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IntroductionThirteen years ago, in the Spring

2003 issue of The Gold Cross, our CEUarticle was on the topic of strokes.Written by Charles Prestigiacomo,MD, that article was one of the mostcomprehensive that has everappeared in this publication. In fact,for the EMT who wishes to obtain amore thorough understanding of theepidemiology and physiology of“brain attacks,” we’ve converted theentire article into a PDF documentand made it available on our website:www.leopub.com.

Some of the material contained inDr. Prestigiacomo’s article alsoappears in this one, but our focushere will be slightly different. Ratherthan examining the brain and itsstructures, divisions and functions,we will look at the stroke patientsEMTs are likely to encounter in thefield: who they are and the signs andsymptoms they present.

Strokes are common – on average,someone in the United States has astroke every 4 0 seconds – yet the

typical EMS team responds to onlyfour to ten stroke patients per year. Ithas been estimated that emergencypersonnel forget about one-half ofthe stroke care instructions by 12months after a training session. Also,because the availability of acutestroke care, and the recommendedprehospital assessment and care pro-tocols, are continually updated, EMTsshould refamiliarize themselves onstroke care basics as frequently astwice a year. This article will coverthose basics.

But first, let’s update a few statisticson strokes:

Rate Down, Total Incidents UpAs Dr. Prestigiacomo noted in his

2003 article and an accompanyingsidebar, the treatment of cerebrovas-cular accidents (CVAs) was evolvingrapidly. What had been consideredthroughout history to be an untreat-able “stroke” of God’s hand (hence thename), was in the 21st Century beingtreated rapidly, aggressively and effec-tively. As a result of these treatments

and a few other factors, CVAs havegone from being America’s third-leading cause of death in 2003, to fifthplace as of 2014 – behind heartdisease, cancer, respiratory diseasesand accidents. (Figure 1).

At the same time that CVA fatalitieshave been declining, so has the overallrate of stroke occurrences. Studiesshow that, thanks to an increased use

of medications that attenuate strokerisk, the incidence of strokes hasdecreased over the past few decades.Control of diabetes mellitus and highcholesterol and smoking cessationprograms, particularly in combina-tion with hypertension treatment,also appear to have contributed to thedecline in stroke mortality.

Recognizing And Reacting To Strokes (CVAs) And TIAs

by Pat Leonardby Pat Leonard

The Gold Cross CONTINUING EDUCATION SERIESThe Gold Cross CONTINUING EDUCATION SERIES

Strokes (CVAs) have gonefrom being America’sthird-leading cause ofdeath in 2003 to fifth

place as of 2014.

Strokes (CVAs) have gonefrom being America’sthird-leading cause ofdeath in 2003 to fifth

place as of 2014.

After reading this article, the EMT willbe able to:

• list the types of patients who are mostat risk of having a stroke (CVA);

• recognize the signs and symptoms ofstroke;

• list the various types of strokes andconditions that might mimic them;

• explain how to assess, manage andtransport the stroke patient.

After reading this article, the EMT willbe able to:

• list the types of patients who are mostat risk of having a stroke (CVA);

• recognize the signs and symptoms ofstroke;

• list the various types of strokes andconditions that might mimic them;

• explain how to assess, manage andtransport the stroke patient.

EMT ObjectivesEMT Objectives

Annual Deaths in U.S., by Cause(Expressed in thousands; data for 2014. Source: CDC)

614 592

147 136 13394 76 55 48 43

HeartDisease

Cancer ChronicLower

RespiratoryDiseases

Accidents CVAs(Strokes)

Alzheimer’sDisease

Diabetes Influenza&

Pneumonia

Nephritis,Nephrosis

Suicide

Figure 1:

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That’s the good news. The bad newsis that these decreases have not beenuniformly distributed across all ageand ethnic groups. Stroke rates havedeclined for whites, but not forblacks. (Figure 3) And while ischemicstroke rates have declined signifi-cantly in people aged 60 and over,they have remained largelyunchanged in those aged 45 to 59.Also, through age 75, women gener-ally have lower incidence rates thanmen (Figure 2), but more women thanmen actually die of stroke each yearbecause of the larger number ofelderly women. Women accountedfor 58% of US stroke deaths in 2013.

Nor is the incidence of strokesevenly distributed nationwide.Residents of southeastern states havea considerably higher incidence ofstrokes and stroke fatalities than thenation at large (Figure 4, next page). (As awhole, New Jersey has a lower-than-average incidence rate, except for thesouthwestern counties of Cumber-land, Gloucester and Salem.)

