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50 APRIL 2016 | EMSWORLD.com affected part of the body but are noticeably weaker. Stroke is the most common cause of hemiparesis. Hemiplegia is defined as unilateral paralysis. Hemiple- gia can occur just in the face, arm or leg, or in a combi- nation all on the same side. Causes of hemiparesis/hemiplegia: stroke/TIA, head trauma, Todd's paralysis (temporary weakness after a seizure), migraine headaches, Bell's palsy (face only). Upper extremities—To test the upper extremities, have the patient hold their arms out at shoulder level with palms up and eyes closed. Observe both arms for 10 seconds, noting any downward drifting of the arm or inward rota- tion of the palm (pronator drift). Asymmetrical upper-extremity weakness is present if the patient cannot raise one arm, if one arm drifts down or if one arm has a pronator drift. Pronator drift is a sign of subtle weakness and is present when one palm begins to turn inward while the other remains up. If both palms rotate inward or both arms drift downward equally, it is simply general weakness and usually not a sign of stroke. Again, asymmetry is what we are looking for. Lower extremities—To test lower-extremity strength, have the patient lie supine and raise their leg straight up to an angle of about 30–35 degrees, then hold it there while you count to five. If the leg drifts downward, touches the bed or can't be raised to begin with, it is a positive test. Be aware that pain and decreased mobility from prior hip surgery and chronic bilateral muscle weakness may explain these findings. Unilateral weakness in the absence of prior surgery or other preexisting explanation indicates possible stroke. Sensory Function This tests for alteration in the sense of touch. Numbness is loss of sensation. Paresthesia is an abnor- mal sensation such as tingling, "pins and needles" or burn- ing of the skin and is most common in the extremities. Alteration of sensation can be elicited by a light touch test. Have the patient close their eyes then lightly touch their right leg, left leg, then both legs at the same time. Repeat the process for the arms and face. Each time the patient is touched, ask them to identify where they are being touched and if it feels the same on both sides. On the simultaneous touch, if a patient only identifies one side even though you are touching both, it's an indication of neglect, a stroke symptom where the patient ignores some stimuli from the affected side of the body. Acute numbness or paresthesia causes include stroke (unilateral symptoms), hyperventilation syndrome/panic attacks (generally bilateral paresthesia) and spinal cord injuries. After the above examinations are performed, the para- medic will have tested the majority of the various brain functions. Any abnormal finding may indicate a stroke or other serious pathology and warrants further investiga- tion in the hospital. Neurological Emergencies Instead of an exhaustive review of the neurological his- tory, which would be beyond the scope of this article, we will review some clinical clues present in the history and physical exam that will assist the paramedic in making the correct prehospital diagnosis. We have only included some of the more common types of neurological emergen- cies, with the pertinent positives listed in each section (see Tables 2–4). Stroke There are two types of stroke: ischemic and hemorrhag- ic. Ischemic stroke is further broken down by large ves- sel obstruction (LVO) and small vessel obstruction. LVO strokes have recently been proven to have better outcomes when treated with interventional therapy known as stent retrieval. 2,3 It is important for paramedics to know which hospitals in their area can provide this type of advanced care. Ischemic and transient ischemic (TIA) strokes—One of the most frequently missed yet most important pieces of information with respect to available treatment options is a stroke's time of onset. Paramedics must rapidly deter- mine when the patient was last known to be normal. This is not necessarily the same time the symptoms To perform the finger-to-nose exam, stand in front of the patient. Have the patient touch their nose with their index finger, then have them touch your finger. Lew Steinberg