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What’s the Scoop on Expanding Neurologic
AssessmentBob Matoba M.Ed., EMT-P
Lead Instructor St. Anthony Paramedic [email protected], 303-358-7640
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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.
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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.
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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.
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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.
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Pre-Hospital Stroke Scales
An expanded neurologic assessment
starts with performing a stroke scale.
• Cincinnati Prehospital Stroke Scale
(CPSS)
• FAST Stroke Scale
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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.”
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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
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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?
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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.
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• 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
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• Low sensitivity
– Increases the accuracy of people who test “true positive” for the disease.
3 with disease: 7 without disease:
Sensitivity – Detecting
Trade off:Increases the number of diseased people who DON’T get identified as having the condition.
Testing to Detect Disease
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Sensitivity and Specificity
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.
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• High specificity
– Increases the number of people who test “true negative” for the disease.
3 with disease: 7 without disease:
Specificity – Rejecting
Trade off:Increases the number of diseased people who get FALSELY cleared from having the condition.
Testing to Reject Disease
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Testing to Reject Disease
• Low specificity
– Increases the accuracy of people who test “true negative” for the disease.
3 with disease: 7 without disease:
Specificity – Rejecting
Trade off:Increases the number of healthy people who fall outside the test’s ability to clear them from the condition.
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Sensitivity and Specificity
• 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
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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.
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Neurological Assessment
• Components of a “COMPREHENSIVE”
neurologic assessment.
– Stroke Scale
testing.
– Mental status (MS).
– Cranial nerves (CN).
– Coordination (CO).
– Sensory function (SF).
– Gait (GA).
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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.
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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
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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.
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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.
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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)
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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.
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Planes of ReferenceDuring the Assessment
Frontal Plane Mid-Line Plane
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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.
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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.
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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.
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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
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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.
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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
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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.
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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.
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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.
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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.
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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.
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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.
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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.
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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.
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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.
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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.
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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.
=
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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.
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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.
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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.
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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.
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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.
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Expanded Neurological
Assessment
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Expanded Neurological
Assessment
Any failure of an expanded neurological assessment test
warrants a recommendation for transport and further medical
assessment.
![Page 50: What’s the Scoop on Expanding Neurologic · neurologic tests •High specificity testing •Low sensitivity testing ... •Failing tells you there is a non-specified neurologic](https://reader036.vdocuments.us/reader036/viewer/2022071011/5fc9ac5f6c6d8746bc1e8a82/html5/thumbnails/50.jpg)
Expanded Neurologic Assessment
This “expanded” assessment is
NOT a comprehensive
neurological assessment.
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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
Expanded Neurologic Assessment
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
![Page 52: What’s the Scoop on Expanding Neurologic · neurologic tests •High specificity testing •Low sensitivity testing ... •Failing tells you there is a non-specified neurologic](https://reader036.vdocuments.us/reader036/viewer/2022071011/5fc9ac5f6c6d8746bc1e8a82/html5/thumbnails/52.jpg)
Expanded Neurological
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.
![Page 53: What’s the Scoop on Expanding Neurologic · neurologic tests •High specificity testing •Low sensitivity testing ... •Failing tells you there is a non-specified neurologic](https://reader036.vdocuments.us/reader036/viewer/2022071011/5fc9ac5f6c6d8746bc1e8a82/html5/thumbnails/53.jpg)
• Smile
• Arms out palms
facing up with eyes
closed and hold for
at least 10 seconds
• “You can’t teach an
old dog new tricks.”
Steps for an “expanded” neurologic assessment1. Perform stroke scale
Expanded Neurologic Assessment
![Page 54: What’s the Scoop on Expanding Neurologic · neurologic tests •High specificity testing •Low sensitivity testing ... •Failing tells you there is a non-specified neurologic](https://reader036.vdocuments.us/reader036/viewer/2022071011/5fc9ac5f6c6d8746bc1e8a82/html5/thumbnails/54.jpg)
Steps for an “expanded” neurologic assessment1. Perform stroke scale2. Visual acuity
• Have the patient
read some text.
