Bell's Palsy and the Cincinnati Stroke Scale

[PeteBlair]

I begin EMT-B school Monday and maybe I just need to wait until later to pose this question. I'm reading the textbook for the class in preparation and am now about 40 percent through it on my second time through. I'm in the chapter on Neurologic Emergencies.

If you administer the cincinnatti stroke test and notice that one side of the face remains distorted, how do you differentiate between stroke and Bell's palsy? Or is it better to assume and treat like stroke and let the hospital sort it out?

Thanks

 

[MMiz]

I asked the exact same question in my Bell's Palsy thread. There were lots of really good responses.

I can't imagine that treatment would change between the two. Even at the ALS level there isn't much available for pre-hospital treatment of a CVA. I sure wouldn't want to be the one to make a mistake between Bell's Palsy and a more serious condition. That's why the MDs get paid the big bucks and have all the fancy machines.

 

[emtwacker710]

yea, If the pt. happens to fail the stroke test, don't worry yourself trying to figure out which one it is, there is not much you can do at the BLS level for either, except O2, transport to the nearest stroke center/hospital and let them figure out which one it is.

 

[Flight-LP]

Or you can take an interest in what is actually wrong with your patient and be able to offer your professional patient assessment observations to the ER so they could intervene in a timely manner..............(God, I really hate it when people say "don't worry about it, just take 'em to the ER". And we wonder why we are the way we are?!?!)

The Cincinnatti test is alright, but leaves a few questions open. Personally I prefer administering the Los Angeles Pre-hospital Stroke Screen. More in depth and has higher accuracy.

For you, the new EMT-B, the key is a sound history. Age, gender, demographic background, family history, smoking history, A-fib history. These could all point to a CVA.

A recent history of viral infection, especially meningitis, recent facial trauma, known history of Lyme Disease, Epstein-Barr, or Mono. A younger patient. These could all be indicitive of Bell's Palsy.

Bell's Palsy involves damage to the 7th cranial nerve which subsequently causes the facial paralysis. Usually your embolic and thrombotic CVA's will also have some muscular involvement due to systemic hypoperfusion and subsequesnt tissue necrosis. Many will also suffer other significant s/s dependant on location and brainstem or cerebral cortex involvement. Hemorrhagic CVA's will usually have catastrophic s/s due to the bleed and its increase in ICP.

Bell's Palsy patients also will not experience aphasia, loss of consciousness, or experience a severe headache (usually).

 

[Asclepius]

CVA and Bell's Palsy are distinguishable because most CVA's if they affect a certain part of the body will affect the whole side of the body. Whereas Bell's Palsy only affects the face. If a person has positive facial droop, but equal grips and good reflexes than it's likely not a true CVA.

Signs and symptoms of Bell's palsy may include:

• Sudden onset of paralysis or weakness on one side of your face, making it difficult to smile or close your eye on the affected side
• Facial droop and difficulty with facial expressions
• Facial stiffness or a feeling that your face is being pulled to one side
• Pain behind or in front of your ear on the affected side
• Sounds that seem louder on the affected side
• Pain, usually in the ear on the affected side
• Headache
• Loss of taste on the front portion of your tongue
• Changes in the amount of tears and saliva your body produces

I had a co-worker one time that had a sudden onset of Bell's Palsy. He felt fine. Came into work and everyone asked him what was wrong with his face. He said he didn't know, but the rest of him felt fine. We all thought he was stroking. Transported him to the hospital and was diagnosed with Bell's Palsy. They sent him home.

 

[emtwacker710]

well I didn't mean it like that, I'm just going from what we do in my region, we have a 5-10 minute transport time max, to the nearest hospital, if they do need a stroke center the hospital arranges a flight through LifeNet helicopter, sorry if I sounded kinda stupid there, I've only worked in my region and don't know how other operate..

 

[John E]

Hmmm....

What would be the problem with simply noting the condition of the pt. treat and transport and let those who are allowed to diagnose do the formal diagnosis?

Is there harm in treating a potential Bell's Palsy pt. like you would a CVA pt.? For the duration of the ride to the ER?

Getting a good history and noting any discrepancies between a "typical CVA" and a "typical Bell's Palsy" pt. would seem to be about all an EMT-B can do.

There's a huge difference between taking an interest in a pt. and attempting to go beyond one's scope of practice isn't there? I take an interest in every pt. but I don't try to diagnose above and beyond what I've been trained to do.