Furthermore, as the average age of

the population increases, the totalnumber of incidents will go up – evenas the incident rate stabilizes ordeclines. Projections show that by2030, an additional 3.4 million peopleaged 18 and over will have had astroke, a 20.5% increase in prevalencefrom 2012. The highest increase (29%)is projected to be in Hispanic men.

Types of Stroke There are two major types of stroke:

ischemic and hemorrhagic. • Ischemia is a local decrease in

blood supply due to mechanicalmeans such as a narrowed or pluggedartery. Most often this is caused by abuild-up of plaque in the arteries, awell-known condition called ather-

sclerosis. (Photo 1) The cells within thearea become ischemic, or oxygen-starved. If the condition is notreversed, the cells infarct, or die.

A cerebrovascular accident occurswhen a blood vessel in the brainbecomes obstructed by a clot (throm-bus) which may have formed in a nar-rowed artery or may have originatedin a different site and traveledthrough the blood stream to thevessels of the brain. Once obstructed,the area of brain cells becomesischemic, and if the condition is notreversed, infarcts. (Figure 5, next page)

A clot that originates at one site andtravels to another is called anembolus. (Plural: emboli) Emboli canbe fat globules, air bubbles or mostcommonly, bits and pieces ofatherosclerotic plaque such as lipiddebris that have detached from a dis-eased carotid artery or elsewhere. Thebloodstream moves the embolus toanother site, such as a pulmonaryartery or the brain where it becomes

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Women have lower incidence rates of stroke,

but more women thanmen actually die of strokedue to the larger number

of elderly women.

Women have lower incidence rates of stroke,

but more women thanmen actually die of strokedue to the larger number

of elderly women.

-continues on page 10

Incidence of CVA/TIA, by Sex & Race(Per 1000 person years; data for 1987-2001. Source: National Heart, Lung and Blood Institute)

White Men

White Women

Black Men

Black Women

2.4 2.4

9.7

7.26.1

4.8

13.1

10.0

12.2

9.9

16.215.0

Ages 45 to 54 Ages 55 to 64 Ages 65 to 74

Figure 3:

Photo 1 - Athersclerosis

Death Rates for Stroke, by Sex & Race/Ethnicity(Per 100,000; data for 2013. Source: National Center for Health Statistics and National Heart, Lung and Blood Institute)

Whites Blacks Hispanics

Males

Females

34.9 34.5

55.645.9

31.827.6

Figure 2:

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lodged. Patients with a cardiac condi-tion called atrial fibrillation candevelop clots within the heart’satrium which then break off andembolize into the cerebral circula-tion. Other patients at risk of develop-ing thrombi and possible CVAinclude women who take birthcontrol pills which makes the bloodmore prone to form clots. (For a list ofindividuals at risk for a stroke, see Figure 6.)

For stroke management, “time lostis brain lost.” After an ischemic stroke,the amount of irreversible damageincreases steadily as long as brainregions remain without sufficientblood supply. In those parts of the

affected region that have no bloodflow, neurons begin to die in less thanten minutes. In those areas with lessthan 30% of normal blood flow,neurons begin to die within an hour.In those areas with 30–40% of normalblood flow, some neurons begin todie within an hour, but others can berevived for many hours.

• Hemorrhagic CVA occurs whenthere is a sudden rupture of a bloodvessel in the brain. This may becaused by the effects of severe hyper-tension or drug use (e.g., cocaine),which results in bleeding within thebrain. Hemorrhage may also be theresult of a ruptured aneurysm, or atear of a weakness along a wall of anartery supplying the brain.

Ischemic CVAs occur far more fre-quently than hemorrhagic CVAs

(roughly 85% of strokes are ischemic),but hemorrhagic CVAs are usuallymore deadly. One recent studyshowed that the mortality rate after astroke (both types) was 10.5% at 30days, 21.2% at one year, 39.8% at five

years, and 58.4% at the end of follow-up. Mortality rates after a hemor-rhagic stroke were 67.9%; after anischemic stroke the mortality rateswere 57.4%.

Although it is not your job as an

CEU Article: Recognizing Strokes-continued from page 9

Ischemic CVAs occur farmore frequently than

hemorrhagic CVAs, buthemorrhagic CVAs areusually more deadly.

