NREMT Neurological Emergencies & Stroke Care 2 — Questions and Answers
Question 1: A patient presents with sudden onset of facial droop, arm weakness, and slurred speech. Using the Cincinnati Prehospital Stroke Scale, which finding is NOT one of the three assessed?
- Facial droop
- Arm drift
- Speech
- Pupillary response (Correct answer)
Correct answer: Pupillary response
The Cincinnati Prehospital Stroke Scale assesses facial droop, arm drift, and speech. Pupillary response is not part of this specific tool.
The Cincinnati Prehospital Stroke Scale (CPSS) is a validated, easy-to-use tool for EMTs to rapidly identify potential stroke patients. It has three components: (1) Facial droop — ask the patient to show their teeth or smile and observe for asymmetry; (2) Arm drift — ask the patient to close their eyes and hold both arms out for 10 seconds, watching for one arm to drift downward; (3) Speech — ask the patient to repeat a simple phrase and note any slurring, wrong words, or inability to speak. If any one of the three findings is abnormal, the probability of stroke is approximately 72%. If all three are abnormal, the probability exceeds 85%. The scale's simplicity makes it ideal for rapid prehospital assessment when time is critical. Pupillary response, while important in neurological assessment generally, is not part of the CPSS. Pupillary findings can suggest brainstem involvement or herniation but are assessed separately. Once stroke is suspected using CPSS, EMTs should establish the time of symptom onset (or last known well), perform a blood glucose check, and transport rapidly to a stroke center. Time to treatment is critical — for ischemic stroke, every minute without treatment results in approximately 1.9 million neurons dying.
Question 2: A patient with a suspected stroke has a blood glucose reading of 45 mg/dL. The EMT's priority should be:
- Transport immediately to the stroke center without treating the hypoglycemia
- Administer oral glucose if the patient can swallow and is alert enough
- Wait for ALS backup before treating
- Perform the Cincinnati Stroke Scale and contact medical direction about glucose treatment (Correct answer)
Correct answer: Perform the Cincinnati Stroke Scale and contact medical direction about glucose treatment
Hypoglycemia can mimic stroke symptoms. The EMT should reassess using the CPSS after treating hypoglycemia, and contact medical direction since glucose administration protocols vary and stroke workup should continue.
Hypoglycemia is a common and potentially life-threatening mimic of stroke symptoms, capable of producing focal neurological deficits including hemiparesis, facial drooping, and altered speech. Blood glucose measurement is a critical part of the prehospital stroke assessment for this reason. When hypoglycemia is identified in a patient with stroke-like symptoms, the EMT should treat it appropriately (oral glucose if the patient is alert and can swallow, or follow protocols for administration of dextrose if ALS is available). After treatment, reassessment of neurological deficits should be performed — if the deficits resolve with glucose correction, the diagnosis may be hypoglycemia rather than stroke. However, even if symptoms improve, the EMT should continue to transport the patient for evaluation, as hypoglycemia can occur concurrently with stroke. Medical direction should be contacted to guide management and confirm destination. If symptoms do not resolve after glucose correction, stroke remains the working diagnosis and the patient should be transported emergently to a stroke center capable of thrombolytic therapy or mechanical thrombectomy.
Question 3: What is the significance of establishing the 'last known well' time for a potential stroke patient?
- It determines whether the patient qualifies for pain medication
- It establishes the window for thrombolytic (tPA) therapy eligibility (Correct answer)
- It tells the receiving hospital when the patient last ate
- It determines how fast the EMT needs to drive to the hospital
Correct answer: It establishes the window for thrombolytic (tPA) therapy eligibility
The 'last known well' time determines whether a patient is within the therapeutic window for tPA (typically 3-4.5 hours from onset), making it one of the most critical pieces of prehospital information.
The 'last known well' time — the last time the patient was observed to be at their neurological baseline — is arguably the most critical piece of information the EMT can obtain for a potential stroke patient. This is because the primary treatment for ischemic stroke, tissue plasminogen activator (tPA), has strict time-based eligibility criteria. Current guidelines allow tPA administration within 3 to 4.5 hours of symptom onset for eligible patients. Beyond this window, the risk of hemorrhagic transformation from thrombolysis outweighs the potential benefit. When a patient wakes up with stroke symptoms, the last known well time is when they went to sleep — not when they were found — which often means they are outside the tPA window. Mechanical thrombectomy (endovascular clot removal) has a longer treatment window, potentially up to 24 hours from last known well in select patients. Knowing the exact time helps interventionalists determine eligibility. EMTs should ask witnesses, family members, or review any available surveillance or phone records to establish the most accurate last known well time. This information must be communicated clearly and documented in the PCR.