• Count fingers if you
suspect illiteracy.
Expanded Neurologic Assessment
![Page 55: What’s the Scoop on Expanding Neurologic · neurologic tests •High specificity testing •Low sensitivity testing ... •Failing tells you there is a non-specified neurologic](https://reader036.vdocuments.us/reader036/viewer/2022071011/5fc9ac5f6c6d8746bc1e8a82/html5/thumbnails/55.jpg)
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
• Back to center…
• Inward then outward
Expanded Neurologic Assessment
![Page 56: What’s the Scoop on Expanding Neurologic · neurologic tests •High specificity testing •Low sensitivity testing ... •Failing tells you there is a non-specified neurologic](https://reader036.vdocuments.us/reader036/viewer/2022071011/5fc9ac5f6c6d8746bc1e8a82/html5/thumbnails/56.jpg)
Steps for an “expanded” neurologic assessment1. Perform stroke scale2. Visual acuity3. Eye movement4. Peripheral vision
• Independent right perspective
• Independent left perspective
• Simultaneous bilateral perspectives
Expanded Neurologic Assessment
![Page 57: What’s the Scoop on Expanding Neurologic · neurologic tests •High specificity testing •Low sensitivity testing ... •Failing tells you there is a non-specified neurologic](https://reader036.vdocuments.us/reader036/viewer/2022071011/5fc9ac5f6c6d8746bc1e8a82/html5/thumbnails/57.jpg)
Steps for an “expanded” neurologic assessment1. Perform stroke scale2. Visual acuity3. Eye movement4. Peripheral vision5. Fingers then nose
Expanded Neurologic Assessment
• 2 different locations on right
• 2 different locations on left
![Page 58: What’s the Scoop on Expanding Neurologic · neurologic tests •High specificity testing •Low sensitivity testing ... •Failing tells you there is a non-specified neurologic](https://reader036.vdocuments.us/reader036/viewer/2022071011/5fc9ac5f6c6d8746bc1e8a82/html5/thumbnails/58.jpg)
Steps for an “expanded” neurologic assessment1. Perform stroke scale2. Visual acuity3. Eye movement4. Peripheral vision5. Fingers then nose6. Pupil reactions
Expanded Neurologic Assessment
• Direct R pupil reaction
• L pupil accommodation
• Direct L pupil reaction
• R pupil accommodation
![Page 59: What’s the Scoop on Expanding Neurologic · neurologic tests •High specificity testing •Low sensitivity testing ... •Failing tells you there is a non-specified neurologic](https://reader036.vdocuments.us/reader036/viewer/2022071011/5fc9ac5f6c6d8746bc1e8a82/html5/thumbnails/59.jpg)
Steps for an “expanded” neurologic assessment1. Perform stroke scale2. Visual acuity3. Eye movement4. Peripheral vision5. Fingers then nose6. Pupil reactions7. Facial sensation
Expanded Neurologic Assessment
• Bilateral forehead, zygoma, chin and
mandible
• Repeat with a deliberate exclusion
![Page 60: What’s the Scoop on Expanding Neurologic · neurologic tests •High specificity testing •Low sensitivity testing ... •Failing tells you there is a non-specified neurologic](https://reader036.vdocuments.us/reader036/viewer/2022071011/5fc9ac5f6c6d8746bc1e8a82/html5/thumbnails/60.jpg)
Steps for an “expanded” neurologic assessment1. Perform stroke scale2. Visual acuity3. Eye movement4. Peripheral vision5. Fingers then nose6. Pupil reactions7. Facial sensation8. Raise eyebrows
Expanded Neurologic Assessment
![Page 61: What’s the Scoop on Expanding Neurologic · neurologic tests •High specificity testing •Low sensitivity testing ... •Failing tells you there is a non-specified neurologic](https://reader036.vdocuments.us/reader036/viewer/2022071011/5fc9ac5f6c6d8746bc1e8a82/html5/thumbnails/61.jpg)
