Saturday, December 31, 2011

PALS Review Questions

61.  Hypoglycemia is defined as have a blood glues level less than ____ in neonates and ____ in infants and children?
45mg/dl in neonates
60mg/dl in infants and children

62. What is the volume of blood that is transfused in a pediatric patient with hemorrhagic shock?
10-15ml/kg of PRBCs

63. What are the ECG characteristics of SVT?
Heart rate > 220 for infants
Heart rate > 180 for children
P waves absent or abnormal
PR interval absent
QRS complex is usually narrow
Rhythm is regular

64. What are some conditions that may predispose a patient to torsades de pointed
Long QT syndrome
Hypomagnesemia
Antiarrhythmic drug toxicity
Other drug toxicities phenothiazines, tricyclic antidepressants. calcium channel blockers

65. Name some examples of distributive shock. 
Septic shock, neurogenic shock, and anaphylactic shock.

Friday, December 30, 2011

PALS Review Questions

56. When treating a pediatric patient without a known underlying cardiac problem, what is the initial amount of fluid boluses that can be administered?
20ml/kg then reassess the patient

57.  What is the compression-ventilation ratio for two rescuer CPR?
15:2

58. During the treatment of pulseless VF/VT, what are the joule settings for the subsequent defibrillations?
2-4J/kg

59. During the treatment of SVT, what is the initial dose of adenosine?
0.1mg/kg IVorIO

60. When is transcutaneous pacing indicated during the treatment of pediatric bradycardia?
It is used when the bradycardia is not corrected by oxygenation, medications, or when a primary cardiac problem has been recognized.

Thursday, December 29, 2011

PALS Review Questions

51.  Describe the ECG characteristics of ventricular tachcardia
The rate is greater than 150
The QRS complexes are greater than .12 sec
QRS complexes may be either uniform or multiform
P waves are absent

52.  How does one verify asystole on the monitor?
Increase the gain
Check the rhythm in another lead
Verify all electrical cords are connected
Verify all electrodes are in place

53. What are four precautions that should be observed before applying the defibrillator pads to the patient?
Make sure the skin surface is fry
Avoid pacemakers and other devices
Avoid letting the pads touch

54. What is the maximum cumulative dose of atropine in a child and an adolescent?
1mg for the child and 2mg for the adolescent

55. What is the dose of bicarbonate in a pediatric cardiac arrest?
1mEq/kg IVor IO

Wednesday, December 28, 2011

PALS Review Questions

46. Describe four vagal maneuvers that can be used in the initial treatment of SVT.
Valsalva maneuver
Blowing through a straw
Ice water to the face
Coughing

47. When treating pediatric shock, what is the correct volume of fluid that should be administered to a pediatric patient with a suspected cardiac problem?
5-10ml/kg

48. During transcutaneous pacing, what is meant by mechanical capture and how would you assess for it?
Mechanical capture refers to actual contraction of the myocardium and results in a palpable pulse

49. What is the initial dose of Amiodarone in pediatric pulseless VF/VT?
5mg/kg IV or IO

50.  During the treatment of PEA the aim of the treatment is to identify and treat the underlying cause of the rhythm?  True or False
True

Tuesday, December 27, 2011

PALS Review Questions

41.  What are two antiarrhythmics that are used in the treatment of pulseless VF/VT?
Amiodarone and Lidocaine

42.  Describe the technique for giving Adenosine during the treatment of SVT.
Fast-flush technique

43. Name the steps for using an AED.
Power on AED
Apply pads to patients chest
Plug in cord
Analyze heart rhythm

44. What is maximum cumulative dose of Lidocaine during the treatment of pulseless VF/VT?
3mg/kg

45. What is the correct dose and concentration of epinephrine that can be administered through the endotrachial tube?
0.1mg/kg of a 1:1000 solution

Monday, December 26, 2011

PALS Review Questions

36. SVT typically produces heart rates greater than____ in children and ____ in infants?
180, 220

37.  What is the dosage of magnesium used in the treatment of torsades de pointe in pediatric patients?
25-50grams IV

38.  What is the maximum initial dosage of atropine in a child?
0.5mg

39.  Adenosine is indicated in the treatment of what dysthythmia?
SVT

40.  After the initial defibrillation, what is the subsequent joule settings in the treatment of pulseless VF/VT?
4J/kg

Sunday, December 25, 2011

PALS Review Questions

31.  What is the minimum dosage of atropine that is recommended during the treatment of unstable bradycardia?
0.1mg

32.  What is meant by the term PEA?
Pulseless electrical activity is when the monitor displays a rhythm but the patient does not gave a pulse.

