# Possible CVA call



## JCEMTB (Oct 10, 2011)

Okay so tonight we got a call for Mental Status Change. Our patient was a0x1, nonverbal, and could not follow commands, pupils = but slow to react. Patient is normally aox2, somewhat verbal, and follows commands. History of a-fib and past CVA. vital signs all within normal limits. onset of symptoms appox. 3 hours.

Patient has left sided facial droop, cannot get her to grip hands or speak, or follow commands to check for arm drift. The staff is unsure if facial drooping is new or old onset (as patient has hx of cva). We decide to run it as a priority r/o stroke given the mental status decrease, inability to follow commands etc. This decision was coupled with the hx of a-fib which I know can cause clots to be thrown. The hospital threw a fuss at us and said it was probably just sepsis, but she didn't feel febrile to us. Anyways, given what i've told you, would you do the same? I felt running it as a priority was the right thing to do.


----------



## Anjel (Oct 10, 2011)

This was running as a bls call?

I probably would of did the same.


----------



## Trauma_Junkie (Oct 10, 2011)

The AMS would be enough of a cause for it to be run priority. While the hx is good to know (specifically hx of CVA and A-fib), it wouldn't change my treatment of the PT in this case.


----------



## abckidsmom (Oct 10, 2011)

Coming from a nursing home?  All AMS has sepsis high on the list until proven otherwise.  

No fever?  Means nothing.  In that case, they probably just missed the fever 3 days ago, and she's in failure now.

In my little world, all nursing home patients who are transferred out immediately have pneumosepsis or urosepsis until proven otherwise by something else.  This is really true in at least 80% of cases, no exaggeration.  

A&0x2 at the baseline?  I would need some good, clear, obvious signs (plural) to call a stroke alert.  3 hours out (especially in a nursing home, where 3 hours NEVER EVER means 3 hours) the time saved is not worth calling the alert.  

My .02.


----------



## ArcticKat (Oct 10, 2011)

Hmm, onset was 3 hours ago?  How much time did it take you to get to the hospital with your lights and sirens?  If you didn't save more than 30 minutes then you shouldn't have gone L/S.


----------



## mycrofft (Oct 10, 2011)

*Sounds like a high potential for CVA.*

Tell the receiving ER your brain scanner is broken.
Yeah, sepsis...some older folks never "spike" a temp when septic.


----------



## jjesusfreak01 (Oct 11, 2011)

Related question. What kind of response in hospital does a "code stroke" receive at arrival, in reference to everyones different experiences? Unless they call in the neurologist and open the cath lab, I can't see it being a big deal to call the code ahead of time.


----------



## exodus (Oct 11, 2011)

jjesusfreak01 said:


> Related question. What kind of response in hospital does a "code stroke" receive at arrival, in reference to everyones different experiences? Unless they call in the neurologist and open the cath lab, I can't see it being a big deal to call the code ahead of time.



A stroke code means rapid intake, and then 90% of the time straight from our gurney to the CT table.


----------



## CAOX3 (Oct 11, 2011)

JCEMTB said:


> Okay so tonight we got a call for Mental Status Change. Our patient was a0x1, nonverbal, and could not follow commands, pupils = but slow to react. Patient is normally aox2, somewhat verbal, and follows commands. History of a-fib and past CVA. vital signs all within normal limits. onset of symptoms appox. 3 hours.
> 
> Patient has left sided facial droop, cannot get her to grip hands or speak, or follow commands to check for arm drift. The staff is unsure if facial drooping is new or old onset (as patient has hx of cva). We decide to run it as a priority r/o stroke given the mental status decrease, inability to follow commands etc. This decision was coupled with the hx of a-fib which I know can cause clots to be thrown. The hospital threw a fuss at us and said it was probably just sepsis, but she didn't feel febrile to us. Anyways, given what i've told you, would you do the same? I felt running it as a priority was the right thing to do.



Its probably sepsis but it could be a CVA, you made a call, stand by it.

Dont sweat it, people will be second guessing you everday in this field.


----------



## Oiball (Oct 11, 2011)

That approx. 3 hours becomes relevant in this case, if it is in fact a CVA.  Since your brain scanner was offline at the time (attempt at humor), rapid transport was certainly warranted.  It seems the case was pushing the limits for tPA, so every minute counts.


----------



## Handsome Robb (Oct 11, 2011)

We have neurologists here using tPA as far out as 6 hours. Never personally seen anything longer but I've had co-workers tell me the have seen it as given at 8 hours.


----------



## JPINFV (Oct 11, 2011)

NVRob said:


> We have neurologists here using tPA as far out as 6 hours. Never personally seen anything longer but I've had co-workers tell me the have seen it as given at 8 hours.