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
Expanded Neurologic Assessment
• Thumbs creating resistance on eyebrows
![Page 62: What’s the Scoop on Expanding Neurologic · neurologic tests •High specificity testing •Low sensitivity testing ... •Failing tells you there is a non-specified neurologic](https://reader036.vdocuments.us/reader036/viewer/2022071011/5fc9ac5f6c6d8746bc1e8a82/html5/thumbnails/62.jpg)
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
Expanded Neurologic Assessment
![Page 63: What’s the Scoop on Expanding Neurologic · neurologic tests •High specificity testing •Low sensitivity testing ... •Failing tells you there is a non-specified neurologic](https://reader036.vdocuments.us/reader036/viewer/2022071011/5fc9ac5f6c6d8746bc1e8a82/html5/thumbnails/63.jpg)
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
Expanded Neurologic Assessment
![Page 64: What’s the Scoop on Expanding Neurologic · neurologic tests •High specificity testing •Low sensitivity testing ... •Failing tells you there is a non-specified neurologic](https://reader036.vdocuments.us/reader036/viewer/2022071011/5fc9ac5f6c6d8746bc1e8a82/html5/thumbnails/64.jpg)
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
Expanded Neurologic Assessment
12. Tongue out
![Page 65: What’s the Scoop on Expanding Neurologic · neurologic tests •High specificity testing •Low sensitivity testing ... •Failing tells you there is a non-specified neurologic](https://reader036.vdocuments.us/reader036/viewer/2022071011/5fc9ac5f6c6d8746bc1e8a82/html5/thumbnails/65.jpg)
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
Expanded Neurologic Assessment
12. Tongue out13. Tongue to roof of
mouth
![Page 66: What’s the Scoop on Expanding Neurologic · neurologic tests •High specificity testing •Low sensitivity testing ... •Failing tells you there is a non-specified neurologic](https://reader036.vdocuments.us/reader036/viewer/2022071011/5fc9ac5f6c6d8746bc1e8a82/html5/thumbnails/66.jpg)
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
Expanded Neurologic Assessment
12. Tongue out13. Tongue to roof of
mouth14. Say “ahh…”
![Page 67: What’s the Scoop on Expanding Neurologic · neurologic tests •High specificity testing •Low sensitivity testing ... •Failing tells you there is a non-specified neurologic](https://reader036.vdocuments.us/reader036/viewer/2022071011/5fc9ac5f6c6d8746bc1e8a82/html5/thumbnails/67.jpg)
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
Expanded Neurologic Assessment
12. Tongue out13. Tongue to roof of
mouth14. Say “Ahh…”15. Swallow
![Page 68: What’s the Scoop on Expanding Neurologic · neurologic tests •High specificity testing •Low sensitivity testing ... •Failing tells you there is a non-specified neurologic](https://reader036.vdocuments.us/reader036/viewer/2022071011/5fc9ac5f6c6d8746bc1e8a82/html5/thumbnails/68.jpg)
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
Expanded Neurologic Assessment
12. Tongue out13. Tongue to roof of
mouth14. Say “Ahh…”15. Swallow16. Bilateral hearing
• Speak into right ear while distracting left ear
• Speak into left ear while distracting right ear
![Page 69: What’s the Scoop on Expanding Neurologic · neurologic tests •High specificity testing •Low sensitivity testing ... •Failing tells you there is a non-specified neurologic](https://reader036.vdocuments.us/reader036/viewer/2022071011/5fc9ac5f6c6d8746bc1e8a82/html5/thumbnails/69.jpg)