33.  What is the initial joule setting when preparing to cardiovert pediatric SVT?
0.5-1J/kg

34. Amiodarone is used in the treatment of what two rhythms?
Pulseless VF/VT and stable VT

35. What are 3 products that are used in fluid replacement therapy during pediatric shock?
Crystaloids, colloids, blood products

Saturday, December 24, 2011

PALS Review Questions

26.  Pediatric pads are recommended for children weighing less than____?
15kg

27. What are five components of the primary survey during the treatment of pediatric cardiac arrest?
Assess the patient
Support ABCs
CPR
Attach defibrillator/monitor
Assess the heart rhythm


28. Name the "T" reversible causes in the treatment of asystole.
Tension pneumothorax
Toxins/tablets
Tamponade, cardiac
Thrombosis coronary
Trauma

29. What are 4 medications that can be administered through the ET tube?
Narcan, epinephrine, atropine, lidocaine

30. What is the first vasoconstrictor that is administered during a pulseless arrest?
Epinephrine 0.01mg/kg

Friday, December 23, 2011

PALS Review Questions

21.  In the treatment of PEA the rescuer is asked to look for reversible causes- the Hs & Ts.  Name the Hs.
Hypoxia, hypovolemia, hydrogen ions, hyperkalemia, hypokalemia, hypoglycemia, hypothermia

22. What are 5 signs and symptoms of shock or clinical instability?
Hypotension, altered mental status, cold, clammy skin, delayed capillary refill, absent or weak, thready pulses


23.  What are four differences between defibrillation and cardioversion?
Cardioversion delivers electrical current to the heart during a specific time during the cardiac cycle, treatment of choice for SVT
Defibrillation does not need synchonized with the ECG, it uses higher energy levels, used in the treatment of pulseless vfib/vtach

24. What is the dosage of Lidocaine used in the treatment of pulseless VF/VT?
1mg/kg IV/IO

25. What is the dosage and method of administration of dopamine during unstable bradycardia?
2-20mcg/kg/min IV/IO as an infusion

Thursday, December 22, 2011

PALS Review Questions

16. Describe the location for placing the defibrillator pads
Anterior/posterior
Apex/right chest wall

17. AVPU describes what?
Describes the patient's level of consciousness.
Alert
Responds to voice
Responds to pain
Unresponsive

18. What is meant by the term decompensated shock?
When their are clinical signs of poor systemic perfusion accompanied by hypotension

19. Describe sinus tachcardia.
Sinus tachycardia is a nonspecific clinical sign; often related to a specific cause: fever, pain, activity;  P aves are normal and present; heart rate below 180 for a child and 220 for an infant

20 What is the initial joule setting in the treatment of pediatric SVT?
0.5-1J/kg

Wednesday, December 21, 2011

PALS Review Questions

11. Magnesium is the drug of choice in the treatment of what dysthythmia?
Polymorphic Vtach or torsades de pointe

12. What is meant by the term compensated shock?
When the patient exhibits signs of poor profusion but exhibits a normal blood pressure

13.  SVT in infants produces a heart rate greater than_____bpm?
220

14.  What is the dose of Procainamide used in the treatment of Vtach with a pulse?
15mg/kg over 30-60 minutes

15. Name three medications used in the treatment of unstable bradycardia?
Atropine, epinephrine, dopamine

Tuesday, December 20, 2011

PALS Review Questions

6.  What are four non-profusing heart rhythms in s pediatric patient?
Asystole, PEA, pulseless VF, and pulseless VT

7. In the treatment of asystole, how often can epinephrine be repeated?
Every 3-5 minutes

8. What is the dose of atropine used in the treatment of unstable bradycardia?
0.02mg/kg IV/IO

9. What is the primary treatment for ventricular fibrillation?
Defibrillation

10. Name five ways in which you can positively confirm ET tube placement
Direct cord visualization
End-tidal CO2
Bilateral breath sounds
CXR
Continuous capnography

Monday, December 19, 2011

PALS Review Questions

PALS review
1.  What's is the dose and concentration of epinephrine used in the treatment of PEA?
0.01mg/kg of a 1:10,000 solution IV or IO

