Code Stroke

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//Are you kidding me?!// It's 3 AM on a cold, dark, winter night in the middle of February and the hospital's grab-and-go cafe is out of coffee. //'Ugh, I can't wait for night float to be over with,'// you mumble. //BEEP-BEEP. BEEP-BEEP,// goes your pager, reminding you that there's still 2 weeks left of this block. //Rapid Response Team to 6924.// <<textbox "$name" "Type your name and hit enter" "Start" autofocus>>

You arrive in room 6924. //'Hey, I'm $name, tonight's RRT resident. What's going on?'// //'Something about altered mental status, right?'// says Paula, the RRT nurse, as she turns to the patient's nurse. //'Yeah. She just got up from Emergency. Supposedly is having a TIA. She was answering questions just fine an hour ago but suddenly she's become difficult to arouse and won't stop moaning.'// Analysing the situation, you decide to: [[Evaluate the patient at bedside|Patient Evaluation]] [[Review the patient's chart|EMR]]

Hey, $name! I hope you enjoyed this interactive clinical narrative, and that it has you thinking about similar real-life scenarios. This case is reflective of some of the challenges we face as rapid response and critical care residents, specifically when it comes to the rapid assessment and management of acute stroke symptoms and the implication it can have on patients and their families. There's a lot to unpack from this scenario, so let's go over some key points you can consider: * When responding to Rapid Response calls, it is <b>always</b> best to start at the bedside. Bedside assessment shouldn't come after chart review, as we often don't know what scenario we're walking in to. Consider this as well: your subsequent chart review and data acquisition will be more focused and directed after you've assessed your patient and have a working differential diagnosis. * Acute stroke symptoms can have a broad differential diagnosis. It's important to remember common, easily correctable causes (e.g. hypoglycemia, drug effect) along with the big, bad scary causes. * NIHSS assessments can be very challenging when patients are non-verbal, comatosed, sedated, or confused. It's important to remember techniques like visual threat and noxious stimuli to help you gain a better assessment. Remember to score and document what you see and to not coach the patient on each maneuver. * Timely stroke assessment and management can significantly impact patient outcomes. In such high acuity scenarios it's wise to navigate the hospital's system as smoothly and quickly as feasible. Some strategies that can help make this a habit are to constantly ask yourself what barriers your patient is facing (and how to bypass them), to communicate clearly with all services and staff involved, and to take as much responsibility you can for each step in the patient's care. * It is never inappropriate to ask for help and page the on-call attending or specialist if you ever need to. Patients come first. * Being a resident is tough. Long, consecutive shifts, night float, high patient acuity--to name a few--can quickly take a toll. Sometimes all within a single shift itself. Never forget the impact our role and decisions can have on patients, even when we feel like we aren't doing much. I hope this story reminds you of the purpose we're all forging as young physicians as it's easy to lose sight of it from time to time. //They who have a 'why' to live can bear almost any 'how'//--Friedrich Nietzsche //Written and edited by Amreet Sidhu, MD// //Reviewed by Kat Zechar, MD//

A rapid, initial assessment at the bedside reveals the following: Vitals: * BP 200/120 * RR 25 * HR 95 * SpO2 100% on room air * Afebrile General: Laying in bed is a mid-60s appearing female without any apparent distress Head: Atraumatic, normocephalic Cardiovascular: Irregularly irregular rhythm, tachycardia, systolic murmur heard in all fields, no gallops, no JVD Respiratory: Tachypneic without accessory muscle use, CTABL with shallow respirations Neurological: * Notably difficult to arouse. Required constant tactile and verbal stimulation to maintain alertness for the evaluation. * Does not answer any questions or follow commands. Is constantly repeating "okay" * Eyes are deviated to the left. * No spotaneous limb movement. //'What do you think, doc?'// asks the RRT nurse. <<if not hasVisited("EMR")>>[[You take a moment to obtain more data and review the patient's chart|EMR]]<</if>> <<if hasVisited("EMR")>>[[You review the patient's chart again|EMR]]<</if>> <<if hasVisited("EMR")>> Contemplating available data, your differential diagnoses, and next steps, you consider a few important questions... //What physical exam techniques can I use to get a more thorough neurological evaluation and NIHSS?// <<textarea "$answer1" "What physical exam techniques can I use to get a more thorough neurological evaluation and NIHSS?" autofocus>> //What rapid assessment should always be done at bedside in this scenario? (Hint: metabolic/toxic derangements) <<textarea "$answer2" "What rapid assessment should always be done at bedside in this scenario?" autofocus>> <<button [[Type in your answers, then click here to advance|Patient Evaluation 2]]>><</button>> <</if>>