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
Expanded Neurologic Assessment
12. Tongue out13. Tongue to roof of
mouth14. Say “Ahh…”15. Swallow16. Bilateral hearing17. Push/pull arms/legs
• Separately compare R
arm then L arm
• Separately compare R
knee then L knee
![Page 70: What’s the Scoop on Expanding Neurologic · neurologic tests •High specificity testing •Low sensitivity testing ... •Failing tells you there is a non-specified neurologic](https://reader036.vdocuments.us/reader036/viewer/2022071011/5fc9ac5f6c6d8746bc1e8a82/html5/thumbnails/70.jpg)
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
Expanded Neurologic Assessment
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
![Page 71: What’s the Scoop on Expanding Neurologic · neurologic tests •High specificity testing •Low sensitivity testing ... •Failing tells you there is a non-specified neurologic](https://reader036.vdocuments.us/reader036/viewer/2022071011/5fc9ac5f6c6d8746bc1e8a82/html5/thumbnails/71.jpg)
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
Expanded Neurologic Assessment
13. Tongue to roof of mouth
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 assessment
![Page 72: What’s the Scoop on Expanding Neurologic · neurologic tests •High specificity testing •Low sensitivity testing ... •Failing tells you there is a non-specified neurologic](https://reader036.vdocuments.us/reader036/viewer/2022071011/5fc9ac5f6c6d8746bc1e8a82/html5/thumbnails/72.jpg)
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
Expanded Neurologic Assessment
13. Tongue to roof of mouth
14. Say “Ahh…”15. Swallow16. Bilateral hearing17. Push/pull arms/legs18. Shoulders & Head19. Heel to shins20. Heels to toes
![Page 73: What’s the Scoop on Expanding Neurologic · neurologic tests •High specificity testing •Low sensitivity testing ... •Failing tells you there is a non-specified neurologic](https://reader036.vdocuments.us/reader036/viewer/2022071011/5fc9ac5f6c6d8746bc1e8a82/html5/thumbnails/73.jpg)
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
Expanded Neurologic Assessment
13. Tongue to roof of mouth
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
![Page 74: What’s the Scoop on Expanding Neurologic · neurologic tests •High specificity testing •Low sensitivity testing ... •Failing tells you there is a non-specified neurologic](https://reader036.vdocuments.us/reader036/viewer/2022071011/5fc9ac5f6c6d8746bc1e8a82/html5/thumbnails/74.jpg)
Expanded Neurologic
Assessment
• Switch roles and start back at the beginning…
![Page 75: What’s the Scoop on Expanding Neurologic · neurologic tests •High specificity testing •Low sensitivity testing ... •Failing tells you there is a non-specified neurologic](https://reader036.vdocuments.us/reader036/viewer/2022071011/5fc9ac5f6c6d8746bc1e8a82/html5/thumbnails/75.jpg)
• Smile
• Arms out palms
facing up with eyes
closed and hold for
at least 10 seconds
• “You can’t teach an
old dog new tricks.”
Steps for an “expanded” neurologic assessment1. Perform stroke scale
Expanded Neurologic Assessment
![Page 76: What’s the Scoop on Expanding Neurologic · neurologic tests •High specificity testing •Low sensitivity testing ... •Failing tells you there is a non-specified neurologic](https://reader036.vdocuments.us/reader036/viewer/2022071011/5fc9ac5f6c6d8746bc1e8a82/html5/thumbnails/76.jpg)
Steps for an “expanded” neurologic assessment1. Perform stroke scale2. Visual acuity
• Have the patient
read some text.
• Count fingers if you
suspect illiteracy.
