New stroke treatment has defined a critical role
for the paramedic. Prehospital assessment is crucial,
but its extent may vary. On the one hand, urgent
transport is the goal. Time is Brain. On
the other hand, the more information the paramedic
collects and provides to the Emergency Department,
the better.
The stroke history may be difficult to
obtain from a neurologically impaired patient.
It is, therefore, important to seek information
from a witness, especially regarding the last
time the patient was without symptoms. The focus
of history taking should be on whether the patient
is a candidate for t-PA therapy.
The physical examination must balance brevity
and urgent transport against collecting enough
data to assist hospital physicians. The Cincinnati
Prehospital Stroke Scale (CPSS) is a brief, basic
screening exam endorsed by the AHA. It includes
a validated 3-step assessment of Mental Status,
Cranial Nerves, and Limbs (speech, facial droop,
arm drift) that should define whether a stroke
has occurred. We recommend EMS personnel initially
perform the basic 3-step CPSS with the addition
of an assessment of level of consciousness (AVPU).
The 3-step CPSS should be carried out on the
scene. We suggest it be performed during the primary
survey, after the ABCs are completed, specifically
during the D, or disability, component. If
time is available en route, we encourage performance
of the expanded Miami Emergency Neurologic Deficit
(MEND) Exam which is a more detailed Neurologic
assessment that incorporates the Cincinnati scale.
Remember that the goal of EMS is to rapidly
identify the problem and transport patients to
an appropriate center. As part of this goal,
the CPSS and MEND exams will:
(1) Ensure that an accurate and easy-to-learn
basic screening is carried out immediately; if
a stroke is suspected, the paramedic team should
“load and go.”
(2) Allow additional observations that permit
paramedics to expand the examination in order
to assess stroke severity and identify the stroke
syndrome.
This practice session will introduce you to the
hands-on prehospital stroke examination. You will
first practice the basic, 3-component CPSS that
you will immediately carry out in the field (seen
in the shaded boxes). The expanded MEND Examination
will also be practiced, and may be carried out en
route to the hospital along with supportive therapies.
The MEND Examination checklist is shown below. The
following pages outline the exact procedure to follow,
step by step. These documents will guide you as
you examine your “patient” during the
practice session.
MEND EXAMINATION
– “HEAD TO TOE”
MENTAL STATUS
Check if abnormal
Level of Consciousness (AVPU)
Speech “You can’t
teach an old dog new tricks.” (repeat)
Abnormal = wrong words, slurred speech, no speech
Questions (age, month)
Commands (close, open eyes)
CRANIAL NERVES
Facial Droop (show teeth or
smile)
Abnormal = one side does not move as well as other
RT
LT
Visual Fields (four quadrants)
Horizontal Gaze (side to side)
LIMBS
Motor–Arm Drift (close
eyes and hold out both arms)
Abnormal = arm can’t move or drifts down
RT
LT
Leg Drift (open eyes and lift
each leg separately)
Sensory–Arm and Leg (close
eyes and touch, pinch)
Coordination---Arm and Leg (finger
to nose, heel to shin)
THE MEND
EXAM---An Expanded Prehospital Stroke Exam Exact
Procedure to Follow (“Head to Toe”) with Normal
Findings
MENTAL STATUS
AVPU:
You
communicate with the patient using
questions and
Commands and, if necessary, painful stimulation
with a pinch.
The Patient is categorized
as Alert, responsive to Verbal
Stimuli, responsive to Painful stimuli,
or Unresponsive.
SPEECH:
You
ask the patient to say: “You can’t
teach an old dog new
tricks.”
The Patient responds with
no aphasis, i.e., no wrong words
Or “mixing up” of words and
no dysarthria, i.e., no slurring
(the letter is a cranial nerve abnormality).
QUESTIONS:
You
ask “How old are you?” and then
“What month is this?”
The Patient responds correctly.
COMMANDS:
You say “Close your eyes
tight” and then “Open your eyes
wide.”
The Patient responds appropriately.
CRANIAL NERVES
FACIAL
DROOP:
You
say: “Show me your teeth” and/or
“Smile for me.”
The Patient responds appropriately
with both sides of the face moving up
equally.
VISUAL
FIELDS:
You
say: “Look at my nose.” You
hold your hands out on
the right and left and wiggle your fingers
in one quadrant
(left upper or lower, right upper or lower).
You say “Point
to where my fingers are moving.”
You repeat this for the
other 3 quadrants.
The Patient recognizes
finger movement in all four areas.
HORIZONTAL
GAZE:
You say: “Follow
my finger movement with your eyes.”
and you move your finger fully to the
left and right.
The Patient follows completely
to both sides.
LIMBS
MOTOR
–
ARM DRIFT:
You
say: “Hold out both arms in
front of you with your palms down and close
your eyes.”
The Patient responds appropriately.
Both arms move the same and do not drift
down.
LEG
DRIFT:
You
say: “Lift this leg up in the air.”
(for each side)
The Patient can lift each
leg, with no drift or weakness.
SENSORY-ARM:
You
say “Close your eyes. Can
you feel me touching you
ARM: anywhere” Is it the same on
both sides?” as you touch or lightly
pinch each arm.
The Patient can feel the touch,
tells you where, and says that both sides
feel the same.
SENSORY-LEG:
You say “Close your eyes.
Can you feel me touching you
anywhere” Is it the same on both
sides?” as you touch or lightly pinch
each leg.
The Patient can feel the touch,
tells you where, and says that both sides
feel the same.
COORDINATION
-ARM
You say “Touch my finger
with your finger, then touch
your nose, back and forth,” as you
hold your finger in front of the patient.
The Patient does this rapidly
with no clumsiness.
COORDINATION
-LEG
You say “I want you
to take this heel and touch it to your
knee on the other leg and then run it
down your shin bone.”
(indicate heel and do for each side)
