Clinical approach to numbness

Just finished my first year out of residency. Working at a community shop with limited neuro availability. Wondering how everyone here approaches numbness in the ED setting? The approach I tend to follow is outlined below but I worry if I am wasting consultant's time and bogging down the ED with unnecessary stroke work-ups.

  1. First challenge I've found is figuring out if the patient is actually describing true numbness. Often they are describing paresthesias which I don't consider to be a true deficit. If this is the case I may consider some basic chemistry and/or glucose check.
  2. If no paresthesias then I try to determine does the patient have true numbness or are they describing a subjective decreased sensation. I find this is best assessed on physical exam. This distinction rarely affects my clinical practice but I find neuro often appreciates this distinction - especially when calculating NIHSS.
  3. Next I focus on where these deficits are. If the deficit crosses midline then I am less concerned for a neurologic process such as stroke. However, I find that if the entire hemi-face and/or unilateral extremity/extremities is involved I tend to lean towards considering a neurologic work-up - especially if full hemi-numbness.
  4. Next I focus on duration of symptoms. If going on for months then likely not acute and can be managed as outpatient.
  5. If going on for say a week I usually get a non-con CT head. I'd suspect that if a patient had a large enough ischemic event I should see something abnormal on the non-con (though I appreciate that this is not 100%). If CT (+) I admit for stroke work-up. If (-) then I discharge home with primary care follow-up.
  6. If symptom duration between 24-48 hours I still get the CT but will consider admission for stroke evaluation .
  7. If symptoms <4.5 hours I usually talk to our stroke service but they are rarely impressed by these consults and I worry I am wasting their time. They never feel the deficits are worth the risk of tPA which I tend to agree with. So now I am asking myself is this consult even worth it?

Just trying to figure out how some more seasoned ED doctors approach this issue.

EDIT: Edited for clarity regarding #2. Thank for everyone's advice so far. Very helpful.

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