Chart review provides you with the following summary: Ms. Smith is a 68 year old female who presented to the hospital for concerns of slurred speech the day prior. She also reported experiencing R arm weakness for a few minutes. Past Medical History: * Hypertension * Type 2 Diabetes Mellitus, on insulin * Hyperlipidemia * Coronary Artery Disease * Carotid Artery Stenosis, bilateraly * Tobacco Dependence, with a 30 pack year history Home Medications: * Amlodipine, Insulin glargine and lispro, pravastatin Physical Exam in the ED: * BP 175/90, HR 80, RR 16, SpO2 100% on RA * General: NAD; AOx3; follows commands * Cardiovascular: regular rate and rhythm, S1 and S2 heard * Respiratory: CTABL * NIHSS of 0, no notable dysarthria, weakness, or focal neurological deficits (documented 3 hours ago) Labwork: * Chemistry: Na 138, K 4.1, Cl 103, HCO3 25, BUN 14, Cr 1.2, BGlc 83 * Hematology: WBC 12, Hgb 11, HCT 39, PLT 125 Imaging: * Non-contrast CT head in the emergency department was negative for acute hemorrhage, ischemia, or other abnormalities. Medical Decision Making (as documented by the ED physician): //Ms. Smith is a 68 y/o lady who presents with complaints of dyarthria and RUE weakness. Evaluation in ED is not suggestive of acute ischemic stroke. Will defer further workup to admitting service. Final assessment: Suspected TIA.// <<if not hasVisited("Patient Evaluation")>>[[Evaluate the patient|Patient Evaluation]]<</if>> <<if hasVisited("Patient Evaluation")>>[[Return to Patient Evaluation|Patient Evaluation]]<</if>>

For reference, here's what you were thinking: //What physical exam techniques can I use to get a more thorough neurological evaluation and NIHSS?// $answer1 //What rapid assessment should always be done at bedside in this scenario? (Hint: metabolic/toxic derangements)// $answer2 ---------- Remembering your training, you decide to obtain a fingerstick glucose level and review the medication history for any potential culprits. //'Blood glucose is 125, doc,'// says the RRT nurse. //'Looks like she hasn't gotten any sedatives,'// you add. //'Are we calling a Code Stroke here?'// //'I'm not sure. Let me assess her again.'// A repeat blood pressure is 220/125. You take another shot at a neurological exam, this time hoping to obtain an adequate NIHSS. You think back to the mind-numbing stroke training they put you through and remember that the pocket cards have tips for difficult examinations. //Aha!// You return to the patient's bedside and perform an examination. * Level of Consciousness: the patient still requires constant stimulation to remain alert * Orientation: she does not respond when asked the month and her age * Commands: she does not respond when asked to grip/release your fingers and seems to open her eyes spontaneously in response to tactile stimulation * Gaze: you decide to hold her eyelids open for a moment and notice leftward gaze deviation. Her eyes don't move to track, nor do they move when you turn her head. * Visual Fields: with her eyelids still held open you test her visual fields with visual threat in all quadrants. She blinks each time. * Facial Palsy: you ask her to smile but she doesn't. Hence you proceed by eliciting supraorbital and sinus pressure to look for a grimace. The R angle of her mouth appears to droop. * Motor function: you carefully observe her during the evaluation and notice that her left arm jerked slightly when you applied supraorbital pressure. You then examine this more closely with nailbed pressure and muscle tone, and notice that she isn't moving her R arm and leg at all. Her left arm and leg seem to appropriately withdraw to pain. * Sensation: you use pinprick (distally and proximally) and nailbed pressure to gauge for reactions. There is no limb withdrawal on the right side. * Speech: The patient seems to perseverate the word "okay" over and over, which sounds like it may be slurred. She does not repeat words nor seem to comprehend. * Extinction/Inattention: there is no convincing evidence of hemineglect or inattention. //What is this patient's estimated NIHSS?// <<textarea "$NIHSS" "What is this patient's NIHSS?" autofocus>> <<button [[Type in your answer, then click here to advance|Patient Evaluation 3]]>><</button>>