Expanded Neurologic Assessment
![Page 77: What’s the Scoop on Expanding Neurologic · neurologic tests •High specificity testing •Low sensitivity testing ... •Failing tells you there is a non-specified neurologic](https://reader036.vdocuments.us/reader036/viewer/2022071011/5fc9ac5f6c6d8746bc1e8a82/html5/thumbnails/77.jpg)
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
• Back to center…
• Inward then outward
Expanded Neurologic Assessment
![Page 78: What’s the Scoop on Expanding Neurologic · neurologic tests •High specificity testing •Low sensitivity testing ... •Failing tells you there is a non-specified neurologic](https://reader036.vdocuments.us/reader036/viewer/2022071011/5fc9ac5f6c6d8746bc1e8a82/html5/thumbnails/78.jpg)
Steps for an “expanded” neurologic assessment1. Perform stroke scale2. Visual acuity3. Eye movement4. Peripheral vision
• Independent right perspective
• Independent left perspective
• Simultaneous bilateral perspectives
Expanded Neurologic Assessment
![Page 79: What’s the Scoop on Expanding Neurologic · neurologic tests •High specificity testing •Low sensitivity testing ... •Failing tells you there is a non-specified neurologic](https://reader036.vdocuments.us/reader036/viewer/2022071011/5fc9ac5f6c6d8746bc1e8a82/html5/thumbnails/79.jpg)
Steps for an “expanded” neurologic assessment1. Perform stroke scale2. Visual acuity3. Eye movement4. Peripheral vision5. Fingers then nose
Expanded Neurologic Assessment
• 2 different locations on right
• 2 different locations on left
![Page 80: What’s the Scoop on Expanding Neurologic · neurologic tests •High specificity testing •Low sensitivity testing ... •Failing tells you there is a non-specified neurologic](https://reader036.vdocuments.us/reader036/viewer/2022071011/5fc9ac5f6c6d8746bc1e8a82/html5/thumbnails/80.jpg)
Steps for an “expanded” neurologic assessment1. Perform stroke scale2. Visual acuity3. Eye movement4. Peripheral vision5. Fingers then nose6. Pupil reactions
Expanded Neurologic Assessment
• Direct R pupil reaction
• L pupil accommodation
• Direct L pupil reaction
• R pupil accommodation
![Page 81: What’s the Scoop on Expanding Neurologic · neurologic tests •High specificity testing •Low sensitivity testing ... •Failing tells you there is a non-specified neurologic](https://reader036.vdocuments.us/reader036/viewer/2022071011/5fc9ac5f6c6d8746bc1e8a82/html5/thumbnails/81.jpg)
Steps for an “expanded” neurologic assessment1. Perform stroke scale2. Visual acuity3. Eye movement4. Peripheral vision5. Fingers then nose6. Pupil reactions7. Facial sensation
Expanded Neurologic Assessment
• Bilateral forehead, zygoma, chin and
mandible
• Repeat with a deliberate exclusion
![Page 82: What’s the Scoop on Expanding Neurologic · neurologic tests •High specificity testing •Low sensitivity testing ... •Failing tells you there is a non-specified neurologic](https://reader036.vdocuments.us/reader036/viewer/2022071011/5fc9ac5f6c6d8746bc1e8a82/html5/thumbnails/82.jpg)
Steps for an “expanded” neurologic assessment1. Perform stroke scale2. Visual acuity3. Eye movement4. Peripheral vision5. Fingers then nose6. Pupil reactions7. Facial sensation8. Raise eyebrows
Expanded Neurologic Assessment
![Page 83: What’s the Scoop on Expanding Neurologic · neurologic tests •High specificity testing •Low sensitivity testing ... •Failing tells you there is a non-specified neurologic](https://reader036.vdocuments.us/reader036/viewer/2022071011/5fc9ac5f6c6d8746bc1e8a82/html5/thumbnails/83.jpg)
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
Expanded Neurologic Assessment
• Thumbs creating resistance on eyebrows
![Page 84: What’s the Scoop on Expanding Neurologic · neurologic tests •High specificity testing •Low sensitivity testing ... •Failing tells you there is a non-specified neurologic](https://reader036.vdocuments.us/reader036/viewer/2022071011/5fc9ac5f6c6d8746bc1e8a82/html5/thumbnails/84.jpg)
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
Expanded Neurologic Assessment
![Page 85: What’s the Scoop on Expanding Neurologic · neurologic tests •High specificity testing •Low sensitivity testing ... •Failing tells you there is a non-specified neurologic](https://reader036.vdocuments.us/reader036/viewer/2022071011/5fc9ac5f6c6d8746bc1e8a82/html5/thumbnails/85.jpg)
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
Expanded Neurologic Assessment