Not trying to pick a fight, just curious.

John E.

 

[Ridryder911]

Actually yes there is a problem. Bell's Palsy and CVA is totally two separate conditions and although they may have some similar symptoms, that is all there is to compare it with.

When someone is transporting in emergency status with a CVA or "stroke alert" many hospitals clear CT scans and alert "stroke teams" of the potential patient arriving.

My suggestion is to learn about the differential of a CVA and Bell's Palsy. Learn the differential of other neuro checks, history and underlying symptoms.

I agree there is not much anyone can do for CVA, BLS or even ALS other than recognize the problem.

R/r 911

 

[John E]

I see that once again...

I wasn't as clear as I should have been.

If a pt. presents with symptoms of a CVA or of Bell's Palsy would it not be prudent to transport rapidly and note any discrepancies to give to the ER?

In other words, should an EMT-B decide that a pt. is suffering from Bell's Palsy and not have the ER know that a possible CVA pt. is coming in?

It seems to me that it would be in the best interest of the pt. to notify the ER that you have a POSSIBLE CVA pt. with some symptoms of Bell's Palsy also presenting.

If one calls the ER and tells them that you have a potential Bell's Palsy pt. wouldn't they as a matter of caution, be prepared for a potential CVA pt.?

I know it seems like I'm nitpicking, I'm not trying to believe me. I just think it's better to note that the pt. in question may have Bell's Palsy or they may be in the midst of a CVA and get them to the ER and let those who are allowed to diagnose, do so. And I do understand that there are differences between a "typical" CVA presentation and Bell's Palsy, but there are also similarities that an EMT-B, on the scene may or may not be able to differentiate at the time. Better to transport as a potential CVA while noting any discrepancies isn't it?

Can a Bell's Palsy pt. be harmed if they are initially treated and transported as a potential CVA pt.?

John E.

 

[MMiz]

As an EMT-Basic should am I really in a position to determine whether a patient is presenting with a CVA or Bell's Palsy? Clearly I have no formal training, and I can't find a single state or service that mentions it in their protocols.

Maybe it's just me, but I always struggled with the determination of a true CVA. I had patients present with CVA symptoms when it turned out to be something completely unrelated. I would just hate to be in a position to make the determination and present my dx of Bells Palsy when I don't have the training or technology to make such a determination.

 

[Flight-LP]

I wasn't as clear as I should have been.

If a pt. presents with symptoms of a CVA or of Bell's Palsy would it not be prudent to transport rapidly and note any discrepancies to give to the ER?

In other words, should an EMT-B decide that a pt. is suffering from Bell's Palsy and not have the ER know that a possible CVA pt. is coming in?

It seems to me that it would be in the best interest of the pt. to notify the ER that you have a POSSIBLE CVA pt. with some symptoms of Bell's Palsy also presenting.

If one calls the ER and tells them that you have a potential Bell's Palsy pt. wouldn't they as a matter of caution, be prepared for a potential CVA pt.?

I know it seems like I'm nitpicking, I'm not trying to believe me. I just think it's better to note that the pt. in question may have Bell's Palsy or they may be in the midst of a CVA and get them to the ER and let those who are allowed to diagnose, do so. And I do understand that there are differences between a "typical" CVA presentation and Bell's Palsy, but there are also similarities that an EMT-B, on the scene may or may not be able to differentiate at the time. Better to transport as a potential CVA while noting any discrepancies isn't it?

Can a Bell's Palsy pt. be harmed if they are initially treated and transported as a potential CVA pt.?

John E.

Indirectly, yes from a financial standpoint. Now everyone can say what they want about it "not being about the money, its all about the patient", but when it comes down to the reality of it, this plays a big factor. As we all know, CVA's need to go to a stroke center, not local podunct ER (please no arguments here, 1. I'm too tired to fight and 2. You would be wrong, period). So lets say you have a Bell's Palsy pt., which can be diagnosed with a fair amount of certainty in the field. You rush them to the local stroke center, bypassing your normal ER. They get charged for extra mileage. They then get charges for activation of the stroke team. More charges for CT, Radiologists, ER physicians, Neurologists, Pathologists, etc. All for a simple case of Bell's Palsy. Now if I was that pt. and received those bills, I know an EMT or two who would be paying for it. ASSESSMENT, ASSESSMENT, ASSESSMENT......It cannot be overemphasized.