Question 4: A patient has a seizure that lasts 3 minutes and then stops. Upon your arrival, the patient is confused and difficult to arouse. This postictal state typically:
- Indicates the patient has had a stroke
- Is a normal period of altered consciousness following a seizure that usually resolves over minutes to hours (Correct answer)
- Means the patient needs immediate CPR
- Suggests the patient is faking symptoms
Correct answer: Is a normal period of altered consciousness following a seizure that usually resolves over minutes to hours
The postictal state is a normal period of neurological depression following a seizure, characterized by confusion, drowsiness, and altered consciousness that gradually improves.
The postictal state is a period of neurological recovery that follows a seizure. During this phase, the brain is in a state of metabolic exhaustion, and patients typically present with confusion, disorientation, extreme fatigue, headache, and sometimes temporary focal neurological deficits (called Todd's paralysis) that can mimic stroke. This period can last anywhere from a few minutes to several hours, depending on the duration and type of seizure. EMTs must be careful not to confuse the postictal state with other serious conditions. Todd's paralysis — temporary focal weakness following a seizure — can look exactly like a stroke but resolves as the postictal state clears. The key distinguishing factor is a witnessed seizure prior to the neurological findings. Despite being a normal physiological phenomenon, the postictal state still warrants transport and evaluation for several reasons: the underlying cause of the seizure must be determined, status epilepticus (continuous or rapidly recurring seizures) must be ruled out, and conditions that can trigger seizures (such as hypoglycemia, hyponatremia, or intracerebral hemorrhage) require treatment. During transport, maintain airway, administer supplemental oxygen, monitor vitals, and reassess neurological status frequently.
Question 5: Which of the following is the priority intervention for a patient actively seizing?
- Insert an oral airway to prevent tongue swallowing
- Protect the patient from injury and maintain airway patency (Correct answer)
- Restrain the patient's extremities to prevent injury
- Administer high-flow oxygen via non-rebreather mask immediately
Correct answer: Protect the patient from injury and maintain airway patency
The priority for a seizing patient is protecting them from injury and managing the airway. Hard restraints can cause fractures and should not be used on seizing patients.
Management of an actively seizing patient centers on two priorities: preventing injury and maintaining airway patency. Patients cannot swallow their tongues during a seizure — this is a common myth — but they can bite the lateral tongue, hypersalivate, and obstruct the airway with secretions. Attempting to insert an oral airway or anything else in the mouth of a seizing patient is dangerous and can result in injury to the patient or the EMT. Physical restraint of the extremities is contraindicated during active seizure because the forces generated by the patient's muscles can cause fractures, dislocations, and soft tissue injuries. Instead, the EMT should move dangerous objects away from the patient, protect the head with a folded jacket or blanket, place the patient in a lateral recumbent position if possible (to facilitate drainage of secretions), and maintain close observation of the airway. Once the seizure terminates, suction secretions, apply supplemental oxygen, perform a thorough assessment including blood glucose, and prepare for transport. If the seizure continues beyond 5 minutes or the patient has multiple seizures without regaining consciousness, this is status epilepticus — a medical emergency requiring advanced interventions and urgent transport. Contact medical direction and ALS backup early in this scenario.
Question 6: A patient complains of the 'worst headache of my life' with sudden onset. This presentation should increase the EMT's suspicion for:
- Tension headache
- Migraine with aura
- Subarachnoid hemorrhage (Correct answer)
- Cluster headache
Correct answer: Subarachnoid hemorrhage
A sudden, severe 'thunderclap' headache described as the worst of one's life is the classic presentation of subarachnoid hemorrhage (SAH), a life-threatening emergency caused by bleeding into the space around the brain.
The classic description of a subarachnoid hemorrhage (SAH) is a thunderclap headache — a headache that reaches maximum intensity within seconds and is described by patients as 'the worst headache of my life.' This occurs when blood enters the subarachnoid space (between the brain and the arachnoid membrane), typically from a ruptured cerebral aneurysm. The sudden stretching of the meninges causes intense, immediate pain. SAH is a true neurological emergency with high mortality — approximately 30% of patients die within the first 24 hours, and up to 45% die within the first 30 days. Survivors frequently have significant neurological deficits. EMTs should maintain a high index of suspicion for SAH when a patient presents with a sudden-onset, severe headache, especially if accompanied by neck stiffness (meningismus), nausea, vomiting, photophobia, or loss of consciousness. In the prehospital setting, treatment is supportive: maintain airway, administer oxygen, establish IV access if trained, and transport urgently to a facility capable of CT scanning and neurosurgical intervention. Blood pressure management may be important but should follow medical direction guidance. Pre-notify the receiving facility early so that CT scanning can be expedited upon arrival.
NREMT Neurological Emergencies & Stroke Care 2
A patient presents with sudden onset of facial droop, arm weakness, and slurred speech.
Using the Cincinnati Prehospital Stroke Scale, which finding is NOT one of the three assessed?