# 85 Y/O M Fall



## emscrazy1 (Sep 30, 2012)

This morning approx. 03:45 we get a call for a fall. Pt wife states he lost balance and fell. We get there an assess the man and find out he has no head neck or back pain. Also no evidence of him hitting his head. We sit him on the toilet and as we're assisting him to the toilet I notice he is slightly weak on his L side. He has Hx of CHF, TIA, pacemaker. BP 97/63 HR 72. Continued to stay slightly hypotensive. As he finished on the toilet I noticed that he is has noticeable L sided weakness. It has progressed. He states slightly lightheaded pointing to R side of head. He couldn't say much more.  Wife says no deficit from prev TIA and he normally walks and swims. I call ALS and they take him for possible stroke but no stroke alert since the wife couldn't confirm an onset time. What do you think? Stroke alert or no?


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## Aidey (Sep 30, 2012)

No onset time = No stroke alert.


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## Veneficus (Sep 30, 2012)

Aidey said:


> No onset time = No stroke alert.



Agreed.

You could probably make a case if you witnessed the deficits worsening, but I don't think the recieving facility would buy it.

I would take him to a stroke center, preferaly one with direct arterial tPA if you have such in your area.

That way he would get his CT and Neuro at the facility can make the call.


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## Melclin (Oct 1, 2012)

I'd be delving more deeply into the onset times, really trying to nail one down. No clear onset, no draino. 

I recently did a stroke where an elderly woman living with her son was found sitting on the ground having fallen from her chair while eating breakfast, O/E: dysphasia, some minor L sided deficit. The son had seen her the previous night but had not seen her before her fall in the am. The hospital considered this to be a case without a clear onset time, despite my partners argument that she would not have been able to get out of bed, get dressed, shower and prepare breakfast had she been symptomatic before the fall (suggesting the fall could be considered as being approx the same as the onset time). Incidentally, I didn't agree that the level of deficit she had would have prevented her from doing those things, but it is an example of how militant the hospitals can be with onset times.  

Also, here they tend only to thrombolyse strokes causing major motor or speech problems, and sometimes major visual problems. It doesn't sound like this guy had that pronounced a deficit but maybe I'm reading it wrong. 

Certainly could benefit from the experienced multidisciplinary approach of a good stroke centre. Also as vene notes, there are some pretty amazing things they can do at major stoke centres like clot retrieval, IA tPA and hemicraniectomy (although from what little I know, it doesn't sound like he would have been a candidate for some of these).


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