Friday, October 2

You Make the Call...Brain Attack

Brain Attack is the new stroke. Did you not get the memo? In an effort to expand on our similarities, not just our differences, I thought a straight forward medical scenario would do the trick.

You are assigned to your regular response unit and dispatched just after 10 am for a reported altered mental status. You response time is 6 minutes and you are the first care giver on scene.

Family states the late 60s male in the hospital bed in the family living room has an extensive cancer history and has been having difficulty getting up and walking around in recent weeks. This morning he awoke around 530 and had his linens changed, at which time he used a walker to move around the room.

Just a few minutes ago family returned to awake him from his nap and find him unresponsive, left extremeties in a state of contraction and a noted facial droop with drooling, also left sided.

You complete a full assessment finding him actually responding to painful stimuli with a grimace from the non drooping side, no voluntary movement from the contracted left extremeties and faint squeezing on command on the right. Blood sugar is in normal range, EKG and secondary exam all come back normal, previous notations excluded.

Pupils are equal and tracking together, no fixed gaze.
There is no past history of stroke or CVA.

The nearest hospital is 10 minutes away. Another 10 minutes is the regional trauma center, with scanner.

What is your agency's policy for this patient? Is he in the window for stroke center care in your jurisdiction? Does your system offer any in field treatments for this patient? You Make the Call.


mack505 said...

Sure looks like a CVA. (I doubt I'll ever hear the term 'Brain Attack' over the radio.)

Our state protocol requires transport to a Primary Stroke Facility. It turns out all but one or two of the hospitals in the state have been so designated, so he generally goes to the closest facility.

He's outside the 3 hour window for thrombolytics, so that's a moot point. Local Suburban will CT scan him, and in limited circumstances they will transfer him on to Big City Trauma Center for further care. (Basically if he would benefit from neurosurgery.)

Even under 3 hours, there is very little we can do in the field. Drive fast and call an alert is our primary treatment for CVAs.

Triple Beeper said...

I talked with my husband, who is also a paramedic; he said that even though the patient falls outside the typical 3-hour window of stroke care, there are some new treatments that have a 6-hour window so he would still proceed to the stroke center over the closer hospital (we have a similar set up, time-wise, to the situation you described. The only exception being that beyond having a scanner, we have two local hospitals that are deemed stroke centers for reasons I do not know). The exception to this would be if he were an end-stage cancer patient with a DNR or if family clearly stated a wish for comfort care/palliative care only. There is no in-field care other than comfort care that his department uses.

LadyHavoc said...

Sounds like a CVA to me, also. I'm coming at this from a respiratory therapist's point of view, so I usually see the patients after transport.

I know there's been some recent studies done about what the effective window of time is for thrombolytics and it's generally under 4 hours.

In our neck of the woods, the protocol is set to push the heparin for anything under 6 hours and to send them to the Big Daddy med center in town. (>700 beds, with all the toys to go with.)

Anonymous said...

Its a bit of a judgement call...
Last seen at 05:30 walking as normal, then found at 10:00 with apparent right left hemi.
Its unlikely that he stroked out at 05:31, but it has obviously happened fairly soon after that. I have never heard anyone devloping a contracture of a limb so soon after a CVA though??
I would travel to one of our stroke centres as I cannot determine the exact onset of symptoms but it is likely to be within the last four hours (our treatment window)
Interestingly, we are about to embark on a research study called DASH (I think it originated in L.A) within our service. Here is some blurb from the studies web site:

"Thrombolysis is an effective but underused treatment which must be given within a 3 hour time window from onset of symptoms but it is used in less than 1% of cases. Partnership between the ambulance and stroke services is key to achieving rapid hospital admission and there is the potential to involve paramedics in delivering acute stroke treatment such as neuroprotection. Active engagement of patients, carers and the public is essential to develop quality stroke care and identify the best methods to provide information to enable them to make informed decisions about accessing services and receiving treatment in the hyper-acute situation.

In this integrated programme of research we will: determine the effectiveness of a multi faceted community programme to increase awareness of and response to symptoms of stroke by the public, patients and health service staff; seek the views of clinicians, public, patients and next-of-kin about the risks and benefits of thrombolysis and other hyper-acute treatments and identify how to best engage patients/next-of-kin in decision making; establish the cost effectiveness of five models of delivering intravenous thrombolysis to the population of the North East Strategic Health Authority (SHA) through modelling, and to implement and evaluate one or more models of care across the SHA; and evaluate the feasibility of paramedic delivered hyper-acute stroke treatments"

Should be interesting!!

brendan said...

Stroke Center designation is the new thing around here, so much so that it's almost hard NOT to go to one. I actually have a choice of three, one of which has the "rotor rooter" PCI-style treatment that they've told us can be used up to 8 hours post-event.

Out field treatment for us. I try to start 2 IVs, one with a lock that hasn't been flushed to speed blood draw at the ER.