# Stroke?  Or what?



## adamjh3 (Dec 2, 2011)

BLS unit dispatched to a vascular access center at 1412 info en route states you have an 81 yo M hypoglycemic. No further info available. 

You arrive on scene at 1432 to find an 81 yo M sitting upright in a wheelchair, unresponsive but breathing. Story from the nurses and correlating paperwork states he came in at approximately 1200 for a declotting of his fistula. You are unable to obtain a history on the patient other than he's normally a&oX1 but always alert. 

At about 1230 s/p scheduled procedure the patient goes unresponsive. Facility nurses then recorded a bgl of 45 and administered 2 amps of D50 via IV. bgl rechecked at 1345 and is recorded at 234, pt remains unresponsive. Facility calls pts son to authorize bls transport to a hospital 15 minutes away. 

Pts vitals are as follows
P:110 with a fib/flutter on the facilities monitor. Palpated pulse  correlates and is strong at the radial site
R:12 full and effective w/clear lungs W/spO2 @98% on room air.
BP: 126/58
Eyes PERRL @ 3
Skins are pink cool and dry. 

Contact with your base hospital (the aforementioned hospital 15 minutes away) to activate a stroke code ends up with them requesting you transport l&s but go directly to an ED room. No stroke code is activated.

My thinking with calling a stroke code was a clot could moved into the brain during the declotting of the fistula. The ED staff seemed unworried and pretty much brushed us off. 

Offload was about ten minutes shy of three hours from the onset of symptoms.

Your thoughts? 

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## NomadicMedic (Dec 2, 2011)

Could be a CVA. When was his last dialysis?


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## adamjh3 (Dec 2, 2011)

n7lxi said:


> Could be a CVA. When was his last dialysis?



48 hours prior to the procedure

Forgot to mention, pt has bilateral BKAs if that's important here. 

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## NomadicMedic (Dec 2, 2011)

Why was no stroke code activated? Did the PT go right to CT? Any sign of hyperk on the 12 lead? Did you see any labs or an ABG?


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## adamjh3 (Dec 2, 2011)

n7lxi said:


> Why was no stroke code activated? Did the PT go right to CT? Any sign of hyperk on the 12 lead? Did you see any labs or an ABG?



I called to request a stroke code, the radio nurse requested we go to an ED bed. Pt did not go to CT as of when we cleared which was about 30 minutes post arrival.

No 12 lead available, this was a BLS truck, we used the three lead at the vascular center that was already hooked up. EKGs are out of my scope. 

No labs provided. 

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## JPINFV (Dec 2, 2011)

It doesn't sound like a stroke. Assuming he's a dialysis patient, I'd like a chem 7 and a CBC and maybe a CT. 

In regards to the fistula causing a stroke, what are the 2 big organs with lots of capillaries that stands between the fistula and the brain?


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## adamjh3 (Dec 2, 2011)

JPINFV said:


> It doesn't sound like a stroke. Assuming he's a dialysis patient, I'd like a chem 7 and a CBC and maybe a CT.
> 
> In regards to the fistula causing a stroke, what are the 2 big organs with lots of capillaries that stands between the fistula and the brain?


Lungsband heart.

Someone already called me out on that via PM (which I'll reply to when I get home, its a pain to quote segments on my phone).

I didn't even think about that until they brought it up.

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## NomadicMedic (Dec 2, 2011)

As a BLS truck, you did the right thing. 

Can't tell anything without any additional diagnostics, stuff that you don't have. 

I'm still guessing a CVA, close second is an electrolyte imbalance. Again, can't tell without CT and labs.


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## JPINFV (Dec 2, 2011)

Specifically the lungs unless some other disorder (such as a septal defect or patent ductus arteriosus) is present. Clots from the veins causes PEs, clots in the arteries causes organ infarct (spleen, kidneys, heart, brain).


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## JPINFV (Dec 2, 2011)

n7lxi said:


> I'm still guessing a CVA, close second is an electrolyte imbalance. Again, can't tell without CT and labs.



Unless the issue with the fistula is being treated as a red herring, what is making you think CVA?


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## Handsome Robb (Dec 2, 2011)

JPINFV said:


> It doesn't sound like a stroke. Assuming he's a dialysis patient, I'd like a chem 7 and a CBC and maybe a CT.
> 
> In regards to the fistula causing a stroke, what are the 2 big organs with lots of capillaries that stands between the fistula and the brain?



Seeing as chronic afib is a recognized risk factor for a CVA I'm not seeing your point. Not arguing just wondering if there's something I'm missing. I don't foresee a clot from the fistula getting caught in the heart unless it gets caught in the turbulent flow in the atria from the afib and with what I said before about chronic afib and CVAs a clot could definitely make it through the lungs.


