# Massive STROKE



## Chris EMT J (May 13, 2022)

Patient in there 70s CC of not acting right. History of hypertension, 3 past TIAs, and diabetes type 2. Vitals as followed HR 108 and irregular BP 230/139 RR 9 O2 95% on Ra BGL was 105. Patient was mixing up words, was confused, and limping around. Got her to sit down the established a line, paramedic did a ECG and said it was AFib with RVR, proceeded to ask a few more questions to family and hasn't seen her in a few hours just got back from shopping. So we packed up patient and went to closest stroke center got there in about 15minutes. Another stressful call... I feel bad that the family member has had already 3 scares and this 1 may have been the nightmare they were expecting.


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## Aprz (May 14, 2022)

Nah, strokes are like the easiest "emergency" we can run. Don't be such a nervous bee. 

My priority on scene is to do a FAST exam or equivalent. Find out the patient's baseline mental and neuro. Are they normally confined to bed or use a wheelchair? Did they have a seizure (Todd's paralysis)? Get a blood sugar before stroke alerting.

Clarifying the time the patient was last seen normal "0900 today" is superior to "a couple of hours ago." More than once, a witness has made me look like an arsehole saying something like "1 hour ago", and then find out later that they have absolutely zero sense of time (and space). This is true for other conditions as well. You might get a patient who said their chief complaint started "15 minutes ago", but then when you get your call times, find out that they called 20-30 minutes ago.  I always clarified with my times. "15 minutes ago? You called 20 minutes ago. You sure? Is it OK if I say 9 AM?"

My history would focus on prior strokes, seizure history, "blood thinners", any recent trauma or surgery, cancer, radiation treatment, and DNR status.

If I could, I'd get any medication list or grab the medications physically and bring them with me in a bag to the emergency department.

I'd grab the patient's ID, insurance card, witness name and phone number, and bring it with me to the emergency department. I personally liked bringing the witness with me, if I could.

Do an IV during transport, but not sweat it too much if I didn't do one. Somewhat low priority. Nice for the hospital if it is somewhat average to big, at least 6" (whoops, bad joke), and somewhat proximal. Hopefully don't blow any veins. No more than 2 tries, but don't utilize both antecubital if you blew one already. Better to not do an IV than to blow it for the receiving facility.

Do a 12-lead if I could, but not sweat it too much. Me personally, this was probably the lowest of the low priority for me and only did it on somewhat longer transports. My agency wanted me to do 12-leads on strokes. When I did a 12-lead on strokes, I was really just going through the motions and didn't personally care too much about the 12-lead. Very low priority.

It's so common for atrial fibrillation to be fast. I wouldn't be too worried about it being a little fast.

Vital signs for the most part I wouldn't sweat. For me, most strokes didn't really have absurd vitals. Like I am aware of Cushing triad, but I've only appreciated that ONCE in like 6 years of being a paramedic and at least dozens of calls where I stroke activated (note: possible I missed strokes maybe). Under most circumstances, you don't have the right tools to treat hypertension so not a big deal. PS Don't give nitroglycerin to these patients pl0x.

Note: On prior interfacility transfers I've ran, we could treat or continue treatment for hypertension associated with a stroke. We'd do

2.5-15 mg/hr cardene by far the most popular
20-80 mg labetolol max 300 mg

We'd treat ischemic stroke that didn't receive tPA if the blood pressure was >220/120.

If they received tPA, >180/105.

Hemorrhagic stroke systolic >160 mmHg.

More specifically, if subarachnoid bleed systolic >140 mmHg.

Under some circumstances, we'd give 3% saline (hypertonic saline).

Anyways, for the most part, stroke patients just need a quick smooth ride to usually a primary stroke center. Sometimes they met criteria for comprehensive care. Some of them need intubation, but that hasn't been common in my experience. Crushing triad (hypertension or widening pulse pressure, bradycardia, irregular breathing) I've only appreciated once in my very short career. That patient rapidly deteriorated from being a stereotypical stroke call to being unresponsive with snoring respirations, needed intubation. Hypertension by itself was more common for me to see, but not that common still. Atrial fibrillation was pretty common for me to see, but even in non stroke calls. I've never seen cerebral T waves in real life. I constantly hear about people seeing STEMI with their strokes, but I personally never seen it (of course, 12-lead was low priority for me and usually the last thing I did, if time permitted). Personally, I also don't see unequal or unreactive pupils too often, even in stroke patients.






