Stroke vs overdose

[joe007]

So I had a very interesting case last night. I had a 66 y.o. female come in who had hx, DM, pvd, CABGx3, and heart cath... no stroke history. Anyhow, it was reported to me by EMS and family that the pt. became tired since she took her medications twice that night and had "altered mental status," though on arrival was able to recite year, city, and president. Pt. seemed lethargic, not excessively confused. No weakness on R or L side. No facial droop. Just lethargic with slightly slurred speech which was in line with the report of ativan and trazodone overdose since she took two doses instead of one that night. Family also said they weren't quite sure which meds the pt. took because a new person had recently taken over sorting pt's medications. I pretty much ran an overdose panel on her while waiting for the doctor to put in for a CT or other scans and triaged her as a level 2 not thinking she was having a stroke since trazodone overdoses will make one have slurred speech and be tired. Two hours later the ER doc orders a CT (really ****** me off in retrospect seeing as how she was triaged as a level 2), which I promptly executed, and bam; this lady had multiple areas of damage from varying strokes over the last month since she had a prior CT a month earlier, and they needed to R/O a new area of ischemic stroke to see if it was old or new. Pt. was started on heparin drip. The entire time the pt. was improving cognitively and was becoming less tired and less slurred. She tested positive for codeine and benzos. Anyhow, it was hard to understand if any of the symptoms she was having since she came into the hospital had anything to do with stroke, or if it really was just related to the drugs she had taken earlier in the night. This was the first time I had someone come in as an overdose, who was diagnosed with stroke. It seemed atypical and the overdose masked the stroke symptoms if there were any...

[EmergencyNurse2012]

Wow, that's an interesting one. If we have someone come in like this, the docs will generally order a head CT almost right away.....but they won't put it in as "stroke protocol" just as a head CT. In our facility, a stroke protocol head CT means no one gets in that scanner until that patient's scan is done, and it's done as soon as they can roll the person to the machine. we even send them on the ambulance stretcher some times. I don't see how you could have seen your patient above as a CVA off the bat. I think most nurses would have done exactly what you did. Thanks for the post. Very thought provoking.

[foragreatergood]

I wouldn't have gone down the stroke pathway with this patient! All her presenting symptoms were compatible with overdose.

A few weeks ago we had a woman in her 40's with a psych history come in after being found unresponsive by family with empty pill bottles that had contained soma, dilauded and Ativan. But she had a significant facial droop - that made our triage shift to stroke. If she hadn't had the droop - she would have been managed as an overdose and maybe not have had a head CT

Do you that if you would have gone to the doc and told him the story that he would've ordered a CT? And unless there was a clear last known well time - she probably wouldn't have been a TPA candidate, right?

[AnnieOaklyRN, BSN, RN, EMT-P]

Remember and ACUTE stroke that is ischemic will not show up on a CT for days! I am not sure how long your lady had her symptoms, but chances are those were "old" strokes and not related to her current symptoms.

HPRN

[LakeEmerald]

This is why our ER runs a CT on most (if not all) altered patients. They don't all go code stroke, but they get a stat CT. Reason is: A: You cannot always trust the accuracy of what you've been told by family; B: It's PROBABLY a drug overdose, but what if it isn't? It could be a surprise bleed.

We were told by our stroke specialist, "If the little old lady gets dizzy and weak at the hairdresser, run a CT just in case." In her experience, she has seen plenty of patients with vague symptoms that turn out to be strokes.

And Happy is correct, it may not show up on CT for days, but at our hospital heads will roll for disregarding the possibility of stroke at the outset. And for not doing the swallow screen before PO, the NIH, and all that jazz.

I would have considered your patient as probably an overdose, based on report; but sometimes report is just wrong. Be it good or bad, our hospital is CYA, CYA, CYA. I can usually get a stat CT early by recommending it to the MD based on symptoms. It's kind of like how we do an EKG for every chest pain.

But I don't know about other hospitals. Your MD saw the patient, too, and made a judgement call to do the CT later than stat? That should fall more on the MD than you, right? Maybe our hospital is more CYA than others?

Thanks for your thought-provoking post!

[Sassy5d]

How about TPA for a person with Alcohol level over 400? That was my oddest.

I wouldn't have thought acute stroke

[foragreatergood]

How accurate could the NIHSS be on an impaired person? Not to mention consent for the TPA?

Just wondering!

[Sassy5d]

How accurate could the NIHSS be on an impaired person? Not to mention consent for the TPA?

Just wondering!

I hope I never have to be placed in that position again. But I looked it up, intoxication is not an exclusion or reason not to give TPA.. I was uncomfy.

[Altra, BSN, RN]

How accurate could the NIHSS be on an impaired person? Not to mention consent for the TPA?

Just wondering!

Though we all know how difficult neuro assessment can be on an intoxicated patient, marked unilateral deficits are hard to miss.

Consent ... now that's another issue. Hope family was able to be contacted.

[icuRNmaggie, BSN, RN]

I had a 30 year female pt in the ICU who was intubated in the field for unresponsiveness.

Significant other said she used a lot of cocaine that night.

She was not scanned in the ED.

In the am she did not awaken from sedation and her pupils were blown.

CT showed a massive head bleed.