2.  What is the maximum cummulative dose of Amiodarone in treating pulseless VF/VT?
15mg/kg

3. In a pediatric patient, Lidocaine is indicated in the treatment of what two cardiac problems?
Pulseless VF/Vtach and VT with a pulse

4.  Name 5 causes of bradycardia in a pediatric patient.
Hypoxia, hypothermia, heart blocks, head injury, heart medications, high vagal tone

5.  In a pediatric patient, what is indicated when the heart rate is less than 60 with accompanying and poor systemic perfusion?
CPR

Sunday, December 18, 2011

EKG Rhythm Strips 23: Paced Rhythms

Identify the following rhythms:


1.




2.

3.

4.



5.



Answers
1.









Ventricular Demand Pacing.   The patient has an underlying atrial flutter.

2.
Ventricular Demand Pacing









Ventricular Demand Pacing.  The underlying rhythm looks like atrial flutter.  The pacer spikes are small and difficult to see on complexes 3, 4, 5, and 7.  My first thought about this rhythm was that the patient was having some ventricular escape beats.  But I learned that the patient had a pacemaker and that the 12 lead also showed a functioning pacemaker.  If the patient was having some escape beats then I would suspect a primary pacemaker failure. 

3.
Ventricular Paced Rhythm










Ventricular Paced Rhythm.   The rhythm is regular.  The rate is 60. The PR interval is 20.  A pacer spike occurs before each QRS complex.  

4.












100% ventricular paced with some demand atrial pacing.

5.
Biventricular Pacing







Biventricular Pacing with PVCs.   The rhythm is irregular.  There are P waves before each paced beat.  There are biventricular pacer spikes before each QRS complex.  There are unifocal PVCs present occurring alone and as a couplet.



Reviewed 3/1/16

Saturday, December 17, 2011

EKG Rhythm Strips 22: Paced Rhythms

Identify the following paced rhythms:

1.

2.
3.

4.




5.






Answers
1.
Demand Atrial Paced
Demand Atrial Paced.   There are no pacemaker spikes on the second and fourth complexes.  The P waves are the patient's own native P waves.  But on the other complexes a pacer spike preceeds each of the P waves.   It is not possible to determine the exact kind of internal pacemaker a patient has based on the rhythm.   This could be an example of an AAI pacemaker in which the atria are paced.  But when the pacemaker senses a native P wave it is inhibited from producing a paced beat.   



2.
Biventricular Paced










Biventricular Paced.   Two pacemaker spikes precede the QRS complex.   One pacemaker spike for each ventricle.  A PVC is also present. 

3.
Demand AV Paced







Demand AV Paced.   On the 1st and 7th complexes there are very small atrial spikes present.  On all the other complexes there are native P waves present with a very long 1st degree block. 
what is the underlying PR interval?  The ventricles are 100% paced.  Probably a DDD pacemaker. 

4.
Ventricular Paced











Ventricular Paced.   There are pacemaker spikes before each QRS complex.  The patient's underlying rhythm is atrial fibrillation.  This could be a VVI pacemaker in which the ventricles are paced but when the pacemaker senses a natural QRS complex it inhibits a paced beat. 

5.
External Paced






External Paced.   The ventricles are being externally paced.  The pacemaker markers at the bottom of the stripe identify the pacing stimulus.   On paced rhythms the QRS complex will be much wider than native QRS complex.  The inital deflection will be negative while the terminal deflection will have an opposite polarity and have ST segment elevation.  What is the pacing rate in this strip?   How do you access for mechanical capture?


Reviewed 3/1/16

Friday, December 16, 2011

ACLS review: Acute Stroke Part 5

Complications of Fibrinolytics
·         Symptomatic intracranial hemorrhage
·         Orolingual angioedema (1.5%)
·         Acute hypotension
·         Systemic bleeding

Note:  Symptomatic intracranial hemorrhage occurred in 6.4% of the 312 patients treated in the NINDS trials and 4.6% of the 1135 patients treated in 60 Canadian centers


Fibrinolytic Precautions
·         Care dose calculation
·         Removal of excess medication
·         Holding anticoagulants and anitplatelet medications for 24 hours until repeat CT scan shows no hemorrhage

Note:  Removal of excess rtPA help prevent inadvertent administration of excess rtPA


