Acute Ischemic Stroke

[SanDiegoEmt7]

A person I know had stroke last year and I had some questions regarding her care. Symptoms were aloc, +n/v, +dizziness, +tingling/numbness right upper extremity, -hemiparesis but +facial droop/tongue deviation, moderate headache, visual difficulties. Onset was at around 2100 the night of the event, unfortunately 911 was not activated (to my great dismay). The other family members there didn't recognize the stroke but did drive her directly to their area's level 1 ED, which is also a primary stroke center.

Her arrival to the ED triage was at 2200. Vitals at 2200: GCS 15, pulse: 89, BP 151/80, Resp 18, O2 Sat 98% RA. Here are the nurse notes in ED:

2200- 48 F GCS 15 IV started blood to lab waiting for Doctor eval
2320- Doctor in to eval
2335- Doctor orders EKG for pt ***she started feeling CP at this point***
0300- pt waiting to go to MRI
0415- pt to MRI
0505- pt back in room
0615- MRI positive for stroke, pt aware of findings

From there the notes go on to include general monitoring of pt and her symptoms, and a Neuro eval at 0915. She was then transferred to the ICU for cont. of care.

Here's where I would like some input, specifically from paramedics with experience and RNs. I don't understand why there was a such a delay in treatment/evaluation. Is it normal to wait 6 hours before getting an MRI? She was not given tPA therapy, she had no contraindications of getting thrombolytics that I can see. All the symptoms I noted above were recorded in the original triage paperwork. What are your general feelings and insights on how this was handled?

The CVA has left her with disabling visual deficits that resulted in the loss of her job (she was an RN) and inability to drive. She also has less obvious deficits in higher level reasoning abilities. It has now been 10 months with little improvement.

 

[vquintessence]

Sorry for your friend When you say onset was 2100 and initial medical eval began at 2200, is this the same evening?

It is concerning that obvious neuro deficits were not addressed until a couple hours after arrival, especially with sudden onset in a 48 Y/O. Any single indicator meeting 1 of the 4 criteria of Boston Stroke Scale has 33% probability. Her additional neuro deficits should have helped to focused the initial stages of assessment. Little caveat however, do you have access beyond your friends ED PCR? Meaning, were there any specialists notified/involved whom you don't have records about?

Regarding your question about time lapse to getting an MRI: that is difficult to answer. You said it's level 1 trauma center, so is it safe to assume the MRI is on site at the facility? If there was, what hours of operation does it have? There is also the unfortunate possiblity of there being more ostensibly "pressing cases" that had to be done.
Example: Boston Medical Center is a level 1 trauma center with two campuses, yet one campus shuts down it's CT and MRI scanning past 23:00.

About tPA initiation, I cannot answer your question because of uncertainties with your timeline. The window of optimal opportunity can be stretched to 4 1/2 hours (according to ostensibly successful yet still ongoing trials).

 

[VentMedic]

Who did and when was this assessment done since you said the family didn't recognize this as a stroke?

aloc, +n/v, +dizziness, +tingling/numbness right upper extremity, -hemiparesis but +facial droop/tongue deviation, moderate headache, visual difficulties.

What was her physical presentation like initially in the ED? When was the Stroke Team notified?

 

[Sasha]

Is it normal to wait 6 hours before getting an MRI?

Machines can get backed up, there are other patients in the hospital.

 

[paccookie]

We took a pt in for a possible CVA about two months ago. Took her to a level I trauma center that was recently certified as a stroke center. Pt was showing some signs - unequal grip strength, aphasic, confusion, slight facial drooping, difficulty ambulating. I can't remember her age, but she wasn't over 50. BP was high. We did IVs, 12 lead, blood draw, glucose level, etc in the field and transported 10-18. I think it took about 20 minutes to get to the hospital. Onset time was about 30 minutes prior to calling EMS (she was at work at a cardiologist's office...lucky her!). We spent about 15 minutes on scene, so total time since on set was about 65 minutes upon arrival to the ER. She went to CT within 10 minutes of arrival to the ER. CVA was diagnosed and interventions were done. She was discharged several days later with only a slight weakness on one side. My partner and I actually got a "brain saver" award from the hospital for that call, as did all of the other people who assisted in her care.

Your friend was unfortunate. I think it's difficult to judge from just one piece of documentation. Machines do back up, hospitals do have very critical patients come in that may need to be bumped to the front of the line, but your friend shouldn't have waited so long for a scan. I'm not sure why a CT wasn't done...I understand that to be the tool of choice for CVA diagnosis. If a hospital has an MRI machine, surely they have a CT machine. I'm not sure how it works at that particular hospital, but at our trauma center, CVAs are treated with the same urgency as STEMIs. I thought it was supposed to be the same way everywhere.

 

[Ridryder911]

I don't understand why there was a such a delay in treatment/evaluation. Is it normal to wait 6 hours before getting an MRI? She was not given tPA therapy, she had no contraindications of getting thrombolytics that I can see. All the symptoms I noted above were recorded in the original triage paperwork. What are your general feelings and insights on how this was handled?

The CVA has left her with disabling visual deficits that resulted in the loss of her job (she was an RN) and inability to drive. She also has less obvious deficits in higher level reasoning abilities. It has now been 10 months with little improvement.

