What is the STOP mnemonic for rapid bedside assessment of acute neurological problems and how is it applied?

STOP Mnemonic in Neurology

I was unable to identify a validated "STOP" mnemonic for rapid bedside neurological assessment in the provided evidence or established neurological literature. The evidence instead strongly supports alternative structured approaches for acute neurological evaluation.

Validated Rapid Assessment Tools for Acute Neurological Problems

For acute stroke assessment, use the FAST mnemonic (Face, Arm, Speech, Time) at triage, which has demonstrated 87.5% sensitivity for identifying stroke at initial contact. 1, 2 This tool is specifically recommended by stroke guidelines for rapid screening in emergency settings. 1

Primary Structured Approach: Serial Neurological Examination

The mainstay of neurological assessment remains standardized serial bedside examination, not mnemonics. 1 For acute neurological problems, particularly stroke, the following structured approach is recommended:

Immediate Assessment Components

• Airway, Breathing, Circulation (ABCs) must be evaluated first, with attention to respiratory status and oxygen saturation (supplemental oxygen if <94%). 3

• Vital signs monitoring including heart rate/rhythm, blood pressure, temperature, oxygen saturation, hydration status, and seizure activity. 1, 3

• Capillary blood glucose measured immediately, as hypoglycemia is a common neurological mimic requiring urgent correction. 3

• Time last known well must be documented for all treatment window calculations. 3

Standardized Neurological Scales

Use validated stroke severity scales rather than mnemonics: 1

• National Institutes of Health Stroke Scale (NIHSS) is the gold standard for quantifying stroke severity and guiding treatment decisions. 1, 3 The NIHSS should be performed on arrival, before treatment, and after treatment with thrombolytics. 1

• Glasgow Coma Scale (GCS) combined with pupillary examination for comatose patients with acute brain injury. 4

• Serial examinations should include mental status, brainstem reflexes (pupillary light response, oculocephalic, corneal, cough/gag reflexes), and motor examination. 1

Frequency of Assessment

• Daily assessment by neurologist/neurointensivist when available improves neurological care. 1

• Bedside nursing assessment every 1-4 hours based on acute brain injury risk is reasonable. 1

• For ICU patients with acute brain injury, continuous multimodality monitoring is the standard approach rather than isolated examinations. 4

Alternative Mnemonic: BRAIN ATTACK

While not a "STOP" mnemonic, the "BRAIN ATTACK" mnemonic has been described in nursing literature for managing acute stroke complications, though it lacks the validation of standardized scales. 5 This is primarily an educational tool rather than a validated assessment instrument.

Critical Pitfalls to Avoid

• Do not wait for laboratory results to initiate neuroimaging or acute treatment, except for specific situations (e.g., INR in warfarin patients). 1, 6

• Neurological evaluation is frequently confounded by sedatives and paralytics in the early post-cannulation period for ECMO patients, necessitating multimodal monitoring. 1

• Fixed dilated pupils during CPR after epinephrine administration should not be equated with irreversible brain injury, as patients can achieve favorable outcomes despite these findings. 1

• Avoid relying on isolated monitoring values—review trends and integrate multiple data sources during clinical decision-making. 4

Recommended Structured Protocol Instead of STOP

For acute stroke team response, implement a "Code Stroke" protocol that includes: 1

1. Prenotification from ambulance to ED/stroke team
2. Rapid ABC assessment with triage category assignment (<10 minutes)
3. Rapid patient registration or pre-registration alias
4. Priority CT scanner access
5. Immediate IV access with blood draw
6. Immediate CT transfer with focused history (time last normal, anticoagulant use)
7. Rapid imaging interpretation with NIHSS completion
8. Blood pressure control per thrombolysis criteria
9. Thrombolytic bolus/infusion initiated at CT scanner when possible

This structured protocol achieves door-to-needle time <60 minutes and door-to-imaging <25 minutes, which are the validated time targets that improve morbidity and mortality. 1