls

• Head trauma

• Patients with

numbness

• Substance abuse

• REFUSALS• Others etc…

Stroke scales (high sensitivity)

• Good at identifying MAJOR

neurological abnormalities.

Expanded neurological

assessment (high specificity)

• Better at identifying subtle

neurological abnormalities.

• Immediately improves the clinical

foundation for all levels of EMS

practitioners.

Summary

What’s the Scoop on Expanding Neurologic Assessment

Review

• Playing the game of EMS.

• Stroke scales.

• Specificity vs. sensitivity

of medical tests.

• Components of an

expanded neurologic

assessment.

• Practice an expanded


References

• Brooker, C. The Neurological Exam…Made Simple.

Neurologyexam.com

• Fuller, Geraint (2004). Neurological Examination Made

Easy. Churchill Livingstone. ISBN 0-443-07420-8.

• Murray E.D.; Price B.H. (2008) The Neurological

Examination. In: Comprehensive Clinical Psychiatry, First

Edition. ISBN 978-032347432

• Nicholl D.J.; Appleton J.P. (2014). Clinical neurology: why

this matters in the 21st century. Journal of Neurology,

Neurosurgery, and Psychiatry. 86: 229–33.

• Rank, W. (2010). Simplifying Neurological Assessment.

Nursing Made Incredibly Easy. Volume 8, issue 2, page 15-

19.

Bob Matoba, M.Ed., EMT-P

Lead Instructor St. Anthony

Paramedic Academy

[email protected]

303-358-7640

mailto:[email protected]

What’s the Scoop on Expanding Neurologic · neurologic tests •High specificity testing •Low...

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