Yep, and it's even trickled down to medical school already. 3 hours, sometimes 4, but we're being taught that some neurologists are pushing further. That time frame isn't quite as hard as it seems.


----------



## ArcticKat (Oct 11, 2011)

Oiball said:


> That approx. 3 hours becomes relevant in this case, if it is in fact a CVA.  Since your brain scanner was offline at the time (attempt at humor), rapid transport was certainly warranted.  It seems the case was pushing the limits for tPA, so every minute counts.



The OP doesn't indicate how far away the hospital was.  If it was only a 10 minute drive then a stat transport wasn't appropriate.  Our nearest CT scanner is 175kms away.  We only use our L/S if we are able to cut the time sufficiently to have an onset to CT time of 4 hours....basically, if we depart the scene within 2 hours of onset, no lights and sirens because we have plenty of time to get there, likewise, over 2 hours and thirty minutes, also no lights and sirens because we'll never make it within the alloted window. Between those times we'll run L/S to make it within the window.


----------



## FFEMT427 (Oct 11, 2011)

The current guidelines for TPA is 4 1/2 hours which was pointed out that in a NH that can mean anywhere from a day to a week depending on when they get aroung to looking at there patients. If you feel that going L/S was in this patients best interest and it was done as safe as possible hold your ground (unless you carry a CT in your back pocket)


----------



## Remeber343 (Oct 14, 2011)

FFEMT427 said:


> The current guidelines for TPA is 4 1/2 hours which was pointed out that in a NH that can mean anywhere from a day to a week depending on when they get aroung to looking at there patients. If you feel that going L/S was in this patients best interest and it was done as safe as possible hold your ground (unless you carry a CT in your back pocket)




Those CT's aren't standard issue for everyone!?  We must be spoiled with ours then!


----------



## exodus (Oct 14, 2011)

ArcticKat said:


> The OP doesn't indicate how far away the hospital was.  If it was only a 10 minute drive then a stat transport wasn't appropriate.  Our nearest CT scanner is 175kms away.  We only use our L/S if we are able to cut the time sufficiently to have an onset to CT time of 4 hours....basically, if we depart the scene within 2 hours of onset, no lights and sirens because we have plenty of time to get there, likewise, over 2 hours and thirty minutes, also no lights and sirens because we'll never make it within the alloted window. Between those times we'll run L/S to make it within the window.



Erhm. If you're 2+ hours away from a CT to r/o a stroke and start TPA. How is an air transport (fixed wing or helicopter) NOT indicated?

This study is for MI's but it's the same concept, tissue death. We want the intervention AS FAST as possible. No reason to drive the 2.5 hours when you can cut that time by more than an hour by using air transport. 

Source



> Early thrombolysis was associated with lower overall mortality rate (< 2 h, 5.5%; > 4 h, 9.0%), but no additional relative benefit resulted from earlier treatment with accelerated t-PA versus streptokinase (p = 0.38). Longer presentation and treatment delays were both associated with increased mortality rate (presentation delay < 1 h, 5.6% and > 4 h, 8.6%; treatment delay < 1 h, 5.4%, and > 90 min, 8.1%).


----------



## ArcticKat (Oct 14, 2011)

exodus said:


> Erhm. If you're 2+ hours away from a CT to r/o a stroke and start TPA. How is an air transport (fixed wing or helicopter) NOT indicated?



Erhm, I thought my post was pretty clear.  We're 175km from the CT, that would be 1:45 transport time following the rules of the road.  Dunno where you got the idea that we're 2+ hours away. 

Because the nearest helo is 800km away and the nearest airstrip capable of handling the King Airs we use is 120km away in the wrong direction.  Ground transport here isn't the fastest option, it's the only option.

The difference between the brain and the heart is vasculature.  The brain has far more of it, therefore the ischemia caused by the clot isn't going to progress toward necrosis as quickly as it would in the heart.  Check out an actual study on the brain.

Reperfusion Therapies for Acute Ischemic Stroke
Current Pharmacological and Mechanical Approaches

    Carlos A. Molina, MD, PhD


----------



## Sasha (Oct 14, 2011)

abckidsmom said:


> Coming from a nursing home?  All AMS has sepsis high on the list until proven otherwise.
> 
> No fever?  Means nothing.  In that case, they probably just missed the fever 3 days ago, and she's in failure now.
> 
> ...



Nursing patients always have: urosepsis and MRSA.

I wouldn't stress. The ER was probably having a bad day and needed someone to take it out on. What were the vitals??

Sometimes people never have a fever, sometimes 98 degrees IS a fever for folks, and sometimes you just miss the fever. A fever or lack thereof should not rule in or rule out sepsis.


----------

