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

Perform BEFAST stroke assessment:

Balance	Eyes	Face	Arm	Speech	Time
Trouble walking, stumbling, falling, dizziness, or spinning sensation	Vision loss, blurry vision, or double vision	One side of face is weak or numb, the face appears uneven, or drooping	Weakness or numbness in the arm (or leg), especially if it is only one side	Slurred speech, trouble getting words out, or speaking gibberish	Begin rapid transport to a stroke center and complete stroke assessment and treatment

If ANY deficit: Perform the STROKE Assessment below.
If NO deficits: Transport to any ER, however, consider performing the STROKE Assessment below anyway.

STEP 2

Last Seen Normal (Calculate based on arrival at a STROKE center)	Patient age
Greater than 12 hours ago	Greater than 89 years old	Either >12 hrs OR >89 yr old: Transport to any ER.
8-12 hours ago	Less than 90 years old	Perform STROKE Assessment below.
4-8 hours ago		CLASS 2 STROKE. Perform STROKE Assessment below.
0-4 hours ago		CLASS 1 STROKE. Perform STROKE Assessment below.

STEP 3

Question		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		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		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:

Click "calculate" to show NIHSS score.

NIH greater than 6 = SEVERE STROKE.
NIH 1-5 = Mild to moderate stroke.
NIH 0 = No indication of stroke.

Click "calculate" to show RACE score.

RACE greater than 4 = LARGE VESSEL OCCLUSION.
RACE 0-3 = No LVO.

Definitions:

Aphasia: Loss of ability to understand or express speech.
Apraxia: Inability to carry out familiar tasks.
Ataxia: Loss of full control of bodily movements.
Dysarthria: Difficult or unclear articulation of speech.
Dysphagia: Difficulty in swallowing.
Dysphasia: Difficulty in the generation of speech or its comprehension.
Hemiparesis: Weakness on one side of the body.
Hemiplegia: Paralysis on one side of the body.

NEMSIS Protocol: 9914145 - Medical-Stroke/TIA

Citations:

Protocol 9-010 - References
Aroor, Singh, & Goldstein, 2016
Cauchi, 2019
Chapter 190 - Emergency services, 2012
Designated hospitals, n.d.
Hicks, 2021
Mercy Stroke Team, 2019
Missouri Department of Health & Senior Services, 2019
NASEMSO Medical Directors Council, 2017
NIH stroke scale international, 2003
Powers, et al., 2019
Proposed regulations, 2010
Tan, Alexander, Gopalan, Hannon, & Gunaga, 2019
University of Kansas Hospital
Woolford, 2020

Change Log:

Date	Link to previous version	Description of change
05/05/15	pdf	Created Section 4-052 - NIH Stroke Scale Images for images to accompany NIHSS.
08/24/17	pdf	Developed combined tool utilizing NIH and RACE tools.
08/24/17		Modified images to reflect changes to assessment tool.
03/05/18	pdf	Aligned 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.
07/12/20	pdf	Moved this section from 2-880created a new page.
02/18/21	pdf	Changed document number from 2-880-01 to 2-880-24 to allow for future.
02/18/21		Replaced Cincinnati with BEFAST.
06/06/21	pdf	Moved to emsprotocols.online
10/15/21		Fixed typo on question 9 from MUT to MUTE.

Return to Protocols Table of Contents.

CMH Pre-Hospital Services Mission: "Provide safe, exceptional, and compassionate care to our communities with an emphasis on highly trained and empowered staff."

CMH Mobile Integrated Healthcare Mission: "Provide exceptional, compassionate, and patient-centered care by a mobile collaborative team to improve patient experience, improve quality outcomes, and reduce healthcare costs."

Polk, Hickory, Cedar, & St Clair County EMS Protocols is licensed under a Creative Commons Attribution-ShareAlike 4.0 International License.