11
Sep

Stroke Teaching (ACLS Algorithms)


Alright, now in this scenario you’re gonna
have a patient with a suspected stroke. You’re an ACLS team leader who has a 70
year old female patient. Her friend said that she was watching television
when she started to feel weak. And she suddenly had some difficulty speaking
and her left side became very weak. When her friend tried to help her stand up,
she was unable to walk on her own. The patient is conscious and breathing normally,
but appears agitated. As you ask your patient questions, she has
difficulty speaking and giving appropriate answers. Your patient’s friend said she noticed the
difficulty speaking about 30 minutes ago. Now because the initial signs indicate a possible
stroke, you should perform a stroke assessment. Prehospital providers might perform an abbreviated
assessment known as the “Cincinnati Prehospital Stroke Assessment.” It consists of facial droop, arm drift, speech
and time. In hospital providers, they might perform
a more detailed full NIH stroke score to document neurological status. In our patient’s assessment we found that
she is conscious and alert. However, the patient does have facial droop,
left arm drift, and speech difficulty. This is enough information to call for the
the stroke team to respond and order an emergency CT scan. Now the next step is to get a set of vitals. You direct a team member to place the BP cuff
and O2 sat monitor. The team member tells you that the pulse is
78, respirations are 18, she has a blood pressure of 124 over 100, skin is warm and dry, but
the O2 sat is 96%. Based on the vital signs, the patient does
not need oxygen at this time. At this time, you would attach the monitor
and get a 12 lead EKG. As you look at the 12 lead printout, you see
a normal sinus rhythm. You direct a team member to continue checking
the blood pressure every 5 minutes and keep a close eye on any changes in her breathing. An important diagnostic tool for potential
stroke is blood glucose. Hypoglycemia, or low blood glucose, can mimic
stroke symptoms such as confusion and slurred speech. You direct the assistant to check the glucose
level and it’s normal at 90. In order to consider fibrinolytic therapy,
we need to determine the time since symptoms started. And since she arrived at the emergency room
it has been just about 15 minutes. The symptoms started 30 minutes before arriving
to my care. So now since the patient’s blood pressure,
O2 sat, and glucose levels are within normal limits, and the symptoms started less than
3 hours ago, this patient may be a good candidate for rTPA. If the patient has no history of previous
strokes, is not on blood thinners or other contraindicated medications or other contraindications,
then the CT scan will be the determining factor. If the CT scan shows no hemorrhage, we’ll
be able to go with rTPA. To be ready for potential drug therapy, this
is the time to start an IV. You direct the assistant to start an IV 18
gauge antecubital with normal saline. We’re going to keep this at a TKO rate. The goal is to recognize potential stroke
signs early and get the patient appropriate fibrinolytic therapy or the most appropriate
reperfusion strategy in a timely manner.

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