Ischemic CVAs occur farmore frequently than

hemorrhagic CVAs, buthemorrhagic CVAs areusually more deadly.

Figure 4:

Figure 5:

Figure 6:

An ischemic cerebrovascular accident (CVA) occurs when blood circulation to an area of the brain is blocked (left enlargement)and vital brain tissue dies due to lack of oxygen and nutrients. The sensitive cells of the brain are permanently damaged afteronly four to five minutes without oxygen and glucose. When an area of the brain is deprived of these nutrients, that portion of thebrain dies (right illustration) and the function it provided is altered.

Risk Factors For StrokeRisk Factors For Stroke

In addition to the factors of race andsex illustrated in Figures 2 and 3, indi-viduals with the following conditionsand/or lifestyle choices are at greaterrisk of suffering a CVA or TIA:

• High blood pressure• Diabetes• Heart rhythm disorders (especially

atrial fibrillation)• High cholesterol• Smoking/tobacco use• Physical inactivity• Family history of strokes• Chronic kidney disease• Previous CVA or TIA• Women on birth control and/or

with a history of migraines

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EMT to distinguish between types ofstroke in the prehospital field, it isimperative that you recognize signsand symptoms of stroke, understand aCVA may be in progress and takeimmediate steps to maximize thefunctional outcome of the patient.

Signs & Symptoms of StrokeEMTs cannot assume that victims

know how to recognize potentialstrokes. A survey by the AmericanHeart Association found that only55% of patients who have already had astroke could identify even one strokewarning sign.

Stroke symptoms depend on thearea of the brain that is affected,which is most often the middle cere-bral artery or one of its branches.Symptoms can include: numbness,weakness or paralysis on one side ofthe body (usually contralateral hemi-plegia) or face; confusion, difficultyspeaking or writing, or difficultyunderstanding, difficulty seeingand/or visual field defects; gait devia-tions. (Figure 7; also see Photo 2, next page)

Unlike an ischemic stroke, hemor-rhagic strokes can present with asudden onset of severe (“thunder-clap”) headache. During assessment, apatient may report “the worst head-ache” of his life. The sudden increasein blood volume within the rigid skullcauses a rapid increase in intracranialpressure which may result in a loss ofconsciousness, or even death.

Transient Ischemic Attack At times, symptoms of CVA occur

and disappear within 24 hours ofonset. The EMT is dispatched for“possible CVA” and arrives to discoverthe patient speaking and movingabout normally. This situation,though not a CVA per se, represents atemporary obstruction of blood flowthrough a narrowed vessel, thus a rel-atively mild period of hypoxia to apart of the brain. The temporary con-dition is aptly termed a transient (or“passing”) ischemic attack (TIA).Patients may sometimes describe a“veil” or “window shade” partly cov-ering the vision of one eye whichresolves spontaneously after severalminutes. This in fact represents thetemporary blockage, or occlusion, ofthe retinal artery to the eye by anembolus. There may also be dizzi-

ness, imbalance and generalizedweakness. Patients experiencing newonset or recurrent TIAs need medicalevaluation urgently as left untreated,the condition may result in a CVA.

Evaluation And ManagementRecognizing a stroke may be diffi-

cult. As an EMT, you need to evaluateclues from the patient, family/wit-nesses and the surrounding environ-ment. Note that many other diseaseprocesses may mimic stroke, such as

tumors, infections (meningitis), headinjury and hypoglycemia. It is notyour role, however, to distinguishbetween the many things that canmimic stroke. Rather, you must recog-nize the possibility that a CVA is inprogress and then provide the neces-sary in-field supportive treatment andrapid transportation to a facility thatcan effectively treat acute stroke. (Seelist, page 15) In New Jersey, advancedlife support (ALS) is usually dis-patched for suspected CVA.

• Assessing the Scene : Try toextract as much information from thescene as possible, especially if thepatient is unable to communicatewith you and no witnesses to the

CEU Article: Recognizing Stroke-continued from page 10

Numbness, weakness orparalysis on one side ofthe body are all signs ofstroke. So is a persistentgaze to one side or other.

Numbness, weakness orparalysis on one side ofthe body are all signs ofstroke. So is a persistentgaze to one side or other.