Here's your obtained NIHSS: $NIHSS. ---------- //'I'm getting an NIH stroke score of 25,'// you explain. Becoming increasingly concerned for an acute stroke, you consider the next steps in evaluation and management. //What interventions and/or studies would be considered the best next step?// <<textarea "$answer3" "What interventions or studies would be considered the best next step?" autofocus>> <<button [[Type in your answer, then click here to advance|Management]]>><</button>>

//Here's what you were considering as next steps:// $answer3 ---------------- Recognising that the patient's last known time of normal was her assessment in the Emergency Department 3.5 hours ago now, you recognise the need to act quickly. //'Activate code stroke,'// you instruct the RRT nurse who promptly takes out her hospital phone. You send out a page to the on-call stroke neurologist and consider next steps. //Thrombolytics--Is this patient a candidate for tPA? What contraindications are in place?// <<textarea "$answer4" "Is this patient a candidate for tPA? What contraindications are in place?" autofocus>> //Imaging--What imaging studies would be most beneficial at this time?// <<textarea "$answer5" "What imaging studies would be most beneficial at this time?" autofocus>> <<button [[Type in your answer, then click here to advance|Management 2]]>><</button>>

Here's what you were thinking: //Imaging--What imaging studies would be most beneficial at this time?// $answer5 ----------------- Your RRT phone rings. It's Dr Madhacharya. //'Good morning, sir. This is $name. Sorry to bother you at this time but RRT was called on 6-South...'// You relay details of your findings and receive recommendations to obtain a STAT noncontrast CT head, CT angiography of the head and neck, and a CT perfusion study. //'Alright, he said to get a CTA and CTP.'// [[Order STAT CT studies and ask the RRT nurse to expedite by calling the CT room|CT1]] [[Order STAT CT studies and call the CT room and reading room|CT2]]

Here's what you were thinking: //Prior to administering tPA, what additional data about the patient needs to be obtained? What barriers exist at this time?// $answer6 ---------------- You review inclusion and exclusion criteria for tPA and notice a few gaps and barriers: * Blood pressure > 185/110 * Inability to obtain consent from the patient in her current clinical condition * Unclear history regarding recent procedures and/or bleeding * Coagulation parameters --------------- The nurse states that the patient's only known relative is a sister. She is widowed and has no children. Her sister is contacted by telephone and you relay the situation to her, including risks and benefits of tPA administration. Thankfully she know's the patient's history well. //'Please help her doctor. She's all I have left. We lost our mother to a stroke. I can't lose her.'// You are given verbal consent, witnessed by two nurses. --------------- STAT coagulation studies reveal a PT/INR of 11/1.1 and aPTT of 38. Repeat neurological evaluation is unchanged, so you call Dr Madhacharya yet again to make sure it's okay to give alteplase. He urges you to administer tPA as soon as feasible. //Everything is going to be okay.// Hesitantly, you enter a weight-based order for alteplase and prepare for administration. Repeat vitals show BP 225/120, HR 95, RR 16, SpO2 94% on RA. You decide to... [[Order 20 mg of IV labetalol, x1|IV Antihypertensive]] [[Order a continuous infusion of IV nicardipine, starting at 5 mg/hr|IV Antihypertensive]] [[Order 0.1 mg of PO clonidine, x1|PO Antihypertensive]]