General Stroke Care
·         Prevention of hypoxia
·         Manage hypertension
·         Glycemic Control
·         Temperature Control
·         Nutritional support
·         Prevention complications (Pneumonia, DVT, UTI)
·         Initiation of secondary stroke prevention
·         Transfer to stoke unit or stroke center


Prevention of hypoxia
·         ABCs
·         Oxygen to maintain saturations over 94%
·         Advanced airway placement and ventilation


Manage hypertension
·         Depends on whether or not fibrinolytic or intra-arterial therapies were used
·         In patients who are excluded from further intervention more liberal acceptance of hypertension is recommended
·         Normal saline at 75 to 100 mL/h is used to maintain euvolemia


BP Management During and After Reperfusion Therapy
·         Monitor blood pressure every 15 minutes for 2 hours from the start of rtPA therapy; then every 30 minutes for 6 hours; and then every hour for 16 hours
·         If systolic BP 180–230 mm Hg or diastolic BP 105–120 mm Hg
Labetalol 10 mg IV followed by continuous IV infusion 2–8 mg/min, or
Nicardipine IV 5 mg/h, titrate by 2.5 mg/hr every 5–15 minutes, maximum 15 mg/h
If blood pressure not controlled or diastolic BP >140 mm Hg, consider sodium nitroprusside


BP Management in Patients Ineligible for Reperfusion Therapy
·         Consider lowering blood pressure in patients with acute ischemic stroke if systolic blood pressure >220 mm Hg or diastolic blood pressure >120 mm Hg
·         Consider blood pressure reduction as indicated for other concomitant organ system injury
Acute myocardial infarction
Congestive heart failure
Acute aortic dissection
A reasonable target is to lower blood pressure by 15% to 25% within the first day


Glycemic Control
·         Hyperglycemia is associated with worse clinical outcome
·         SQ or IV Insulin when the serum glucose level is >185 mg/dL (Class IIa, LOE C)


Temperature Control
·         Hyperthermia is associated with increased morbidity and mortality
·         Treat fever >37.5°C (99.5°F)
·         Limited data on the role of hypothermia specific to acute ischemic stroke


Dysphagia Screening
·         NPO until screened for dysphagia
·         Perform simple bedside swallowing evaluation
·         If dysphagia present give medications either through NG/OG tube, IV, or IM routes



Note:  A simple bedside screening evaluation involves asking the patient to sip water from a cup. If the patient can sip and swallow without difficulty, the patient is asked to take a large gulp of water and swallow. If there are no signs of coughing or aspiration after 30 seconds, then it is safe for the patient to have a thickened diet until formally assessed by a speech pathologist.



Nutritional support
·         Patient may have thickened diet until formally assessed by a speech pathologist
·         Enteral feedings for patients with dysphagia


Prevention complications
·         DVT prophylaxsis with medications may begin within 24 hours after fibrinolytics once a repeat CT scan is negative for intracranial hemorrhage
·         Keep HOB up and have suctioning available for those with dysphagia
·         Patients treated with rtPA, with severe stroke, posterior circulation stroke, and in younger patients, observe increased intracranial pressure
·         Seizure prophylaxis is recommended only in patients who experience a seizure



Transfer to stoke unit or stroke center
Consistent improvement in 1-year survival rate, functional outcome, and quality of life when patients hospitalized with acute stroke are cared for in a dedicated stroke unit by a multidisciplinary team experienced in managing stroke



Reference:  Jauch EC, Cucchiara B, Adeoye O, Meurer W, Brice J, Chan Y-F, Gentile N, Hazinski MF. Part 11: adult stroke: 2010 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Circulation. 2010;122(suppl 3):S818–S828.

Thursday, December 15, 2011

ACLS review: Acute Stroke Part 4

CT Scan
·         Should be completed within 25 minutes of the patient's arrival
·         Should be interpreted within 45 minutes of ED arrival
·         More advanced neurologic imaging should not delay initiation of IV rtPA
·         During the first few hours noncontrast CT scan may not indicate signs of brain ischemia
·         If negative for intracerebral hemorrhage, the patient may be a candidate for fibrinolytic therapy


Fibrinolytics Inclusion Criteria
·         Diagnosis of ischemic stroke causing measurable neurologic deficit
·         Onset of symptoms <3 hours before beginning treatment
·         Age ≥18 years

