A lot of people seemed to like my last real-life case study and I had another interesting one last night... so thought I'd post it.
Here goes...
40-year-old woman was at work when she experienced sudden and acute onset of numbness, tingling, and weakness in her R arm and the R side of her face.
She was rushed through triage to an open room but none of the pod nurses heard the call... I got involved when a call went out that "Dr. Bill needs nursing assistance in room 8." I walked in to see one nurse starting a line on her right arm, someone getting her onto the monitor, someone else getting the EKG set up...
What do you suppose was my first action? What transpired in the first few minutes? What other pieces of information do we need STAT as we talk this through?
Come play the game with me, even if you don't know the answers.
Waiting for some participants...
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Wow! Ummm, I am just getting into nursing school so I am not quite skilled at this yet!! But I need to ask if starting an IV in the affected side is right? Also, vitals should be taken, sounds like a stroke maybe?
Definitely sounds like a stroke... which can be one of two major types..
No contraindications to starting a line on the affected side of a stroke patient... at least from the ED perspective. My NSICU colleagues might have reasons why they prefer lines on one side or the other but for us, we just need access at multiple sites.
Why the STAT CT? What are we looking for, even before the radiologist sees it?
Looking for either a hemorrhage or area of ischemia
If I could only get one tube of blood, run only one test, which would it be?
Purple top for a pt/ptt, will help explain possible cause of a hemorrhage and/or whether
the bleed will worsen. Also tPA in constraindicated with PT >15sec and Plt
Why multiple lines? Why is large-bore (a) unnecessary and (b) even possibly even counterproductive?
Never heard of a large-bore being unnecessary or counterproductive, we commonly use #18's, reserve #16's for traumas or the like. Will need multiple lines because this pt may require multiple infusions/meds at a time.
Why the EKG and fingerstick?
EKG to determine if the pt has afib which could have caused a clot, leading to stroke.
Accucheck because hypoglycemia can mimick a stroke.
And what about the blood pressure? Is it an issue at this moment? Why or why not? If so, what do we do?
tPA is contraindicated with uncontrolled hypertenion >185/110
What one small, and often incidental, piece of information do we need about this patient? (that nobody has yet touched on)
Are they on any "blood thinners", any LOC or recent head trauma?
I'm just going to put this out there - did anyone ask this lady if she has any history of trigeminal nerve pain or migraines on that side? The intensity of a flare up of EITHER of those can cause similar symptoms; personal experience.
So let's review... pt is hypertensive... yes, has a history of same, yes is on meds, yes, is taking them... but none of that is really critical to where we are at the outset... as always in the ED, we're looking for the seconds-to-minutes emergencies... a BP of 175, even if symptomatic, doesn't rise to that level when compared to the obvious... CVA.
And yet, the BP is concerning in this case... not in and of itself but because of its impact on other treatment. What's up with that?
+++
So, within 10 minutes:
neurology was at the bedside beginning her exam
We had 2 lines started... why 2? And why was I planning to start a 3rd ASAP?
No, they don't need to be large-bore lines... 20's are perfectly fine... probably even preferred in this situation.
[*]Fingerstick... sugar is 125... no smoking gun there
[*]EKG is done... NSR...
[*]Labs are drawn... CBC/BMP/Coags/Trop... All that's needed at this point... all sent first priority (which means we inform the lab that they're there and that they get bumped to the front of the line, even ahead of STAT... our lab has 4 levels... first priority, STAT, ED-routine, routine)
Lipids and that stuff require the patient be NPO for 8 hours and really don't tell us anything useful in the first hour
[*]Pt is taken STAT to CT... who are called ahead of time and will pull someone off the table if need be... Stroke alerts get buzzed ahead of anybody... because time-is-brain.
[*]Neurologist follows along, continues her exam until the pt is in the scanner, and then watches the CT in progress.
....
So:
Why the STAT CT? What are we looking for, even before the radiologist sees it?
If I could only get one tube of blood, run only one test, which would it be?
Why multiple lines? Why is large-bore (a) unnecessary and (b) even possibly even counterproductive?
Why the EKG and fingerstick? (Esme already hit this)
And what about the blood pressure? Is it an issue at this moment? Why or why not? If so, what do we do?
What one small, and often incidental, piece of information do we need about this patient? (that nobody has yet touched on)
Urine... we could put it in the 'nice-to-have' arena but we're not going to delay anything else to get it and, regardless, given the presentation of this patient, it's not going to tell us anything that's likely to change our course of treatment.
Stick with me, this gets a bit more interesting...
Stat CT: I'm still thinking a bleed. Quite visible on CT even as patient is still in the machine.
Multiple lines: several incompatible meds? Large bore could be unnecessary unless you're running fluids and if pt is on anti-platelets could present a bleeding issue.
