New Partner's Grey Cloud

RocketMedic

RocketMedic

Californian, Lost in Texas
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Of Strokes! Four in three days. Two really stand out.

Case 1: 49 yo F, complaining of neck and back pain and "an explosion of pain in my head" when she turned to look at something the day after being rear-ended in an MVC. All vitals were normal, no injuries, looked like generic musculoskeletal pain....until she abruptly started slurring her words and having a very, very hard time speaking 2 minutes from ER. No other deficits, lasted about 20 minutes, then rapidly resolved. All vitals normal. TIA, admit for MRI.

Case 2: 85 M, on warfarin. Fell at 1100, got up, lived life and enjoyed his evening until he suddenly collapsed and became totally unresponsive at 2000. Decorticate posturing to decerebrate during transport, super hypertensive, GCS5 going to 4. I stepped in, called code stroke, and wanted to intubate, but we were less than 6 minutes from the hospital, he was maintaining his own airway (albeit with Cheyne-Stokes) and I took a fire rider and BLSd him in. I feel bad for not tubing him, but I think I did right- all I have is etomidate and versed, and I didnt want to wreck a good, working airway when I only have a few minutes and a half-assed facilitated intubation.
Turned out to be a massive brain bleed.
 
Case 1: She may have had some underlying Carotid Atherosclerosis before the accident which was exacerbated with the MVA causing the TIA. I have heard of strokes after deep tissue neck massages.

Case 2: Not much to say on that one, most likely a poor prognosis. I don't think you did anything wrong by delaying the intubation.
 
I'm also going to say that there may have been underlying carotid atherosclerosis. That's why Carotid sinus massages are discouraged.

For the old man, I'm always going to work CVA calls the same way - load and go ASAP, and do whatever interventions I can get in before we get to the hospital. If certain things don't get done, just document that additional interventions were not performed due to time constraints. Assuming that the pt is maintaining their ventilator status (use ETCO2 to help keep an eye on this), I would prioritize expeditious txp, basic vitals, IV access (BGL off of that), 12 lead, additional IV access, and then consider Drug-Facilitated ETI. Really, with a six minute transport, you're lucky to get vitals, give a report, and maybe get one line before you arrive at the hospital. If he were to stop breathing, the BLS could drop a King (if allowed in your area). The hospital has RSI, so why play around with half-arsed facilitated intubation?
 
Got dispatched to an ECF for a sudden onset stroke of less than 30 minutes (I about fell over when I realized that they didn't wait for 5 days to call us). When we got there, she was slurred, right side was flaccid (happened in front of daughter) pt normally alert * 4. pt had hip replacement was in for rehab.

As we were evaluating her, en route to hospital (7 minute scene time); called ED with stroke alert. I checked blood glucose levels when I started IV. BGL was 42; gave her D-50; and 4 minutes later at the ED she was fine: normal speech, normal muscle tone, no problems at all. Her daughter was almost as shocked as I was.
I have seen D 50 cure BGL problems, but never fully symptomatic stroke.

She was released in less than 2 hours, I kept in touch, while she was in ECF and she was fine
 
johnrsemt said:
I checked blood glucose levels when I started IV. BGL was 42; gave her D-50; and 4 minutes later at the ED she was fine: normal speech, normal muscle tone, no problems at all. Her daughter was almost as shocked as I was.
I have seen D 50 cure BGL problems, but never fully symptomatic stroke.

She was released in less than 2 hours, I kept in touch, while she was in ECF and she was fine
Click to expand...


It was most likely never a stroke. Unilateral weakness is suspicious but not impossible with hypoglycemia. Also, even with a fully resolved TIA she would still be admitted for work up.

Or my favorite Zebra: Seizure w/ Todd's paralysis. Which I actually saw the other day
 
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Chase said:
It was most likely never a stroke. Unilateral weakness is suspicious but not impossible with hypoglycemia. Also, even with a fully resolved TIA she would still be admitted for work up.

Or my favorite Zebra: Seizure w/ Todd's paralysis. Which I actually saw the other day
Click to expand...

I learned that lesson when I called in the cavalry on a 16 month old with a 30 minute seizure and totally down on the right afterward.

I was sure she was bleeding in her head.

I was quite wrong, and the attending helped me learn very strongly. Not the best day for me, but I learned a lot.
 
johnrsemt said:
Got dispatched to an ECF for a sudden onset stroke of less than 30 minutes (I about fell over when I realized that they didn't wait for 5 days to call us). When we got there, she was slurred, right side was flaccid (happened in front of daughter) pt normally alert * 4. pt had hip replacement was in for rehab.

As we were evaluating her, en route to hospital (7 minute scene time); called ED with stroke alert. I checked blood glucose levels when I started IV. BGL was 42; gave her D-50; and 4 minutes later at the ED she was fine: normal speech, normal muscle tone, no problems at all. Her daughter was almost as shocked as I was.
I have seen D 50 cure BGL problems, but never fully symptomatic stroke.

She was released in less than 2 hours, I kept in touch, while she was in ECF and she was fine
Click to expand...

THIS is an assessment issue.

If you're not checking a BGL but bragging about your scene time on your CVA pt, you're screwing up. Period.
 
The brain is like a top fuel dragster. Skip the additives, it (basically) demands oxygen and glucose in, and waste products out. Any part with a standing problem will be affected more (unilaterally) when either O2 or glucose are cut back or denied, such as asphyxia secondary to siezureform activity, or a intercranial arteriospasm, etc.
 
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