What is your call on this

rhan101277

rhan101277

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You are dispatched to a residence for a bilateral leg weakness. No further info.

Upon arrival you find a 72 y/o female who is sitting in a chair next to her bed at her residence. There are three family members around. The pt is alert and oriented x 3 and is answering your questions appropriately.

RR: 16 and normal, clear BBS.
Pupils equal.
Moves extremities fine just can't support herself to walk, she states this has not happened before.
An arm drift and smile test is unremarkable.
B/P 180/93
Pt denies any pain.
Afib on the monitor at a rate of 89
12 lead unremarkable, no st elevation.

Hx: Diabetes, HTN, Afib


So in route you go to pt. requested hospital.
Pt remains AAOx3 and denies pain
B/P now is 233/139
A re-test of arm drift now shows left sided weakness
Smile shows left sided facial droop
No abnormalties w/ speech, no gaze.

I am thinking stroke, I know it is classic. When report was called in I had not done this re-test test yet, I did this 5 minutes out due to the B/P increasing so quickly. I forget to call in and notify ER of changes and get a gruff look from a RN. Dr. comes over and I give him a report. He decided not to do a stroke alert but opts for a CT scan, due to initial c/c of bilateral leg weakness,he suspects she may just be having a HTN episode.

I know I should have called and gave an update but by the time I could have called again we would have been there.

Any ideas? Feedback?
 
Until Paramedics have the ability to predict the future i think you did all you could in this situation. The Doc could be right in a HTN episode that's throwing stroke like symptoms and C/T would be the next step. Upon presentation she showed no signs of stroke so a safe trip to the ED was about all you could do here. Just out of my own curiosity, what meds was she taking and had she started/changed any new meds recently?
 
In our region if we have a suspected CVA we call in a pre-reg the pt. to expedite the process of getting to CT, most cases we take straight through the door back to the imaging room.

With the initial pt. presentation I would have a CVA as a consideration, but also a UTI, HTN episode, TMB and about eleventybillion other things. With the change in condition(vitals, + Cincinnati Stroke Exam) en route a bleed would definitely jump to the absolute top of the list. Would be interested to know if there was an inverse change with the HR in regards to the BP.

I'm curious as to the Doc's decision to not sound a stroke alert (unless that involves a different process in your region). A Hx of AFib would lead me to believe the pt. would be on Coumadin, which is another giant crimson object hung from a pole to suggest a bleed.

Jux I've never seen a HTN episode exhibit a CVA mimic, the HTN emergencies that I've seen have shown tinnitus, visual disturbances, and HA, but I suppose I haven't seen everything

In regards to Tx modalities in this case its a simple matter of IV, upright positioning of pt., and speed. Not something we're gonna fix.
 
Last edited by a moderator:
rhan101277 said:
You are dispatched to a residence for a bilateral leg weakness. No further info.

Upon arrival you find a 72 y/o female who is sitting in a chair next to her bed at her residence. There are three family members around. The pt is alert and oriented x 3 and is answering your questions appropriately.

RR: 16 and normal, clear BBS.
Pupils equal.
Moves extremities fine just can't support herself to walk, she states this has not happened before.
An arm drift and smile test is unremarkable.
B/P 180/93
Pt denies any pain.
Afib on the monitor at a rate of 89
12 lead unremarkable, no st elevation.

Hx: Diabetes, HTN, Afib


So in route you go to pt. requested hospital.
Pt remains AAOx3 and denies pain
B/P now is 233/139
A re-test of arm drift now shows left sided weakness
Smile shows left sided facial droop
No abnormalties w/ speech, no gaze.

I am thinking stroke, I know it is classic. When report was called in I had not done this re-test test yet, I did this 5 minutes out due to the B/P increasing so quickly. I forget to call in and notify ER of changes and get a gruff look from a RN. Dr. comes over and I give him a report. He decided not to do a stroke alert but opts for a CT scan, due to initial c/c of bilateral leg weakness,he suspects she may just be having a HTN episode.

I know I should have called and gave an update but by the time I could have called again we would have been there.

Any ideas? Feedback?
Click to expand...

Ideas about what? Sounds like good work all around.
 
You actually got to experience a rare thing for a medic; a stroke in progress.

You DID catch it, but for some reason, you really didn't communicate it properly, which may have weakened your "case" for more succinct intervention. It's most important to communicate changes at the time they are happening so that the staff is "right there with you."

The Doc calling for a CT scan has nothing to do with good medicine (IMHO), that's all about reliance on technology over one's ability to see what they see.

If, as you say, you made an adequate report to the Doc at the time, then he's the one on the line. That's one of the benefits of the job; you get to "hand-off" your patients to higher authorities.
 
firetender said:
The Doc calling for a CT scan has nothing to do with good medicine (IMHO), that's all about reliance on technology over one's ability to see what they see.
Click to expand...

Nobody supports not relying on technology more than me.

In this case, the doc did the exact right thing. With a stroke in progress, he sent the pt directly to the CT without wasting time to determine if it was hemorrhagic or occlusive, and that is the gold test that determines all else.

It is exactly what the stroke team would have done, and if he alerted them before sending the pt to CT scan they would have thought him deficent since that's the first thing they need.
 
Veneficus said:
Nobody supports not relying on technology more than me.

In this case, the doc did the exact right thing. With a stroke in progress, he sent the pt directly to the CT without wasting time to determine if it was hemorrhagic or occlusive, and that is the gold test that determines all else.

It is exactly what the stroke team would have done, and if he alerted them before sending the pt to CT scan they would have thought him deficent since that's the first thing they need.
Click to expand...

Well no matter what the paramedic thinks is wrong with the patient the physician has to do their own assessment. They must be able to not let the paramedic field diagnosis cloud their judgment. I feel pretty good about all the replies so far, I am just new at this and wanted some feedback.
 
MediMike said:
In our region if we have a suspected CVA we call in a pre-reg the pt. to expedite the process of getting to CT, most cases we take straight through the door back to the imaging room.

With the initial pt. presentation I would have a CVA as a consideration, but also a UTI, HTN episode, TMB and about eleventybillion other things. With the change in condition(vitals, + Cincinnati Stroke Exam) en route a bleed would definitely jump to the absolute top of the list. Would be interested to know if there was an inverse change with the HR in regards to the BP.

I'm curious as to the Doc's decision to not sound a stroke alert (unless that involves a different process in your region). A Hx of AFib would lead me to believe the pt. would be on Coumadin, which is another giant crimson object hung from a pole to suggest a bleed.

Jux I've never seen a HTN episode exhibit a CVA mimic, the HTN emergencies that I've seen have shown tinnitus, visual disturbances, and HA, but I suppose I haven't seen everything

In regards to Tx modalities in this case its a simple matter of IV, upright positioning of pt., and speed. Not something we're gonna fix.
Click to expand...

Yeah our protocols say 30 degree head elevation but when I bring her to the ER she is put supine on the bed, go figure.
 
All great points and the t/x was spot on as already stated. Possibly the reason for bilat. leg weakness good be: Cerebellar (sp) or brainstem stroke. Advanced Stroke Life Support teaches x (5) stroke syndromes including Lt., Rt. dominant, brainstem, cerebellar and hemmorage (sub-aracnoid and intra-cererbal).

325.
 
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