# Stroke?



## RedAirplane (Sep 29, 2015)

Dispatched as a foot team to the corner of Main St & Boring Ave for a 78 year old female "not feeling well."

Upon arrival you find a huddle of people surrounding the lady sitting on the sidewalk hyperventilating. 

You begin taking to her, getting on her level and turning off your radio to try to minimize agitation in what is clearly a stressed patient. A couple questions reveal that the patient is altered. (Slow response to "what is your name?", when asked about what is happening / where she is she says " I don't feel good ... need help")

Bystander advises she had a stroke last year. You ask the pt to smile. The smile is asymetric. You ask her to grip your arms. One arm is strong, the other arm barely is holding on to yours. You ask her to repeat "The sky is blue" and she looks at you and says nothing, but has the "I'm thinking / I'm confused" look on her face.

You advise partner of possible stroke and he starts coordinating with PD for the ingress of an ALS ambulance through the crowd. 

A quick measurement with the pulse oximiter gives HR 91 and SpO2 99% on ambient air. Pt has a history of panic attacks leading to hospitalization with unspecified Rx used to treat. Pt also had a stroke last year, takes Lipitor. Pt had breast cancer and underwent radiation therapy and is thus taking an estrogen blocker. The pt is confused and the bystanders are unsure about any additional medications.

It's hot outside (90-100 degrees). The pt was seated indoors all day in air conditioning and came out for a walk and to see the festival, has been here about 20 minutes. Previously they were at a fast food place where pt ordered a large soft drink, so bystanders advise "she shouldn't be dehydrated." Later you learn that the pt didn't drink any of the soft drink, so you suspect dehydration.

As paramedics arrive, you begin talking with them and answering their questions. Meanwhile your partner decides to do a quick reassessment and finds that the pt is no longer hyperventilating and is now no longer confused, and is A&Ox4.

Paramedics assume care of the patient. They do a 12 lead, blood glucose, etc and then load into the rig and presumably transport.

Is this the presentation of a stroke? Could it be residual mental status deficits from the previous stroke? TIA since she apparently got better? Could panic or heat exhaustion mimic the stroke scale symptoms? Anything you would have done differently? (BLS level).


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## Brandon O (Sep 29, 2015)

Need to try and sort out what her baseline is after the prior event.


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## Flying (Sep 29, 2015)

> Could it be residual mental status deficits from the previous stroke?


Good question to ask during the basic exam. How off is the patient during the event? How off is she when the symptoms "resolved"?

Stroke history and +Cincinnati screen would've warranted questions about timing of the symptoms and when and where the previous stroke was treated. Pupillary rxn would be nice to have.

As a BLS unit, patient would be immediately transported, taking on ALS line-of-sight is acceptable, but we're planning on beelining to a stroke center. Dehydration gets a second seat, quickly note motility of skin in a few seconds during the basic exam (signs of tenting? sunken eyes/cheeks?). Blood pressure would be nice to have as well.

Whether or not panic/heat would mimic those symptoms seems to me a worthless question, the means to address the problem (a change in environment) should be introduced by you even when assuming stroke.


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## RedAirplane (Sep 29, 2015)

Flying said:


> Whether or not panic/heat would mimic those symptoms seems to me a worthless question, the means to address the problem (a change in environment) should be introduced by you even when assuming stroke.



Was just curious to know what was actually happening, obviously you err on the side of assuming a stroke.



Flying said:


> As a BLS unit, patient would be immediately transported, taking on ALS line-of-sight is acceptable, but we're planning on beelining to a stroke center. Dehydration gets a second seat, quickly note motility of skin in a few seconds during the basic exam (signs of tenting? sunken eyes/cheeks?). Blood pressure would be nice to have as well.



Good point. If we were a BLS ambulance I'd do that. As a first response unit we had to wait.



Flying said:


> Stroke history and +Cincinnati screen would've warranted questions about timing of the symptoms and when and where the previous stroke was treated. Pupillary rxn would be nice to have.





Brandon O said:


> Need to try and sort out what her baseline is after the prior event.



Pupils were pinpoint, but it was bright daylight, so... 

Family members advise "she is sometimes a bit off." 



Flying said:


> How off is she when the symptoms "resolved"?



I didn't have a chance to notice. My partner chimed in that as I was handing off to paramedics, she became A&O.


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## Flying (Sep 29, 2015)

RedAirplane said:


> Was just curious to know what was actually happening, obviously you err on the side of assuming a stroke.


Can't say anything without a better history, CT, blood tests, and other hospital resources I neglect to know. Stroke mimics are an area of study in themselves.


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## Akulahawk (Sep 29, 2015)

Sometimes you just have to follow your instincts on something. A couple weeks ago I had a drunk patient that had recently had a ground level (actually seated) fall. He never lost consciousness, and the fall was witnessed. No previous neuro history, no previous significant cardiac history. Pt had a very slightly weaker grip and push/pull on his left side, but he could move all extremities just fine. He also had a barely perceptible facial droop on that left side. He had slurred speech... and an EtOH level around .240... so some of this stuff was expected. We had the MD examine the patient very early on though the MD wasn't too concerned yet, we got the MD to do a head CT sooner than later. That CT showed a bilateral subdural hematoma. 

The other RN that was working with me on this patient and I both pushed for this guy to be looked at more in-depth because we knew something wasn't right, something more than "just" being drunk. If we hadn't pushed for a more thorough workup early on... The point is, know how to do your assessment and be able to better quantify your findings. You never know when something being just a "little off" can lead to, like telling you something more profound is occurring than is immediately obvious.


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## NTXFF (Oct 1, 2015)

This is tricky because of the change of mental status so quickly back to A&OX4.  I'd lean more towards TIA.  Calling for an ALS ambulance I feel is the right decision because it could of been something as simple as little heat exhaustion or something as serious as you mentioned earlier, a stroke.  The important thing is you formed your working field diagnosis and continued your assessment.


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