Protocol 2-880-24 - Suspected Stroke - Assessment Tool

CMH EMS & MIH Protocols


Score only the first attempt. Do not coach. Do not go back and re-score.

STEP 1

STEP 2


STEP 3

Question Answer RACE Options NIHSS Options
1A Level of consciousness? NA 0 - Alert
1 - Drowsy
2 - Stuporous
3 - Coma
1B Ask the patient two questions one at a time:
  • What month is it?
  • What is their age?
NA 0 - Both answers correct
1 - Only one answer correct
2 - Neither answer correct
1C Upon verbal command (simultanously given):
  • Open and close eyes.
  • Grip and release good hand.
0 - Both tasks complete
1 - Only one task complete
2 - Neither task complete
0 - Both tasks complete
1 - Only one task complete
2 - Neither task complete
2 Can patient follow your finger horizontally with their eyes? 0 - Normal
1 - Only one direction
2 - Neither direction
0 - Normal
1 - Only one direction
2 - Neither direction
3 Can patient see all four quadrants peripherally (one eye at a time)? NA 0 - No loss
1 - One eye with loss
2 - Both eyes with loss on same side
3 - Both eyes with loss on both sides

Question Answer RACE Options NIHSS Options
4 After demonstration, can the patient do the following one at a time:
  • Show teeth?
  • Raise eyebrows?
  • Close eyes tightly?
NA 0 - Normal
1 - Minor paralysis
2 - Lower paralysis only
3 - Complete paralysis
5A Unaffected side arm drift: Palm down, 90° for 10 seconds. If ataxic due to weakness, select "no drift." NA 0 - No drift
1 - Drift or jerky
2 - Some effort but falls
3 - No effort
4 - No movement
5B Affected side arm drift: Palm down, 90° for 10 seconds. If ataxic due to weakness, select "no drift." 0 - No drift
0 - Drift or jerky
1 - Some effort but falls
2 - No effort
2 - No movement
0 - No drift
1 - Drift or jerky
2 - Some effort but falls
3 - No effort
4 - No movement
6A Unaffected side leg drift: 30° for 10 seconds. If ataxic due to weakness, select "no drift." NA 0 - No drift
1 - Drift or jerky
2 - Some effort but falls
3 - No effort
4 - No movement

Question Answer RACE Options NIHSS Options
6B Affected side leg drift: 30° for 10 seconds. If ataxic due to weakness, select "no drift." 0 - No drift
0 - Drift or jerky
1 - Some effort but falls
2 - No effort
2 - No movement
0 - No drift
1 - Drift or jerky
2 - Some effort but falls
3 - No effort
4 - No movement
7 Test unaffected side first, then affected side:
  • Can patient touch nose with finger?
  • Can patient slide heel against other shin?
NA 0 - Able to complete
1 - Unable in one limb
2 - Unable in multiple limbs
8 Can patient feel pinprick to face, arms, trunk, and legs? NA 0 - Normal
1 - Mild to moderate loss
2 - Severe loss
9 Measure the best response:
  • "What is your name?"
  • "Describe what you see in the picture?"
  • "Read the sentences."
0 - No aphasia
1 - Mild to moderate aphasia
2 - Severe aphasia
3 - Mute or global aphasia
0 - No aphasia
1 - Mild to moderate aphasia
2 - Severe aphasia
3 - Mute or global aphasia
10 Can the patient repeat the following words:
  • "Mama"?
  • "Tip-top"?
  • "Fifty-fifty"?
  • "Thanks"?
  • "Huckleberry"?
  • "Baseball player"?
NA 0 - Normal articulation
1 - Mild to moderate dysarthria
2 - Severe dysarthria

Question Answer RACE Options NIHSS Options
11 Can the patient answer appropriately:
  • "Whose arm is this?" (showing affected arm)
  • "Can you move this arm?" (indicating affected arm)
0 - No neglect
1 - Not recognized OR unable to move
2 - Not recognized AND unable to move
0 - No neglect
1 - Not recognized OR unable to move
2 - Not recognized AND unable to move

STROKE scores:

Definitions:


NEMSIS Protocol: 9914145 - Medical-Stroke/TIA

Citations:


Change Log:

DateLink to
previous
version
Description of change
05/05/15pdfCreated Section 4-052 - NIH Stroke Scale Images for images to accompany NIHSS.
08/24/17pdfDeveloped combined tool utilizing NIH and RACE tools.
08/24/17Modified images to reflect changes to assessment tool.
03/05/18pdfAligned numbers to NIHSS. Added comment to arm drift if ataxic rate at 0. Add list of terminology definitions. Changed NIH score to transport to level I center from >21 to >6.
07/12/20pdfMoved this section from 2-880created a new page.
02/18/21pdfChanged document number from 2-880-01 to 2-880-24 to allow for future.
02/18/21Replaced Cincinnati with BEFAST.
06/06/21pdfMoved to emsprotocols.online
10/15/21Fixed typo on question 9 from MUT to MUTE.

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