# Stroke or.....what?



## proseqtr (Feb 24, 2015)

Give me your opinions of what in the heck this was. Alright, dispatched to possible stroke. Once on scene, we find a male patient who is in his early 60s is sitting in a chair with all positive stroke test symptoms. BP 188/102, pulse 111 BPM, SPo2 89, Resp. 10 shallow light wheezing, blood glucose 90, skin is hot, slightly clammy with cold fingers on right side (same side as facial drooping), right pupil is fixed, patient is incontinent of urine, and patient responds to voice with grunts and will follow most directions- GCS: 11. Family members say symptoms started about 45 minutes prior to calling and that he hasn't wanted to eat or drink anything for approximently the last 36 hours so he's obviously dehydrated at this point. He has a history of hypertension and is allergic to nitro. Enroute to hospital, patient is given o2 at 2 LPM via NC and IO normal saline (IO instead of IV because no good vein access due to dehydration.) After a few minutes his BP just skydives down to 138/70, pulse 79, SPo2 100, resp. 15 normal. The facial drooping goes away, and he just sits up and says "oh hey fellas, what's up?" He is fine for several minutes then his BP drops to 88/52, pulse 48, resp. 32 shallow-which is the exact opposite of where we started! The facial droop returns, still awake, just doing the same as at first now. Then next thing I know, he's fine again. We get to the hospital and he is still fine until we get him in the bed and then everything goes back to how we first found him. Any ideas?


----------



## BlueJayMedic (Feb 24, 2015)

This sounds to me like an epidural bleed.  I had something similar in a 40 year old female one time and that was her final dx before transfer.  High pressure sustained for a short time and then return to GCS 15 A/Ox3 and then back to a decreased LOA and hemodynamic instability. This is interesting as I would not expect to see the decrease in BP for the second set of vitals you listed in a bleed and I wouldn't expect repeating symptoms with a clot. Were you able to return to the hospital to find results of a CT or anything?


----------



## Brandon O (Feb 24, 2015)

Tricky. There's a fellow who needs a 12-lead and a more thorough history and exam.


----------



## Ewok Jerky (Feb 24, 2015)

Any falls? EtOH or drugs? Med list? Anything like this ever happen before? Headache? N/V? Gradual onset or sudden?

Any Hx besides HTN? Cancer? Does he have a cardiologist?

Can you elaborate on "all positive stroke test symptoms"? What else on physical exam? Did you check extraoccular movements? Did he have any gaze deviation? SOB? Chest pain?

Iinteresting case. Would love to get the CT results.


----------



## proseqtr (Feb 24, 2015)

BlueJayMedic said:


> This sounds to me like an epidural bleed.  I had something similar in a 40 year old female one time and that was her final dx before transfer.  High pressure sustained for a short time and then return to GCS 15 A/Ox3 and then back to a decreased LOA and hemodynamic instability. This is interesting as I would not expect to see the decrease in BP for the second set of vitals you listed in a bleed and I wouldn't expect repeating symptoms with a clot. Were you able to return to the hospital to find results of a CT or anything?


Wasn't able to learn anything at that time because the hospital we had to transport him to was a fair drive off and they needed units back in county but I happened to have a transfer to that hospital today and ran into the same doctor I left this interesting case with. See bottom of this post.



Brandon O said:


> Tricky. There's a fellow who needs a 12-lead and a more thorough history and exam.


Well we had him hooked to a 4-lead on scene which the medic and I both agreed it looked to be a slightly tachy sinus rhythm at that time, however down the road in the truck we were having problems with the leads staying on because as I said his skin was clammy plus the we had that night wasn't out usual truck, it was older and VERY bumpy on the road so you don't get a good reading while driving and since we suspected stroke and since the stroke center was a fair length drive, we weren't going to sacrifice any more time than we needed to. As for history, well the family was one of those "we don't know and hell no you ain't looking in our medicine cabinet" types when it came to meds. Also see bottom of this post please.



Ewok Jerky said:


> Any falls? EtOH or drugs? Med list? Anything like this ever happen before? Headache? N/V? Gradual onset or sudden?
> 
> Any Hx besides HTN? Cancer? Does he have a cardiologist?
> 
> ...


He did have pronounced gaze deviation and arm drift. No chest pain or signs of it from what I could tell though. As for history and the rest, please see below.



Alright everyone, I caught up with the doctor I left this patient with the other night. He told me that the patient had a moving clot in his brain so, as the MD put it, he was trying to have a stroke. Now things get very interesting. This is what the MD said he pieced together from all the different points of view he got. One of the family members had apparently crammed one of the patient's immediate release Isoptin tablets down his throat when he was unresponsive then ran off several minutes later to call 911 and while doing so, the clot started trying to move again so he became aware of himself and guess what? He remembered, "oh I should probably take some of my blood pressure meds." Which he did, swallowing yet another IR Isoptin without water "as he usually does." Well remember, he's had nothing to eat or drink in the past 36 hours. His stomach isn't moving anything fast. Those tablets aren't dissolving like they normally would. Then here I come giving him an IO of normal saline. Things start processing at a more normal pace now that we got some fluids going. The clot moves and his blood pressure med starts kicking in as well and BP skydives but then they start working too much because he has accidentally ODed so then BP bottoms out. Well then that clot gets stuck again and and plus the by now I finally managed to get venous access and so he has saline IO AND IV moving the meds through their course rather quickly so his BP starts rising again and by the time we are at the hospital he's back to how he was to begin with. He got TPA though and I was told he is doing fine, just had a bad day that day.


----------



## Brandon O (Feb 25, 2015)

Cool. Sounds like a House episode.


----------