![Page 86: What’s the Scoop on Expanding Neurologic · neurologic tests •High specificity testing •Low sensitivity testing ... •Failing tells you there is a non-specified neurologic](https://reader036.vdocuments.us/reader036/viewer/2022071011/5fc9ac5f6c6d8746bc1e8a82/html5/thumbnails/86.jpg)
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
Expanded Neurologic Assessment
12. Tongue out
![Page 87: What’s the Scoop on Expanding Neurologic · neurologic tests •High specificity testing •Low sensitivity testing ... •Failing tells you there is a non-specified neurologic](https://reader036.vdocuments.us/reader036/viewer/2022071011/5fc9ac5f6c6d8746bc1e8a82/html5/thumbnails/87.jpg)
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
Expanded Neurologic Assessment
12. Tongue out13. Tongue to roof of
mouth
![Page 88: What’s the Scoop on Expanding Neurologic · neurologic tests •High specificity testing •Low sensitivity testing ... •Failing tells you there is a non-specified neurologic](https://reader036.vdocuments.us/reader036/viewer/2022071011/5fc9ac5f6c6d8746bc1e8a82/html5/thumbnails/88.jpg)
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
Expanded Neurologic Assessment
12. Tongue out13. Tongue to roof of
mouth14. Say “ahh…”
![Page 89: What’s the Scoop on Expanding Neurologic · neurologic tests •High specificity testing •Low sensitivity testing ... •Failing tells you there is a non-specified neurologic](https://reader036.vdocuments.us/reader036/viewer/2022071011/5fc9ac5f6c6d8746bc1e8a82/html5/thumbnails/89.jpg)
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
Expanded Neurologic Assessment
12. Tongue out13. Tongue to roof of
mouth14. Say “Ahh…”15. Swallow
![Page 90: What’s the Scoop on Expanding Neurologic · neurologic tests •High specificity testing •Low sensitivity testing ... •Failing tells you there is a non-specified neurologic](https://reader036.vdocuments.us/reader036/viewer/2022071011/5fc9ac5f6c6d8746bc1e8a82/html5/thumbnails/90.jpg)
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
Expanded Neurologic Assessment
12. Tongue out13. Tongue to roof of
mouth14. Say “Ahh…”15. Swallow16. Bilateral hearing
• Speak into right ear while distracting left ear
• Speak into left ear while distracting right ear
![Page 91: What’s the Scoop on Expanding Neurologic · neurologic tests •High specificity testing •Low sensitivity testing ... •Failing tells you there is a non-specified neurologic](https://reader036.vdocuments.us/reader036/viewer/2022071011/5fc9ac5f6c6d8746bc1e8a82/html5/thumbnails/91.jpg)
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
Expanded Neurologic Assessment
12. Tongue out13. Tongue to roof of
mouth14. Say “Ahh…”15. Swallow16. Bilateral hearing17. Push/pull arms/legs
• Separately compare R
arm then L arm
• Separately compare R
knee then L knee
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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
Expanded Neurologic Assessment
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
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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
Expanded Neurologic Assessment
13. Tongue to roof of mouth
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 assessment
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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
Expanded Neurologic Assessment
13. Tongue to roof of mouth
14. Say “Ahh…”15. Swallow16. Bilateral hearing17. Push/pull arms/legs18. Shoulders & Head19. Heel to shins20. Heels to toes
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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
Expanded Neurologic Assessment
13. Tongue to roof of mouth
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
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Expanded Neurologic Assessment
What type of patient complaints might it
be beneficial to acquire this amount of
information?
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Expanded Neurologic Assessment
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…
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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
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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
neurologic assessment.
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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.
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Bob Matoba, M.Ed., EMT-P
Lead Instructor St. Anthony
Paramedic Academy
303-358-7640