Couple of things. MRI is not routinely performed for initial CVA diagnostics as a CT scan is much faster and more define for those types of injuries. I do not know why there was a MRI in lieu of a CT scan and why there would be a "gap" of time. Most will declare to see if the CVA is either ischemic or hemorrhagic, to consider and determine the use of fibrolytics.

If the patient displayed any possible contraindications such as neuro improvements or possible bleed, then that could be the reason.

I would investigate further and not to be rude, but be sure all of the facts are as described. If they are a stroke center, immediate evaluation from a physician should have been performed and most have CT of brain w/o infusion as a standing order. I would contact their Director of the program of your concerns.

R/r 911

 

[SanDiegoEmt7]

I am pulling all of this information off of the hospital chart, but I'm not sure if other information exists somewhere else.

Arrival at the ED was at 2200 hours the same day

The assessment I wrote was what they found on the initial triage exam. All of those symptoms were included. In the chart there is no mention of CVA until the MRI. Which makes me think they never called it a stroke code (which would have gotten an immediate CT) instead they did a non emergent MRI to further investigate and realized it was a CVA, because they didn't do an extensive neuro evaluation until 0930 when the neurologist was called after they got the MRI results.

To Sasha: yes machines get backed up, especially MRI, but how long does it take to do CT to rule out hemorrhage. And yes the hospital has two in house CT scanners as well as at least one portable CT scanner. This hospital is the only level one trauma center for hundreds of miles in all directions, I would assume they would have 24 hour services available.

I have the entire patient chart for her stay at the hospital, but yes there was a neurologist involved who might have other records.

There was no way to show improved neuro improvements because they never did an initial in depth neuro evaluation. They did say in the discharge summary that patient improved, but this is regarding the n/v and headache, her deficits never improved, in fact she told me that when she initially got there her vision wasn't that bad just a little blurry, as she sat there it got worse and worse. Not to mention that she was extremely altered and confused, when I visited her it 2 days later it was still very apparent. Based on their assessment and vital signs and looking at the nationally accepted indications/contraindications for fibrolytics she seemed like a candidate for therapy, but in that hospital apparently there are only two neurologists that can provide that treatment. The one that was on call that day was not called in until 0930 after the MRI, approximately 12 hours after onset at which point the thrombolytics probably would have been ineffective, or the risks outweighed the benefits.

This hospital is supposed to be an integrated stroke center that takes "a multidisciplinary approach to provide state-of-the-art care for patients suffering acute stroke" with a specialized stroke team in the ED that includes specialized reperfusion nurses and a vascular neurologist, along with ED physicians, radiologists, specialized telemetry nurses, etc.

 

[Ridryder911]

Most hospitals do not require neurologist or strokelogist to make a determination to give fibrolytics or not. After a CT is performed and declared non-bleed the stroke protocol is initiated. I would find it hard to believe that they would have to wait for permission to activate the protocol as time is precious.

If the patient wants or pursue, then I would do so.

 

[JPINFV]

Any single indicator meeting 1 of the 4 criteria of Cincinnati Stroke Scale has 33% probability.

Fixed that for you. Just because Massachusetts sets a specific and lame wording for the speech test doesn't give them the right to steal the test and claim it as their own. Besides, the Los Angeles Prehospital Stroke Screen is better.

 

[vquintessence]

Fixed that for you. Just because Massachusetts sets a specific and lame wording for the speech test doesn't give them the right to steal the test and claim it as their own. Besides, the Los Angeles Prehospital Stroke Screen is better.

Yes, Cincinnati was the "originator". My mind wanders sometimes, but thanks for the imperative correction!

 

[JPINFV]

One of the numerous things that bugged me about working in Massachusetts was that bit of stupidity and, in my opinion, verges on intellectual dishonesty. On that note, the comfort care/DNR protocol is incredibly too unwieldy.

 

[vquintessence]

One of the numerous things that bugged me about working in Massachusetts was that bit of stupidity and, in my opinion, verges on intellectual dishonesty. On that note, the comfort care/DNR protocol is incredibly too unwieldy.

Intellectual stupidity verging on narcissicm? To imply my mistake was done deliberately, in an attempt to promote Massachusetts? Can't say I understand your angle, but hell, alright. Perhaps an agent of the MA advocacy council has infiltrated EMTLIFE. Fact of the matter is it was a brain fart. Either way I'm enjoying the irony of being labelled a promoter of Massachusetts. If your comment wasn't on a personal level, I apologize for the tongue and cheek; just confused by the above comment.

 

[JPINFV]

Intellectual stupidity verging on narcissicm? To imply my mistake was done deliberately, in an attempt to promote Massachusetts? Can't say I understand your angle, but hell, alright. Perhaps an agent of the MA advocacy council has infiltrated EMTLIFE. Fact of the matter is it was a brain fart. Either way I'm enjoying the irony of being labelled a promoter of Massachusetts. If your comment wasn't on a personal level, I apologize for the tongue and cheek; just confused by the above comment.

Oh, no, there was nothing personal about it, unless you developed the BSS. I worked for 6 months outside of Boston before I moved back to California, so I'm familiar with the setup, and stupidity, of Massachusetts OEMS.