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## NomadicMedic (Dec 2, 2011)

A suddenly unresponsive PT who's normally alert? I'm going to guess a CVA, especially if he was alert when he came in, he has Afib and is undergoing treatment for a clot. ;/ 

CT him. If its not a clot (or a bleed, made worse by those 2 amps of D50) great. Then we can look for a secondary cause. 

Now, is he septic? Maybe. Is it hyperkalemia? Maybe. A simple UTI? Maybe. Who knows without diagnostics that the OP can't provide. Maybe some follow up from the call will come. 

Until then it's just a guessing game.


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## adamjh3 (Dec 2, 2011)

As far as sepsis, the patient would generally have a fever, yes? Sublingual temp was 98.3

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## Handsome Robb (Dec 2, 2011)

adamjh3 said:


> As far as sepsis, the patient would generally have a fever, yes? Sublingual temp was 98.3
> 
> Sent from my DROID X2 using Tapatalk



Generally but not always. Wouldn't be the first time a septic patient was afebrile.


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## NomadicMedic (Dec 2, 2011)

adamjh3 said:


> As far as sepsis, the patient would generally have a fever, yes? Sublingual temp was 98.3
> 
> Sent from my DROID X2 using Tapatalk



Not necessarily.


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## JPINFV (Dec 2, 2011)

NVRob said:


> Seeing as chronic afib is a recognized risk factor for a CVA I'm not seeing your point. Not arguing just wondering if there's something I'm missing.



You're missing that I missed that the patient was in a-fib.


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## Akulahawk (Dec 2, 2011)

JP: It still could very well be a CVA. Given that there's known Atrial Fibrillation... Who knows if the patient is on some anticoagulant, and even then he could have developed a clot, which dislodged, and floated to the brain.

I'm certainly not getting the feeling that that this is/was a PE. To me,this "sounds" more like a CVA, and that close to the 3 hour mark, that patient would have run out of time well before reaching the CT scanner...

Just my thoughts.


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## DV_EMT (Dec 2, 2011)

Well Afib and fistula de-clot make me think Neuro, maybe they did have a stroke/CVA. Its hard to tell though since they're unresponsive. Did you see any facial droop and was the patient leaning even while in bed as though motor function was lost.

Could also be a clot that manifested elsewhere, but the vitals dont really show a good indication that it might be a PE.

As everyone has stated, Labs/CT would be the best course of action given the presentable info. Stroke Code was a good call (even my wife, a neuro RN of 6 years, agreed). 

Whats the PT History? why the BTK Amputation? ESRD (assuming since they are dialysis)? Diabetic?


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## JPINFV (Dec 2, 2011)

n7lxi said:


> A suddenly unresponsive PT who's normally alert? I'm going to guess a CVA, especially if he was alert when he came in, he has Afib and is undergoing treatment for a clot. ;/



Clots because of a surgical vascular anomaly (what he's being treated for) and clots because of a-fib aren't really the same. A clot generated from a fistula isn't going to cause a stroke without a right to left shunt.


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## JPINFV (Dec 2, 2011)

Akulahawk said:


> JP: It still could very well be a CVA. Given that there's known Atrial Fibrillation... Who knows if the patient is on some anticoagulant, and even then he could have developed a clot, which dislodged, and floated to the brain.
> 
> I'm certainly not getting the feeling that that this is/was a PE. To me,this "sounds" more like a CVA, and that close to the 3 hour mark, that patient would have run out of time well before reaching the CT scanner...
> 
> Just my thoughts.



In this thread, a page of "But he's in a-fib you stupid med student." :wacko:

I agree that there's no indication that the patient is having a PE. I'm guessing/assuming that the shunt is for dialysis access, which makes me concerned about the patient's electrolytes and RBC count.


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## Handsome Robb (Dec 2, 2011)

JPINFV said:


> You're missing that I missed that the patient was in a-fib.



It all makes sense now! I agree on liking to see some labs but with what we know now I'm with n7lxi and adamjh3 putting CVA at the top of my list of suspicion, hyperK does make sense too but no access to a 12lead pretty much ties your hand on that one.


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## JPINFV (Dec 2, 2011)

adamjh3 said:


> As far as sepsis, the patient would generally have a fever, yes? Sublingual temp was 98.3
> 
> Sent from my DROID X2 using Tapatalk



Fever is one diagnostic criteria for sepsis, but it isn't the only or a make or break criteria. This is especially true if there is any type of immunocompromise for any reason.


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## adamjh3 (Dec 3, 2011)

Hyponatremia? Though I didn't notice any seizure activity

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## JPINFV (Dec 3, 2011)

Do all cases of hyponatremia present with seizures?


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## adamjh3 (Dec 3, 2011)

JPINFV said:


> Do all cases of hyponatremia present with seizures?



Certainly not. Especially if it develops over a period of days rather than acutely... right? 