SUDDEN:

numbness orweakness of

face, arm or leg,especially on oneside of the body

confusion, trouble

speaking orunderstanding

troubleseeing in

one orboth eyes

trouble walking,

dizziness, loss of balanceor coordination

severe headache

with noknown cause

Figure 7:

• In Memory Of Our Fellow Squad Members •• In Memory Of Our Fellow Squad Members •Cornelius Bryant YoungRamsey Ambulance Corps

Theresa J. TigheSea Isle Vol. Amb. Corps

Jim RivickiUpper Greenwood Lake VAC

Shirley SchenckUpper Twp. EMS

Lenny BaumJRW Oakland FAS

Andrea RaffettoSpring Lake First Aid Squad

Frank Pazienza Jr. Avon First Aid & Safety Sqd.

Margaret Babich Milton First Aid Squad

Bernie Shapiro Westfield Vol. Rescue Squad

Alyce Karbach Surf City VFC#1&EMS

Alan Harvey Point Boro First Aid

Thomas Hamburg Point Boro First Aid

Mort SchmerlingLine of Duty DeathUpper Twp. EMS

Steve LevineMarlboro FA&RS &Englishtown-Manalapan FA

Resolutions of Condol-ence have been adoptedby the EMSCNJ.

John TymonChair - EMSCNJ Pastoral Committee

event are present. Time ofonset of symptoms is veryimportant. Therefore,assess the scene for cluesas to when the event mayhave occurred.

• Initial Assessment: Attimes, the general impres-sion of the patient mayclearly suggest a stroke: Apatient who is not movinghis left arm and leg, and ispersistently looking to theright , must be quicklytriaged as a strong candi-date for CVA. Numbness,weakness or paralysis onone side of the body are allsigns of stroke. So is a per-sistent gaze to one side orthe other. After assessingthe mental status, obtainthe chief complaint , ifpossible. Ask the patient what iswrong. Pay particular attention to hisspeech pattern to determine if hiswords are slurred or incomprehensi-ble. Does what he says make sense?

While assessing the A-B-Cs, look

for possible airway obstructions suchas dentures, blood or saliva. If thereare snoring or gurgling respirations,be prepared to suction. When assess-ing for breathing, put a nonre-breather mask with 100% oxygen on

any patient with adepressed level ofresponsiveness. B eprepared to use posi-tive pressure ventila-tions (bag-valve-maskwith oxygen) if thepatient is breathinginadequately.

After assessing theA-B-Cs, quickly evalu-ate the consciouspatient for CVA byperforming the Cin-cinnati PrehospitalStroke Scale. (Figures 8& 9) This is a rapidmethod which withinseconds assesses thepatient’s facial mus-cles, arm movementand speech function.

• Ask the patient tosmile and show you his teeth. (Don’tjust ask for a smile; some people’snormal smile is asymmetrical. To showhis teeth requires a patient to stronglycontract facial muscles on both sides

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Photo 2: Signs of CVA include facial droop and asymmetrical arm drift.

-continues on page 14

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of the mouth. Weakness on one sideproduces a lopsided grin revealingmore upper teeth on the strongerside.) If you see a degree of facial asym-metry or lopsidedness, this is anabnormal finding.

• Ask the patient to close his eyesand hold out his arms. Again, if onearm drifts down or does not moveequally, the finding is abnormal.

• Ask the patient to repeat: “Youcan’t teach an old dog new tricks.”Abnormal findings include slurring ofwords (dysarthria), saying inappropri-ate words (dysphasia), or not speakingat all (aphasia).

Any abnormal findings on theCincinnati Prehospital Stroke Scaleshould make you aware that thepatient is probably having (or has had)a CVA and should be treated as a high

priority patient. Definitivetreatment critically dependsupon arriving at the hospi-tal within a short time ofonset . Complete thefocused history anddetailed physical exam enroute.

• SAMPLE History:When obtaining a completeSAMPLE history, you needto identify certain parame-ters either from the patient,witnesses or family. It is vitalto note the time signs andsymptoms began. If therewere no witnesses at thetime of onset, find out whothe last person was to seethe patient without symp-toms and determine whenthat was. Carefully docu-ment this time as it coulddetermine if a patient canbe treated with currentintravenous or intraarterialtherapies.

It is also important to note if thepatient had headaches or seizuresassociated with the onset of symptoms.The presence of headache or seizure

activity is usually associated with hem-orrhagic CVA.