TL; DR FAST, last seen normal, what is normal, seizure, DNR, SAMPLE, witness name and phone number, quick smooth transport, do IV during transport, but don't sweat the IV too much. I feel like it is easier than the average call. Giving them a ride is probably the most important part prehospitally.


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## NomadicMedic (May 14, 2022)

This is probably the one call where an emergent transport is appropriate. 

The LKW time is the most important info you can gather. As precise as possible. Blood glucose is also a required data element on PCRs. You can’t lock a chart without one. 

At the request of our regional stroke coordinators, we ask ALS providers to get a 18g IV in the left AC, but to not delay transport. 

As @Aprz said, these are very simple meat and potatoes calls for us and almost never require more than an easy ride and lots of reassurance for what is probably a very frightened patient.


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## NomadicMedic (May 14, 2022)

And as an aide, this is not a “massive stroke”. This is a simple CVA. I hate the term “massive” when describing medical conditions, but if you insist on using that term, I’d reserve it for a CVA that is catastrophic, usually the result of a bleed. These are the patients that may require significant airway management and usually expire quickly.


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## DrParasite (May 14, 2022)

ChrisEMTA said:


> Patient in there 70s CC of not acting right. History of hypertension, 3 past TIAs, and diabetes type 2. Vitals as followed HR 108 and irregular BP 230/139 RR 9 O2 95% on Ra BGL was 105. Patient was mixing up words, was confused, and limping around. Got her to sit down the established a line, paramedic did a ECG and said it was AFib with RVR, proceeded to ask a few more questions to family and hasn't seen her in a few hours just got back from shopping. So we packed up patient and went to closest stroke center got there in about 15minutes. Another stressful call... I feel bad that the family member has had already 3 scares and this 1 may have been the nightmare they were expecting.


Not for nothing, but this doesn't sound stressful, but I disagree with asking more questions on scene and doing a 12 lead. 

If I hear a normal BGL, sky high BP, and new onset of "mixing up words, was confused, and limping around" I'm thinking stroke, which is a time-critical condition, and not one we can fix in the field.  I believe there was a study that said 10-25% of CVA patients are having MIs too (don't quote me, I was told this a while ago), but there comes a point when the clock is ticking, and your IV isn't gonna help, prehospital meds aren't gonna help,  and the only important questions are when did it start, and which stroke center do you want to go to.  there might be some more that you should ask on the way to the hospital, but those are the big ones.

I'm not a big fan of L&S to the hospital, because it doesn't save much, but in this case minutes can matter, and a heads up to the hospital is warranted.  Oh, and this shouldn't be stressful, but you should realize that time is of the essence, and move with a purpose.


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## Chris EMT J (May 14, 2022)

DrParasite said:


> Not for nothing, but this doesn't sound stressful, but I disagree with asking more questions on scene and doing a 12 lead.
> 
> If I hear a normal BGL, sky high BP, and new onset of "mixing up words, was confused, and limping around" I'm thinking stroke, which is a time-critical condition, and not one we can fix in the field.  I believe there was a study that said 10-25% of CVA patients are having MIs too (don't quote me, I was told this a while ago), but there comes a point when the clock is ticking, and your IV isn't gonna help, prehospital meds aren't gonna help,  and the only important questions are when did it start, and which stroke center do you want to go to.  there might be some more that you should ask on the way to the hospital, but those are the big ones.
> 
> I'm not a big fan of L&S to the hospital, because it doesn't save much, but in this case minutes can matter, and a heads up to the hospital is warranted.  Oh, and this shouldn't be stressful, but you should realize that time is of the essence, and move with a purpose.


We have the hospital a heads up with the stroke alert and went straight to CT


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## Akulahawk (May 23, 2022)

One of my final patients at triage last night ended up a stroke alert as well. There was decreased sensation and decreased strength on the left side (not flaccid nor completely numb), headache, all beginning a couple hours prior. Face has a very minimal but present droop and speech ever so slightly slurred (both extremely subtle and easy to miss/dismiss). I got the doc involved immediately and he called the stroke alert. Not a massive stroke by any means but sometimes strokes can present with very light symptoms that could be easily explained away.


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