Are you aware of the The Cincinnati Stroke Test?

When I was a younger EMT of course I learned as many skills as I could. Like anyone else I quickly learned that many skills could be found outside the of the classroom and in the ambulance. I was aware of the stroke scale I just never knew it by it’s official name. They were skills picked up by observing paramedics in the field and these skills helped me many times on CVA calls in which we arrived first as BLS responders. I was writing a PCR the other day and it turns out when you document now (in the vital signs section) you have the option to document your patient’s stroke status based on two different systems. Today I’ll only go over the Cincinnati.

First lets have a quick overview for those of you who may have forgotten this scale or those of us who didn’t know it by name. The Cincinnati Stroke Test is a pre-hospital assessment, a brief one at that, that gauges whether the patient is having a stroke using three simple tests. If any of these tests are failed then the pre-hospital provider should assume a stroke is occurring and take appropriate measures. To paramedics that would be pushing medications and in BLS response that would be priority response to the hospital; in either case declaring a stroke alert at whichever facility you transport to. Of course it’s a good key to keep in mind that a stroke occurs in the opposite side of the symptoms. If your patient has right facial droop and a right arm drift then your stroke is going to be found in the left side of the brain.

 

Cincinnati Stroke Test - Facial Droop from Stroke
Facial Droop (right side)

Test 1: Facial Droop

 

The first test is the facial droop test. Sometimes a patient will obvious facial droop and other times a patient won’t look any different than normal. The common way to assess the patient is by the smile test. You simply ask the patient to smile. If the face move normally and bilaterally then there is no implied stroke and the text is passed. In my experience I also find this test brightens the mood of a patient in any situation. For them to stop worrying and being hurt for a moment just to smile on demand usually serves as a relaxation point. So it has benefits outside of testing for stroke depending on  your personality.


Test 2: Arm Drift

Cincinnati Stroke Test - Stroke Patient displays right sided arm drift.
Right sided arm drift resulting from stroke.

The second test is arm drifting. This is a simple test for weakness and the ability to control ones limbs. Have the patient raise their arms horizontally in the air in front of them and hold them up. Observe and then repeat with the patient’s eyes closed. If the patient is able to keep each arm up then they pass the test. A lot of times this test is pretty easy to determine the result from; the patient has no idea that they cannot perform the task and both patient and EMT quickly realize that one of their arms cannot be lifted. Symptoms can be subtle too.

 

Test 3: Speech Patterns

The third test is speech patterns and this one can be tricky. Have your patient say a common phrase such as “you can’t teach old dogs new tricks”. Slurred speech is the point of this test and finding it results in failure. What makes it tricky is that slurred speech can come with many other medical problems. A few that come to mind immediately can be dementia, dysphagia, or even something as simple as drug or alcohol intoxication. Some patients naturally do not speak well, have thick accents, or do not command a good grasp on the English language. This test is entirely up to your professional judgement so be careful.

Other Tests worth including

EMS Stroke Test
EMT’s doing stroke testing. It’s probably better to do it inside the rig though…a dumb mock up picture.

Although The Cincinnati Stroke Test only requires those three assessments there is nothing saying you can’t include extra tests. I know many

providers who do exactly that. Just remember for your documentation that the The Cincinnati Stroke Test score and whatever you do extra are entirely different from one another. Some other tests I perform to make a better determination include:

 

Sensation: Can the patient feel tactile touch on all of their limbs?

Equal Grip Strength: Can the patient squeeze my hands equally?

Strength Tests: Can the patient push my arms up/down. Feet up or down?

Orientation: The patient’s mental status could be an important indicator.

Conclusion

The Cincinnati Stroke Test is an extremely useful tool for us in the pre-hospital setting. You should not be afraid to include it in any assessment that you do (within reason). It can reveal simple things and make simple conclusions and furthermore it in itself is simple. You can learn more about this topic on the American Heart Association website or any reputable medical resource online or offline. Here’s a good article I suggest giving a breeze over to start: Guidelines for the Early Management of Patients With Acute Ischemic Stroke.