The patient is given an IV antihypertensive and blood pressure is reassessed to be 170/95. Alteplase infusion is started and the patient is triaged to the medical ICU after you give detailed face-to-face signouts to the ICU team. Thankfully, it's your chief resident working tonight. //'I'll take it from here. Good work,'// she tells you. The patient subsequently undergoes successful mechanical thrombectomy. Your shift begins to wind down as the day team slowly trickles in to the Residents' Lounge. //'How was last night?'// asks your day-time relief. //'Awful. It was just endless and I had a really tough case on 6-south. I pushed tPA for the first time.'// //'Woah, how was that?'// //'Scary. Anyways, I'll see you later'// Exhausted, with the weight of last night resting on your eyelids, you head home. ----------- You return the next night for yet another shift of night float and are called to the ICU by your chief resident after back to back RRTs at the start of your shift. //Oh no, what now?// //'Hey, $name. Ms Smith wants to see you. She was the patient you gave tPA to last night.'// //'Yeah, I remember. Everything cool--wait, did you say she *asked* for me?'// ----------- You enter Ms Smith's room and are greeted both by her and her sister. Introducing yourself, you're taken aback by how different Ms Smith looks. //'I heard what you did for me, doctor. Thank you. That must have been difficult.'// You're stunned at how much better she looks. //After everything she's been through she's worried about ME?!'// You sit beside them for a while, hearing stories about their life and family. Ms Smith has a ton of nieces and nephews, and they're on their way in to see her. You notice a family photo resting on the window sill--Thanksgiving dinner it looks like, in the large, framed print. //'Her favourite family photo,'// says her sister. //'The last one before Charlie left us.'// A shiny //Get Well Soon!// balloon hovers over a bouquet of flowers at her bedside. She grabs a rose and hands it to you with a smile, albeit an asymmetrical one. Gripping your hand firmly with her right hand, she says she remembers your voice from last night. //'You told me everything would be okay. My guardian angel.'// //'Thank you,'// mouths her sister, noticing your now teary eyes. Suddenly another //BEEP-BEEP...BEEP-BEEP,// from the pager on your waist. It's yet again another winter night in February. But tonight, it's not as cold, not as dark. With a warm heart you head to the next RRT call, ready for whatever awaits. ----END OF SCENARIO---- [[Click here to read the conclusion|Conclusion]]

The nurse tries to administer clonidine however the patient is not following commands well and doesn't seem able to swallow. //'I think we should try something IV, doc,'// she suggests. //'We shouldn't delay tPA.'// You decide to... [[Order 20 mg of IV labetalol, x1|IV Antihypertensive]] [[Order continuous infusion of IV nicardipine, starting at 5 mg/hr|IV Antihypertensive]]

Orders are placed in the EMR and you take a seat at the nurse's station to catch a breath. Fifteen minutes later your phone rings. //'I thought we were going to CT?'// asks the RRT nurse. //'We are, are we ready to go?!'// //'They aren't ready for us down in CT now. They got another STAT after your order.'// //'You didn't call them?'// //'I thought YOU were gonna call.'// //'Forget it, let's just go,'// you reply with frustration. [[Transport the patient down to CT|Management 2.5]]

Orders are placed in the EMR and you personally call both the CT technician and on-call radiology resident about the pending study. //'Reading room, this is Dr Ray D. Ologie'// //'Hey, Ray. Wanted to give you a heads up about an inpatient code stroke in 6924. I just ordered some STAT CT studies.'// //'Hey, $name. Yup, CTA and CTP--I see em. Will call you back with a read soon.'// //'Sounds good, thanks!'// Re-entering the patient room is the RRT nurse. //'Just got a text from CT. They're ready for us. Let's move.'// [[Transport the patient down to CT|Management 2.5]]

Here's what you were thinking: //Thrombolytics--Is this patient a candidate for tPA? What contraindications are in place?// $answer4 ------------------ The CT studies are completed and are negative for acute intracranial hemorrhage. CT perfusion reveals an acute ischemic infarct of the L MCA region with a discernible penumbra. Angiography is suggestive of a large, proximal L MCA occlusion. Dr Madhacharya calls you back after reviewing the case and the images and instructs you to administer tPA and transfer the patient to the ICU. //Prior to administering tPA, what additional data about the patient needs to be obtained? What barriers exist at this time?// <<textarea "$answer6" "Prior to administering tPA, what additional data about the patient needs to be obtained?" autofocus>> <<button [[Type in your answer, then click here to advance|Management 3]]>><</button>>