Fibrinolytics Exclusion Criteria
·         Head trauma or prior stroke in previous 3 months
·         Symptoms suggest subarachnoid hemorrhage
·         Arterial puncture at noncompressible site in previous 7 days
·         History of previous intracranial hemorrhage
·         Elevated blood pressure (systolic >185 mm Hg or diastolic >110 mm Hg)
·         Evidence of active bleeding on examination
·         Acute bleeding diathesis, including but not limited to
Platelet count <100 000/mm3
Heparin received within 48 hours, resulting in aPTT >upper limit of normal
             Current use of anticoagulant with INR >1.7 or PT >15 seconds
·         Blood glucose concentration <50 mg/dL (2.7 mmol/L)
·         CT demonstrates multilobar infarction (hypodensity >1/3 cerebral hemisphere)



Fibrinolytics Relative Exclusion Criteria
·         Only minor or rapidly improving stroke symptoms (clearing spontaneously)
·         Seizure at onset with postictal residual neurologic impairments
·         Major surgery or serious trauma within previous 14 days
·         Recent gastrointestinal or urinary tract hemorrhage (within previous 21 days)
·         Recent acute myocardial infarction (within previous 3 months)

Note:  Recent experience suggests that under some circumstances—with careful consideration and weighing of risk to benefit—patients may receive fibrinolytic therapy despite 1 or more relative contraindications. Consider risk to benefit of rtPA administration carefully if any of these relative contraindications is present.

Patients From 3 to 4.5 Hours From Symptom Onset Who Could Be Treated With rtPA

Inclusion Criteria
·         Diagnosis of ischemic stroke causing measurable neurologic deficit
·         Onset of symptoms 3 to 4.5 hours before beginning treatment

Exclusion criteria
·         Age >80 years
·         Severe stroke (NIHSS  score >25)
·         Taking an oral anticoagulant regardless of INR
·         History of both diabetes and prior ischemic stroke



Notes:
The checklist includes some FDA-approved indications and contraindications for administration of rtPA for acute ischemic stroke. Recent guideline revisions have modified the original FDA criteria. A physician with expertise in acute stroke care may modify this list
Onset time is either witnessed or last known normal
In patients without recent use of oral anticoagulants or heparin, treatment with rtPA can be initiated before availability of coagulation study results but should be discontinued if INR is >1.7 or PT is elevated by local laboratory standards
Treatment of carefully selected patients with acute ischemic stroke with IV rtPA between 3 and 4.5 hours after onset of symptoms has also been shown to improve clinical outcome, although the degree of clinical benefit is smaller than that achieved with treatment within 3 hours
In patients without history of thrombocytopenia, treatment with rtPA can be initiated before availability of platelet count but should be discontinued if platelet count is <100 000/mm3

Wednesday, December 14, 2011

ACLS review: Acute Stroke Part 3

Critical EMS Assessments
·         Support ABCs: O2 for oxygen saturation <94%
·         Perform CPSS assessment
·         Establish time of onset of symptoms
·         Triage to stoke center
·         Alert hospital
·         Check glucose

Note:  If the patient wakes from sleep or is found with symptoms of a stroke, the time of onset of symptoms is defined as the last time the patient was observed to be normal.
Unless the patient is hypotensive (systolic blood pressure <90 mm Hg), prehospital intervention for blood pressure is not recommended
EMS systems should establish a stroke destination preplan to enable EMS providers to direct patients with acute stroke to appropriate facilities
Circulation. 2010; 122: S818-S828 doi: 10.1161/​CIRCULATIONAHA.110.971044


In-hospital Assessment
·         Assess ABCs
·         Provide oxygen
·         Establish IV access and draw labs
·         Check blood glucose
·         Perform neurologic exam
·         Activate stroke team
·         Order CT scan of brain
·         Obtain 12-lead ECG


Note:  A 12-lead electrocardiogram (ECG) does not take priority over the CT scan but may identify a recent acute myocardial infarction or arrhythmias (eg, atrial fibrillation) as the cause of an embolic stroke
Recommend cardiac monitoring during the first 24 hours of evaluation in patients with acute ischemic stroke to detect atrial fibrillation and potentially life-threatening arrhythmias


Neurologic Exam
·         The NIH Stroke Scale
·         Canadian Neurological Scale


Management of Hypertension
Blood pressure must be ≤185 mm Hg systolic and ≤110 mm Hg diastolic
Patients with sustained hypertension  (ie, systolic blood pressure >185 mm Hg or diastolic blood
pressure >110 mm Hg) will not be eligible for IV rtPA