A list of the patient’s medications isvery important in this situation as itcan provide further clues to assist inthe diagnosis. If the patient is on anti-coagulants (e.g., Coumadin® or Love-nox®) or antiplatelets (e.g., aspirin,Ecotrin®, Plavix®, Ticlid®), find out whyand how long the patient has takenthese meds. Though these meds havemany indications for use, includingTIAs, they may also result in intracra-nial hemorrhage. If the patient istaking such medications, determine ifthere has been recent trauma, sinceminor head trauma while taking thesemedications can result in potentiallylife-threatening intracranial hemor-rhages.

Obtaining a past medical historyshould include whether the patienthas a history of hypertension, priorCVA or TIA , diabetes, or coronary

CEU Article: Recognizing Stroke-continued from page 13

Figure 8:

Pocket Guide: NJDOH/OEMS has pub-lished reference cards for emergencyresponders who encounter a patientsuffering from a suspected stroke or (onthe flip side) a myocardial infarction. Torequest cards for your squad, contactTom Hendrickson at 609-633-7777.

Typical Age

Time Course

Upper Face

Lower Face

AssociatedSymptoms

20s-50s

Hours to a Few Days

Always Affected

Always Affected

Typically None(Rare facial numbness)

> 60

Seconds to Minutes

Usually Not Affected

Always Affected

Weakness, numbness, speech difficulty,slurred speech, double vision, facial

numbness, difficulty swallowing,vertical ataxia

Bell’s Palsy Acute Stroke

Typical Presentation of Bell’s Palsy and Acute Stroke

Is It A Stroke… or Bell’s Palsy?Is It A Stroke… or Bell’s Palsy?The two most common causes of acute facial paralysis are Bell’s palsy and ischemic

stroke. Bell’s palsy is a facial weakness that most often affects patients in their 20s-to-50s,and from which patients typically recover within six months. Because acute stroke is a time-critical illness, the distinction between stroke and Bell’s palsy must be made quickly to avoidunnecessary delays in treatment. As an EMT, your objective is not to make a diagnosis but torule out the possibility that your patient’s condition is caused by Bell’s palsy and nothingmore. The most effective way to do that is to look for associated signs and symptoms ofstroke: weakness/numbness in the arm or leg; slurred speech; double vision; difficulty swal-lowing; incoordination; vertigo. If the patient has any of these features present on exam, it’smost likely a stroke. If your patient’s symptoms developed over hours or days, and involvesupper and lower facial weakness only (i.e., otherwise normal), it’s most likely Bell’s palsy.

To show his teethrequires a patient

to strongly contractfacial muscles on both

sides of the mouth.

To show his teethrequires a patient

to strongly contractfacial muscles on both

sides of the mouth.

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artery disease. • Physical Examination: Careful

assessment of vital signs is importantin helping a physician to diagnose theproblem. For instance, a patient withleft-sided weakness and a blood pres-sure of 220/100 may have sustained ahypertensive intracerebral hemor-rhage and not an ischemic CVA. EMTsshould be aware that blood pressurewill sometimes be very high. (Whentaking a blood pressure of a possible

stroke patient, pump-up the cuff to atleast 200 mmHg before auscultating apressure.) The pulse will be boundingon palpation. Pupils may be unequalor unreactive.

A focused physical examination wasalready initiated with the use of theCincinnati Prehospital Stroke Scale.The presence or absence of a gazepreference is important to clinicians at

the receiving hospital. Stroke patients may not be able to

express themselves and/or may notunderstand what is happening aroundthem, or what you are saying or askingthem to do. Nonetheless, they may bequite aware that something is dread-fully wrong. At all times reassure thepatient and keep him as calm as possi-ble. Always explain what actions arebeing taken to help him.

• Transport: Once you haveassessed the patient and suspect hemight be having some type of CVA ,

transport him immedi-ately. Conscious patientsshould be placed onthe litter in a positionof comfort. (Protocolsdiffer on patient posi-tioning: some suggestlaying the patient flatto facilitate oxygenflow to the brain; somerecommend elevatingthe head 20 -30° toprotect against aspira-tion; still others recom-mend the lateral re-cumbent position. Useyour best judgment toevaluate each patient’scondition and act

accordingly.) Unconscious, unintu-bated (non-trauma) patients need tobe transported with an oropharyn-geal or nasopharyngeal airway inplace.

Although ALS should be dis-patched, do not delay transportwaiting on scene. Also, it is importantto alert the receiving hospital andprovide pertinent information so thatthe necessary personnel can be readyto quickly evaluate the patient and ini-tiate treatment, if necessary.

A past medical historyshould include any

history of hypertension,CVA or TIA, diabetes, orcoronary artery disease.

