Stroke Assessment Techniques and Observations

Assessment of Facial Asymmetry

  • Observation of facial asymmetry

    • Begin by assessing the person's face at rest.

    • Identify clear facial droops easily.

    • Subtle differences may require further examination.

    • One measure includes examining the nasolabial fold.

    • Key observation: Flattening of the nasolabial fold can indicate weakness.

  • Testing method:

    • Instruct patients, "Show me your teeth" instead of just "smile."

    • Reason: Lifting the nasolabial fold to show teeth can reveal subtle asymmetries not observed in a resting smile or faint smile.

    • This helps identify subtle deficits that might be associated with conditions like strokes.

Arm Weakness Assessment

  • Cincinnati Stroke Scale method

    • Patients are asked to hold both arms up for a duration of 10 seconds to observe weakness.

    • During assessment, the examiner counts to 10 (1, 2, 3…10) for accuracy.

    • Key observation: If a patient's arm begins to drift before 10 seconds, this indicates potential subtle weakness.

  • NIH Stroke Scale Testing

    • When assessing legs, the count is reduced to 5 seconds due to core strength limitations.

    • Emphasize that each arm and leg needs to be held for the full duration to detect any inconsistencies in strength.

  • Note: If the patient exhibits less than full strength, repeat the test for clarity.

Speech Assessment

  • Terms Clarification

    • Dysarthria: Refers to slurred or blurred speech due to motor weakness affecting speech articulation.

    • Aphasia: A language deficit that affects the ability to produce or comprehend speech.

    • Aphasia Categories:

    • Expressive Aphasia: Difficulty in producing words; severe cases may present as complete muteness, often seen in major strokes.

      • Patients may show frustration during communication attempts, along with paraphrasing errors.

    • Receptive Aphasia: Difficulty in understanding spoken or written language.

      • Testing includes simple commands: "Lift your arm" or "Make a fist."

      • Successful completion may indicate absence of receptive aphasia.

Visual Assessment

  • Three components of visual assessment in strokes:

    • Vision

    • Nystagmus

    • Gaze

  • Vision Testing Protocol

    • Cover one eye and have the patient focus on the examiner's nose or a fixed point.

    • Assess if the patient can detect peripheral movement (wiggling fingers) or count the number of fingers shown.

    • Bilateral vs unilateral assessments can indicate where deficits lie.

  • Gaze Assessment

    • Gaze preference often indicates neglect of one side of the visual field (e.g., eyes may deviate toward the side of a stroke).

    • Forced gaze deviation will prompt eyes to fixate toward the affected side.

Coordination Assessment

  • Dysmetria

    • Definition: Inability to control the range of motion or distance in reaching.

    • Finger-to-nose test: Patient is instructed to touch their nose and then touch the examiner’s finger.

    • Significant errors while approaching indicates dysmetria, signaling a potential cerebellar issue.

    • Variants include examining both sides to identify unilateral issues flowing from focal deficits.

Gait Assessment

  • Initial observation

    • Assess balance by asking the patient to sit with arms crossed to evaluate truncal ataxia.

  • Additional gait assessment

    • Important for identifying posterior strokes, particularly in sudden onset dizziness or inability to walk.

    • Gait observations are essential as many strokes lead to severe balance and coordination problems yet miss assessments due to reliance on other neurological signs.

Neglect and Perceptual Issues

  • Neglect Assessment

    • Neglect refers to the inability to perceive stimuli from one side of the body, often linked to the opposite hemisphere stroke.

    • Severe neglect may result in an inability to recognize one’s limbs.

    • Testing for neglect by asking patients to identify limbs can be revealing. Neglect can hinder rehabilitation as individuals may not recognize their impairments.

Application in EMS and Clinical Practice

  • Utilizing assessments beyond the standard FAST protocol enhances identification of stroke patients.

    • BFAST Guidelines:

    • Balance (dysmetria, gait)

    • Eyes (vision, nystagmus, gaze)

    • Face, Arms, Speech (reiterates traditional assessment parameters)

  • Evidence-based guidelines indicate that thorough assessment leads to better identifying patients with minor strokes, whose deficits may not initially be recognized, optimizing outcomes and care effectiveness.

    • Important for EMS personnel to adopt and include thorough assessments in their protocols to improve diagnosis rates and timely interventions.