Time Management

Attack One responds early one morning for woman who’s unresponsive. Her husband meets the crew at the door and says his wife is in the bedroom. “She’s just looking at me,” he reports.

The crew finds the patient lying on the bed on her left side, and her face appears to be drooping. She is drooling and makes no effort to speak. She is breathing and has a regular, somewhat rapid and bounding pulse at her wrist. The woman looks at the EMTs as they roll her onto her back, and they check her vital signs and gag reflex. Her blood pressure is a little elevated and her pulse rate a little high, but her breathing is normal and, with gag reflex intact, she seems able to protect her airway.

The husband provides the rest of the history to the paramedic: His wife has not had an episode like this in the past, is not diabetic and has had no recent injury. She has elevated blood pressure and a history of a heart attack, which was treated at the local heart center with several stents about three years ago. She has had many family members with heart problems.

The paramedic assesses the patient and finds she cannot move her left side and has a severe facial droop on the right. She is unable to speak. Her right hand has a firm squeeze, but she is unable to follow commands. She withdraws her right leg from pain, but her left is motionless. This completes the three elements of the Cincinnati Prehospital Stroke Scale (CPSS), which the department uses as its evaluation tool.

The paramedic finds no evidence of injury, skin ulcers or elevated temperature. He checks a blood sugar, which is 82.

The paramedic now speaks to the husband: “It is possible your wife is having a stroke. That comes from a problem in blood flow to the brain and must be treated quickly. It is important we find out when it may have happened. When did she seem to have the problem start?”

“I don’t know,” the husband replies. “When I woke up about 6 o’clock she was just sleeping. But then she didn’t move at all, and didn’t speak when I asked her if she wanted coffee. She was just looking at me. She didn’t move, and that’s when I called 9-1-1.”

The paramedic presses with a few more questions, because it’s important to know when the patient could last move or speak. He asks if the husband can remember the patient being up during the night. The husband recalls that the patient was awake at about 4:30 and went to the bathroom. At that time she asked her husband if he wanted a bathroom light left on. With that important recollection, the paramedic can document that the patient was last known to be normal about two hours prior to the 9-1-1 call.

The crew has moved the patient to the stretcher, applied oxygen by cannula and elevated the cot head about 20 degrees. After getting the blood sugar result, they start an intravenous line of normal saline in her left forearm.

The husband will ride in the ambulance along with the patient to a regional hospital with a high-level stroke program. The paramedic explains that they are transporting quickly to that hospital so that emergency department staff can do a rapid set of tests and consult with stroke specialists. The paramedic asks the husband to recall any other details that may help the staff identify the time of onset.

With that, the ambulance gets moving and the paramedic contacts the hospital to activate the stroke protocol.

En route, the husband asks to speak to the paramedic again. He remembers another event that might be related: His wife had an episode about five days before where she was unable to speak for about an hour. It occurred at home in the morning. The patient refused to go to a hospital or be checked by her physician. She told her husband that since she hadn’t had pain, there must not be a significant problem.

The patient has no changes en route to the hospital. Her oxygen saturation stays over 94% on 3 liters of oxygen.

Emergency Department Management

The ED is prepared for the patient’s arrival. Staffers transfer her onto the ED cart, and the husband and paramedic relate when she was last seen up and talking. The paramedic, nurse and emergency physician repeat a full examination, and there are no changes in the woman’s ability to move, speak or respond.

There are only a couple of interventions before the patient is whisked off to the CT scanner: Her blood is drawn and a 12-lead EKG taken that shows a normal rhythm and no acute changes. The stroke team has been activated.

The patient is back in the ED before the Attack One crew has completed their report. Her care is being coordinated by a stroke specialist. The CT scan of her head shows no bleeding in her brain. She is taken to an interventional lab, and her husband offers to provide the Attack One crew with a follow-up when he has it.

Several days later the husband calls. The patient had a clot in a blood vessel on the right side of her brain. The stroke intervention specialist removed the clot, and after a couple of days of treatment, the patient recovered almost all functions. She was released home on blood-thinners and was undergoing physical therapy.

The husband also reported that the physicians believed the episode five days prior was a transient ischemic attack (TIA), a warning indicator that blood flow to the brain is being compromised. The patient was advised to seek emergency care immediately if similar problems occurred again.

Case Discussion

This case demonstrates the changing nature of care for the stroke patient. There have been a number of changes related to the assessment, treatment and transportation of stroke patients over the past few years. These are summarized in an article published in January in Stroke; it has many recommendations related to EMS care.¹

Some relate to the importance of accurate history and physical evaluation. The most important piece of information necessary for stroke treatment is the time of symptom onset, defined as the time the patient was last known normal. Family and bystanders are very important, because the patient is often unable to speak or unaware of his/her deficits. EMS personnel should attempt to transport accompanying family who can provide necessary information.

EMS providers should use some form of prehospital stroke assessment tool. Examples are the Los Angeles Prehospital Stroke Screen and the Cincinnati Prehospital Stroke Scale. The Cincinnati Prehospital Stroke Scale (CPSS) is a three-item scale based on simplification of the National Institutes of Health (NIH) Stroke Scale. It has a high sensitivity and specificity in identifying patients with stroke who are candidates for aggressive care, and has been validated for use by prehospital providers. The simple elements of this scale are in Figure 1.

Treatment is focused on timely care and rapid transportation to a hospital capable of stroke management. EMS providers are asked to assess and manage any problems with airway or breathing. Stroke patients are at risk for aspiration, so the presence of a gag reflex is very important. Many stroke protocols advise elevating the head of the stretcher by about 20 degrees to reduce the risk of aspiration. Patients should not take anything by mouth, and EMS providers should not administer medications by mouth.

The routine use of supplemental oxygen is still in most EMS protocols but actually remains unproven. Supplemental oxygen to maintain saturations above 94% is recommended after cardiac arrest and so is thought reasonable for patients with suspected stroke. Determine blood glucose and treat accordingly. Do not administer dextrose-containing fluids in nonhypoglycemic patients, and do not administer excessive IV fluids.

Paramedics should initiate cardiac monitoring, and a 12-lead EKG should be performed at some point in the evaluation. The finding of a patient in atrial fibrillation is very important, and certain types of stroke are associated with that rhythm.

It is common that stroke patients have some elevation of blood pressure. A great deal of research now indicates that lowering the blood pressure will do harm to the brain, especially if done quickly. Therefore, EMS protocols typically specify that providers not initiate interventions for hypertension unless directed by medical command.

EMS care will facilitate triage and rapid transport to the nearest appropriate stroke hospital. An important element of care is early notification to the receiving hospital that a potential stroke patient is en route, so resources may be mobilized before arrival.

Reference

1. Jauch EC, Saver JL, Adams HP Jr., et al. Guidelines for the early management of patients with acute ischemic stroke: a guideline for healthcare professionals from the American Heart Association/American Stroke Association. Stroke, 2013 Mar; 44(3): 870–947.

James J. Augustine, MD, is an emergency physician and the director of clinical operations at EMP in Canton, OH. He serves on the clinical faculty in the Department of Emergency Medicine at Wright State University and as an EMS medical director for fire-based systems in Atlanta, GA; Naples, FL; and Dayton, OH. Contact him at jaugustine@emp.com.