Patient eligible for acute reperfusion therapy except that BP is >185/110  
Labetalol 10–20 mg IV over 1–2 minutes, may repeat ×1, or
Nicardipine IV 5 mg/hr, titrate up by 2.5 mg/hr every 5–15 minutes, maximum 15 mg/hr; when desired blood pressure reached, lower to 3 mg/hr, or
Other agents (hydralazine, enalaprilat, etc) may be considered when appropriate

During and After Reperfusion Therapy
Monitor blood pressure every 15 minutes for 2 hours from the start of rtPA therapy; then every 30 minutes for 6 hours; and then every hour for 16 hours
If systolic BP 180–230 mm Hg or diastolic BP 105–120 mm Hg
Labetalol 10 mg IV followed by continuous IV infusion 2–8 mg/min, or
Nicardipine IV 5 mg/h, titrate up to desired effect by 2.5 mg/hr every 5–15 minutes, maximum 15 mg/h
If blood pressure not controlled or diastolic BP >140 mm Hg, consider sodium nitroprusside


Patients Ineligible for Reperfusion Therapy
Consider lowering blood pressure in patients with acute ischemic stroke if systolic blood pressure >220 mm Hg or diastolic blood pressure >120 mm Hg
Consider blood pressure reduction as indicated for other concomitant organ system injury
     Acute myocardial infarction
     Congestive heart failure
     Acute aortic dissection
A reasonable target is to lower blood pressure by 15% to 25% within the first day

Monday, December 12, 2011

ACLS review: Acute Stroke Part 2

Warning Signs and Symptoms of Possible Stoke
·         Sudden onset of weakness
·         Sudden confusion
·         Trouble speaking or understanding
·         Sudden trouble seeing in one or both eyes
·         Sudden trouble walking
·         Dizziness or loss of balance or coordination
·         Sudden severe headache with no known cause

Note:  Identifying clinical signs of possible stroke is important because recanalization strategies (intravenous [IV] fibrinolysis and intra-arterial/catheter-based approaches) must be provided within the first few hours from onset of symptoms


Public Education
·         Public must be educated regarding the signs and symptoms of a stroke
·         Public must be educated to activate EMS as soon as symptoms of stroke are recognized
·         Currently half of all stoke patients are drive to the hospital by their family members


Note:  Most strokes occur at home, and just over half of all victims of acute stroke use EMS for transport to the hospital.  Stroke knowledge among the lay public remains poor.  These factors can delay EMS access and treatment, resulting in increased morbidity and mortality.
Educational efforts need to couple the knowledge of the signs and symptoms of stroke with action—call 911


Advantages of Activating EMS for Symptoms of a Stoke
·         EMS personal can quickly assess and identify a stoke patient
·         EMS can quickly transport the stoke patient to the hospital thus minimizing the interval between the onset of symptoms and treatment.
·         Prearrival notification allows the hospital to prepare to evaluate and manage the patient efficiently

The Cincinnati Prehospital Stroke Scale
·         Facial droop
·         Arm drift
·         Abnormal speech

Note:  With standard training in stroke recognition, paramedics demonstrated a sensitivity of 61% to 66% for identifying patients with stroke. After receiving training in use of a stroke assessment tool, paramedic sensitivity for identifying patients with stroke increased to 86% to 97%
Circulation. 2010; 122: S818-S828 doi: 10.1161/​CIRCULATIONAHA.110.971044


Facial droop (have patient show teeth or smile)
·         Normal—both sides of face move equally
·         Abnormal—one side of face does not move as well as the other side


Arm drift (patient closes eyes and holds both arms straight out for 10 seconds)
·         Normal—both arms move the same or both arms do not move at all (other findings, such as pronator drift, may be helpful)
·         Abnormal—one arm does not move or one arm drifts down compared with the other


Abnormal speech (have the patient say “you can't teach an old dog new tricks”)
·         Normal—patient uses correct words with no slurring
·         Abnormal—patient slurs words, uses the wrong words, or is unable to speak


Note:  Interpretation: If any 1 of these 3 signs is abnormal, the probability of a stroke is 72%
The presence of all three findings indicates that the probability of stroke is > 85%
Circulation. 2010; 122: S818-S828 doi: 10.1161/​CIRCULATIONAHA.110.971044