A past medical historyshould include any

history of hypertension,CVA or TIA, diabetes, orcoronary artery disease.

CEU Article: Recognizing Stroke-continued from page 14

New Jersey’s Acute Care Hospitals, by CountyNew Jersey’s Acute Care Hospitals, by CountyAtlantic CountyAtlanticare Reg. Medical Center - CityCampusAtlanticare Reg. Medical Center -Mainland CampusShore Medical Center

Bergen CountyEnglewood Hospital and Medical CenterHackensack University Medical CenterBergen Regional Medical CenterThe Valley HospitalHoly Name Medical CenterHackensack-UMC at Pascack Valley

Burlington CountyVirtua - West Jersey Hospital MarltonVirtua Memorial Hospital of BurlingtonCountyLourdes Medical Center of BurlingtonCounty

Camden CountyCooper Hospital University MedicalCenterOur Lady of Lourdes HospitalKennedy University Hospital - CherryHill DivisionKennedy University Hospital - StratfordDivisionVirtua - West Jersey Hospital Voorhees

Cape May CountyCape Regional Medical Center, Inc

Cumberland CountyInspira Medical Centers, Inc

Essex CountyClara Maass Medical CenterEast Orange General HospitalSaint Barnabas Medical CenterHackensack-UMC MountainsideUniversity HospitalNewark Beth Israel Medical CenterSaint Michael's Medical Center

Gloucester CountyKennedy University Hospital -Washington Twp DivisionInspira Medical Center Woodbury

Hudson CountyCarePoint Health - Bayonne MedicalCenterCarePoint Health - Hoboken UniversityMedical CenterCarepoint Health - Christ HospitalJersey City Medical CenterPalisades Medical CenterMeadowlands Hospital Medical Center

Hunterdon CountyHunterdon Medical Center

Mercer CountyRWJ University Hospital - HamiltonCapital Health Med. Center - HopewellCapital Health System at FuldSt. Francis Medical Center

Middlesex CountyAnthony M. Yelencsics CommunityHospitalRobert Wood Johnson UniversityHospitalSaint Peter's University HospitalRaritan Bay Medical Center - OldBridge DivisionRaritan Bay Medical Center - PerthAmboy DivisionUniversity Medical Center of Princetonat Plainsboro

Monmouth CountyCentraState Medical CenterBayshore Community HospitalMonmouth Medical CenterJersey Shore University Medical CenterRiverview Medical Center

Morris CountySaint Clare's Hospital/Denville CampusSaint Clare's Hospital/DoverMorristown Medical CenterChilton Medical Center

Ocean CountyOcean Medical CenterMonmouth Medical Center-SouthernCampusSouthern Ocean Medical CenterCommunity Medical Center

Passaic CountySt Mary's General HospitalSt. Joseph's Hospital and MedicalCenterSt. Joseph's Wayne Hospital

Salem CountyInspira Medical Center ElmerThe Memorial Hospital of Salem County

Somerset CountyRWJ University Hospital - Somerset

Sussex CountyNewton Medical Center

Union CountyTrinitas Regional Medical CenterRobert Wood Johnson UniversityHospital at RahwayOverlook Medical Center

Warren CountyHackettstown Regional Medical CenterSt. Luke’s Warren Hospital

Cincinnati Prehospital Stroke ScaleCincinnati Prehospital Stroke ScaleTry to elicit one of the following signs. Abnormality in any

one is strongly suggestive of stroke.

• Facial Droop: Have patient smile and show his teeth:Normal: both sides of face move equally wellAbnormal: one side of face does not move as well as theother side

• Arm Drift: Have patient close eyes and hold both armsstraight out for 10 seconds:Normal: both arms move the same or both arms do notmove at allAbnormal: one arm does not move or one arm drifts down

• Abnormal Speech: Have the patient repeat:“You can’t teach an old dog new tricks.”Normal: patient uses correct words with no slurringAbnormal: patient slurs words, uses the wrong words or isunable to speak

Figure 9:

The Gold Cross Magazine name and Logo, and the New Jersey State First Aid Council, Inc. name and Logo, are the property of the New Jersey State First Aid Council. Articles from the Gold Cross Magazine reproduced on this Website are the property of Leonard Publications. None of such articles or any part thereof shall be reproduced, duplicated, copied, sold, resold, or otherwise exploited for any commercial purpose without the prior written consent.