BP: I'd say no, not an issue right now, because you want that brain perfused.
Incidental info: last time patient ate? History of this event? Med list (I'm wondering about anticoags)
Why the STAT CT? What are we looking for, even before the radiologist sees it?
**I would think hemorrhage
If I could only get one tube of blood, run only one test, which would it be?
**I keep thinking platelets, I am thinking because if it's hemorrhagic low platelets would be a bad thing?
Why multiple lines? Why is large-bore (a) unnecessary and (b) even possibly even counterproductive?
**One for fluids (to avoid dehydration), one for meds? one for anesthesia if surgery is necessary??
Why the EKG and fingerstick? (Esme already hit this)
**Rule out Afib and hypo/hyperglycemia?
And what about the blood pressure? Is it an issue at this moment? Why or why not? If so, what do we do?
**I say yes because the MAP is high (128)...I would think some sort of antiHTN, but also wouldn't want to drop BP too much and risk under-perfusing the brain
What one small, and often incidental, piece of information do we need about this patient? (that nobody has yet touched on)
Totally off topic, but to answer your question. Yes there has been times I have gone toe toe with a MD over something when I KNEW I was right. Were there times that a more timely intervention could have changed an outcome? MAYBE...a BIG maybe.
Specializes in Critical Care, ED, Cath lab, CTPAC,Trauma.
Why the STAT CT? What are we looking for, even before the radiologist sees it?
**I would think hemorrhage
If I could only get one tube of blood, run only one test, which would it be?
**I keep thinking platelets, I am thinking because if it's hemorrhagic low platelets would be a bad thing?
Why multiple lines? Why is large-bore (a) unnecessary and (b) even possibly even counterproductive?
**One for fluids (to avoid dehydration), one for meds? one for anesthesia if surgery is necessary??
Why the EKG and fingerstick? (Esme already hit this)
**Rule out Afib and hypo/hyperglycemia?
And what about the blood pressure? Is it an issue at this moment? Why or why not? If so, what do we do?
**I say yes because the MAP is high (128)...I would think some sort of antiHTN, but also wouldn't want to drop BP too much and risk under-perfusing the brain
I am thinking possible hemorrhage as well. But a stroke nonetheless
One tube of blood. What ONE lab value do you need if you are considering anti-coagulants or thrombolitics? What ONE lab value is important for treatment?
IV lines more than one...why? One for drips and one for codes/emergent treatment. If possible one for lab draws if thrombolytics are used. If you are considering thrombolytics why could large bore IV cause a problem?
That is a good though about the B/P. You need to remember to be concerned about Cerebral perfusion pressure.
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Cerebral Perfusion Pressure (CPP) is defined as the difference between the Mean Arterial Pressure (MAP) and the
This represents the pressure gradient driving cerebral blood flow (CBF) and hence oxygen and metabolite delivery. The normal brain autoregulates its blood flow to provide a constant flow regardless of blood pressure by altering the resistance of cerebral blood vessels.
These homeostatic mechanisms are often lost after head trauma (cerebral vascular resistance is usually increased), and the brain becomes susceptible to changes in blood pressure.
Those areas of the brain that are ischaemic, or at risk of ischaemia are critically dependent on and adequate cerebral blood flow, and therefore cerebral perfusion pressure.
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Key Recommendations
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[TD=class: boldtext] Maintenance of CPP reduces mortality in severe head injury.[/TD]
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[TD=class: boldtext] CPP should be maintained above 70-80mmHg[/TD]
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[TD=class: boldtext]Systemic hypotension is associated with poor prognosis[/TD]
One tube of blood. What ONE lab value do you need if you are considering anti-coagulants or thrombolitics? What ONE lab value is important for treatment?
**INR?
IV lines more than one...why? One for drips and one for codes/emergent treatment. If possible one for lab draws if thrombolytics are used. If you are considering thrombolytics why could large bore IV cause a problem?
**Large bore and thrombolytics=increased chance of bleeding at insertion site????
That is a good though about the B/P. You need to remember to be concerned about Cerebral perfusion pressure.
**For the one thing not touched on yet, would thrombolytics be contraindicated during menstruation??
Specializes in Critical Care, ED, Cath lab, CTPAC,Trauma.
Not really... it is considered a relative contraindication if under 20 hours from the onset of menses.
Hint for the question how old is this patient? She is only 40. Is she using birth control?
Common questions you consider before thrombolytics...Have you ahve any surgical procedures in the last 3 months. Have you sustained and head injury in the last 3 months....and.....
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No contraindications to starting a line on the affected side of a stroke patient... at least from the ED perspective. My NSICU colleagues might have reasons why they prefer lines on one side or the other but for us, we just need access at multiple sites.