The Code Stroke Handbook

Approach to the Acute Stroke Patient

Andrew Micieli, Raed Joundi, Houman Khosravani, Julia Hopyan, David J. Gladstone

• Publisher: Academic Press
• Year: 2020
• ISBN:
  9780128205235
• Topic: Medizin
• Subtopic: Physiologie

A 65-year-old patient arrives at the Emergency Department with stroke symptoms that began 45 minutes ago. You are called STAT! Acute stroke management has changed dramatically in recent years. Tremendous advances have been made in acute treatments, diagnostic neuroimaging, and organized systems of care, and are enabling better outcomes for patients. Stroke has evolved from a largely untreatable condition in the acute phase to a true medical emergency that is potentially treatable—and sometimes curable. The Code Stroke emergency response refers to a coordinated team-based approach to stroke patient care that requires rapid and accurate assessment, diagnosis, and treatment in an effort to save the brain and minimize permanent damage. The Code Stroke Handbook contains the "essentials" of acute stroke to help clinicians provide best practice patient care. Designed to assist frontline physicians, nurses, paramedics, and medical learners at different levels of training, this book highlights clinical pearls and pitfalls, guideline recommendations, and other high-yield information not readily available in standard textbooks. It is filled with practical tips to prepare you for the next stroke emergency and reduce the anxiety you may feel when the Code Stroke pager rings.

• An easy-to-read, practical, clinical resource spread over 12 chapters covering the basics of code stroke consultations: history-taking, stroke mimics, neurological examination, acute stroke imaging (non-contrast CT/CT angiography/CT perfusion), and treatment (thrombolysis and endovascular therapy)
• Includes clinical pearls and pitfalls, neuroanatomy diagrams, and stroke syndromes, presented in an easily digestible format and book size that is convenient to carry around for quick reference when on-call at the hospital
• Provides foundational knowledge for medical students and residents before starting your neurology, emergency medicine, or internal medicine rotations

Chapter 1

History taking

Abstract

The initial assessment of the code stroke involves identifying whether the clinical presentation is compatible with an acute stroke diagnosis, or a stroke mimic. The first two chapters of this book will provide you with the tools to answer these questions. Like a good detective, you need to gather the important clues, ignore distractions and red herrings, and eliminate the other suspects—all in a timely manner. This chapter will provide you with a stepwise approach to:

❏ Taking an appropriate and focused history by gathering relevant clinical information from multiple sources.

❏ Identifying the common symptoms associated with (and not associated with) acute stroke.

Keywords

Acute stroke; Differential diagnosis; Emergency medical services; History taking; Last seen normal

Beep…Beep…Beep

CODE STROKE in the Emergency Department, Acute zone bed 10.

Welcome to the code stroke; let’s get started.

The initial assessment of the code stroke patient involves identifying whether the clinical presentation is compatible with an acute stroke diagnosis or a stroke mimic. The first two chapters of this book will help answer this question. Like a good detective, you need to gather the important clues, ignore distractions and red herrings, and eliminate the other suspects—all in a timely manner. This chapter will provide you with a stepwise approach to:

• ❏ Taking an appropriate and focused history by gathering relevant clinical information from multiple sources.
• ❏ Identifying the common symptoms associated with (and not associated with) acute stroke.

Chapter 2 will discuss various stroke mimics and how to clinically differentiate them.

Early stroke symptom recognition is important to facilitate rapid transfer to a stroke center. Regional Emergency Medical Services (EMS) have protocols in place to identify and prioritize potential stroke cases, and try to minimize transportation time to the most appropriate stroke center. The mnemonic FAST, which stands for Face (sudden facial droop), Arm (sudden unilateral arm weakness), Speech (sudden speech difficulty), and Time to call EMS, is being used to promote public awareness. Most prehospital stroke screening tools involve some combination of these cardinal symptoms.

