Stroke vs overdose

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.

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?

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

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!

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

I wouldn't have thought acute stroke

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

Just wondering!

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.

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.

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.