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## Handsome Robb (Dec 3, 2011)

adamjh3 said:


> Hyponatremia? Though I didn't notice any seizure activity
> 
> Sent from my DROID X2 using Tapatalk



Wouldn't hyponatremia show ecg changes such as ST elevation along with possibly bradycardia and hypotension presenting? Not enough sodium available for adequate depolarization or do I have it backwards? Again with no 12 lead but I would suspect a 3 lead, although non-diagnostic, would show elevation.


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## DV_EMT (Dec 3, 2011)

NVRob said:


> Wouldn't hyponatremia show ecg changes such as ST elevation along with possibly bradycardia and hypotension presenting? Not enough sodium available for adequate depolarization or do I have it backwards? Again with no 12 lead but I would suspect a 3 lead, although non-diagnostic, would show elevation.



I was thinking exactly the same thing. Hyponatremia will Probably present in ECG findings more likely than a seizure. Prolonged QT is one of the main findings for hyponatremia, whereas hypernatremia is a shortened QT.


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## HMartinho (Dec 3, 2011)

adamjh3 said:


> As far as sepsis, the patient would generally have a fever, yes? Sublingual temp was 98.3
> 
> Sent from my DROID X2 using Tapatalk



Could be hypothermic.


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## Dwindlin (Dec 3, 2011)

There is a lot of information I would like to see, but from what is given I don't know that I agree this is a stroke.  If the area of the stroke was large enough to affect consciousness then there should still be localizing symptoms.  If he is unresponsive and flaccid it could be a stroke in the basilar artery, but the other major arteries would be unlikely.  Same story with bleeds, if it's large enough to affect consciousness I would expect some other findings.

With the given information I'm leaning towards a more global process, metabolic or toxic.  Just my 2 cents.


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## NomadicMedic (Dec 3, 2011)

CVA or an electrolyte imbalance. Or demonic possession. 

Without CT, 12 lead and labs we're all just tossing darts at the board. 

Hey OP, how about some follow up?


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## adamjh3 (Dec 3, 2011)

n7lxi said:


> CVA or an electrolyte imbalance. Or demonic possession.
> 
> Without CT, 12 lead and labs we're all just tossing darts at the board.
> 
> Hey OP, how about some follow up?



Yeah, I shot an email off to my QA last night to see if I can't get some info from the hospital. 

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## NomadicMedic (Dec 5, 2011)

Any updates?


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## adamjh3 (Dec 5, 2011)

n7lxi said:


> Any updates?



Not yet. The joys of BLS in SoCal. It'll be a while before I hear back from my company. 

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## NomadicMedic (Dec 10, 2011)

Guess we'll never know.


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## Handsome Robb (Dec 10, 2011)

n7lxi said:


> Guess we'll never know.



exactly what I was thinking.


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## adamjh3 (Dec 10, 2011)

Is there any way for me to get the information myself without dealing with the sluggish corporate BS of my company? Who would I talk to at the hospital? I'm completely ignorant when it comes to how QA/QI works

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## Handsome Robb (Dec 10, 2011)

adamjh3 said:


> Is there any way for me to get the information myself without dealing with the sluggish corporate BS of my company? Who would I talk to at the hospital? I'm completely ignorant when it comes to how QA/QI works
> 
> Sent from my DROID X2 using Tapatalk



Theoretically you should be allowed access to his chart being as you were one of his providers. Ask the charge nurse about it. If it truly takes that long for corporate to get you a chart for QA/QI tell her that and if she/he has any sort of reasonableness to her she/he will help you out.


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## JPINFV (Dec 10, 2011)

How often do you visit that specific ED?  Maybe the nurse will remember you and that patient and be able to slip you some information.


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## adamjh3 (Dec 12, 2011)

Heard back from the sup that does QA/QI while I was driving to work this morning, he told me the hospital told him they don't have a pre-hospital care coordinator or anything like that, so to get info about the patient we'd have get a release from the family. I'll stop by the hospital today to see if I can't find anything out on my own.


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## adamjh3 (Dec 13, 2011)

adamjh3 said:


> Heard back from the sup that does QA/QI while I was driving to work this morning, he told me the hospital told him they don't have a pre-hospital care coordinator or anything like that, so to get info about the patient we'd have get a release from the family. I'll stop by the hospital today to see if I can't find anything out on my own.



Yup, the charge nurse told me the same thing when I went in today. 

It was Sharp Memorial, if there's anyone locally in the know who knows someone I can talk to in there that might be able to help me out, please PM me. I want to know what happened with this guy.


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## NomadicMedic (Dec 13, 2011)

Okay... Then for future reference, let's not put the "unsolved mysteries" in the scenario section. 

If you have a call that you're curious about, but don't know the outcome and have no way of learning the outcome, it's good discussion fodder but certainly not a scenario/teaching case.


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