It has been estimated that nearly two million neurons die each minute that elapses during the evolution of an average acute ischemic stroke. Each hour without treatment the brain loses on average as many neurons as 3.6 years of normal aging. This is captured by a commonly used phrase “time is brain.”

Ideal stroke treatment targets

• ❏ Door-to-needle time for intravenous tissue plasminogen activator (tPA): < 30 min
• ❏ Door-to-groin puncture time for endovascular therapy: < 60 min

Disability decreases with quicker treatment; therefore, aim for the fastest assessment for potential brain-saving or lifesaving treatment.

For the resident physcian or medical student on call, the first task is a simple one: write down the time you first received the code stroke page. There are many other time-related parameters that you may need to document throughout the code stroke, including time of patient arrival, time of the first CT scan slice, and time of tPA administration. This becomes important later when calculating door-to-CT scan time or door-to-needle time. After all, the quicker a stroke patient is treated, the more likely they are to have a functionally independent outcome.

Regional variations exist in terms of code stroke triage in the emergency department (ED). Depending on the hospital, the pager may notify you where the stroke patient is in the ED (or on the inpatient hospital ward), or you may need to call the number on the pager to confirm you received the page, ask the location of the stroke patient, and their estimated time of arrival if they are not already in the ED.

Sometimes the ED charge nurse will have some additional information for you. This prenotification clinical information can vary in terms of how detailed it is. Sometimes it is very detailed with a high pretest probability for stroke, such as:

We have a 76-year-old woman from home with a witnessed onset at 1500 hours of aphasia and right face, arm and leg weakness.

At other times, the clinical information is vague and undifferentiated, such as:

“85-year-old man with confusion.” This could be a number of neurological or non neurological conditions (more on stroke mimics to come in Chapter 2).

Not all activated code strokes are from the ED. Inhospital strokes (i.e., a patient admitted to the ward) also occur, though with less frequency. Your approach to the patient should be the same. Often, the patient's medical comorbidities or recent surgery precludes the use of tPA.

Once the code stroke is activated, many different people are set in motion (even before the stroke resident/staff make their way to the patient). The first step is a rapid assessment and rushing the patient to the CT scanner as quickly as possible. In some hospitals, prior to the CT scan, the nurses will insert two cubital fossa IV lines, complete a 12-lead ECG, and draw urgent bloods that are sent stat for: CBC, electrolytes, creatinine, coagulation profile, random blood glucose level, troponin and type and screen. This blood work will help with treatment decisions and contraindications to tPA.

You have now made your way to the stroke patient in the ED. Like any acute situation in medicine, do not forget the basics: ABCs—Airway, Breathing, Circulation. Quickly eyeball the patient and check the vital signs from the monitors or from EMS or the triage nurse. Make sure that the patient is protecting their airway and there are no immediate life-threatening issues. Luckily, this is typically not the case, although some patients have a depressed level of consciousness either from a devastating intracranial event or another systemic issue. If the patient looks unstable, do not hesitate to request help from an ED physician, or rapid response/ICU.

Important initial questions to ask

Make every effort to speak directly to the paramedics, the patient, patient’s family, and any eyewitness to obtain the most reliable medical history. There are 6 key questions to ask first, before we get a more detailed history and understand exactly what happened (specific symptoms and chronology):

1. 1. Clarify the time the patient was “last seen normal” and the exact time of onset of symptoms, or the time the patient was found with symptoms.
2. 2. What are the main neurological deficits? Did they improve or worsen en route?
3. 3. Relevant past medical history and medications (do they have known atrial fibrillation? Are they taking anticoagulant medications? Do they have an allergy to contrast dye?).
4. 4. Baseline functional status and occupation.
5. 5. If arriving by EMS: vitals en route, EMS cardiac rhythm (normal sinus or atrial fibrillation or other?), blood glucose.
6. 6. Did they bypass a closer hospital en route?

1. (1) The most important initial question to clarify with the patient, family, or witness is the stroke onset time and the...