Pr ee en LB ta Rel Case Results Recommended actions scored as bonus points based on difficulty setting Overall Score: 92.8% Your Diagnosis: Ischemic Stroke v Your Disposition: Admit to ICU Vv DETAILED DISCUSSION Click each category for scoring details Review of Systems: -?> Physical Exam: 100.0% >DETAILED DISCUSSI Click each category for scoring details Review of Systems: - Physical Exam: 100.0% Stabilization: 100.0% Investigations: 783% Interventions: 100.0% Communications: 50.0% Answers Revealed Click to Rate the Case wwewwy Frere J cone cue ] vvvvw veyUnnecessary: 2 Harmful: o Critical Actions: 50f6 ECG Assess for any rhythm disturbance that may have potentiated this condition. Fingerstick Blood Sugar A fingerstick should be performed rapidly to rule ‘out hypoglycemia as a cause of symptoms. Blood Type & Screen Make sure thorois a blood bank sample in case this patient needs blood products after definitive treatment. Coagulation Panel Baseline coagulation studies are essential to this patient's therapeutic course. Complete Blood Count (CBC) Assess for anemia and thrombocytopenia. CT - Head ‘An emergent non-contrast head CT is critical to this nationtie manariamant Tha nnmnaca ie tn a xq qqCommunications Score: 50.0% Critical: 1of2 Recommend Oofo Unnecessary: ° Harmful: o Critical Actions: 1of2 Talk to wife x| ‘The wife has critical information that will enable definitive treatment. Consult Neurology ~ A Neurologist will be essential to manage this patient after admission. Recommended Actions: OofoThis patient is suffering from an acute stroke in the left MMCA distribution causing slurred speech and right hemiparesis. The differential diagnosis includes other acute CNS issues such as hemorrhagic stroke, SAH, and SDH (EDH is unlikely given the lack of acute head trauma since itis typically associated with skull fracture rupturing the middle meningeal artery.) Initial stabilization should be focused on establishing IV access and getting a STAT head CT. The primary purpose of obtaining an immediate head CT is to exclude a hemorrhagic stroke in order to consider whether the patient is a candidate to receive thrombolysis (treatment of ischemic stroke with tPA). Of note, CTA would also be appropriate but may not be available in many ED settings; current guidelines require only a noncontrast head CT and a concerning exam so we have made it unavailable in this case. The patient should be examined to make sure he is protecting his airway and does not need to be emergently intubated. Basic labs should be obtained in anticipation of possible thrombolysis based on the head CT result including CBC, Chem-7, coagulationpanel, and blood bank sample. ECG should be obtained which demonstrates atrial fibrillation - this is new onset and the likely cause of the embolic stroke. No intervention is needed for the hypertension on arrival as autoregulation will occur in the setting of ischemic stroke - dropping the blood pressure will worsen ischemia to the stroke penumbra. While MRI/A can be obtained, it is not indicated prior to TPA administration due to the potential time delay in TPA administration. After confirming the head CT is negative for acute hemorrhage, the patient's wife should be interviewed to confirm that the “last-seen- well" time is within 3 hours. She should be consented prior to TPA administration (0.9mg/kg, max dose 90mg, with 10% given as bolus followed by remainder infusing over 60minutes) with the goal of administration within 30minutes of arrival. There is likely benefit to administration of TPA within the 3-4.5 hour window although the positive effect is less pronounced. It is important to note that TPA administration is not without associated risk, the primary risk being intracerebral hemorrhage, which may affect up to 5-7% of patients. Additional interventions may be available at specialist stroke centers including catheter-directed mechanical thrombectomy and may benefit selectpatients up to 24 hours after onset of symptoms. Consultation with neurology can be performed either before or after TPA administration (depending on the ED environment, the ED physician may be the one making the decision to lyse if the neurologist is not immediately available). MRI can be obtained after treatment but is not mandatory in the ED setting. The patient should be admitted to the ICU for post-lytic care. From a procedure standpoint, central line and arterial line placement are contraindicated due to time delay and, if performed, will be scored as harmful actions. Contraindications to TPA administration: ~ onset »3-4.5 hours - CNS bleed (current or prior), neoplasm ~ CNS or spinal surgery within 3 months - concern for infective endocarditis or aortic dissection - uncontrolled HTN >/=185/110 after treatment - GI/GU bleeding in past 21 days - acute bleeding/Acute trauma - CT with major infarct signs (likely irreversible) - bleeding diathesis (INR>17, Plt <100K, high PTT/heparin use within 24hrs, anticoagulant/direct thrombin/direct factor Xa inhibitor use)Relative Contraindications: - mild neurological deficit - non-compressible arterial puncture within 7 days (or LP) - hypoglycemia (<50 mg/dL), untreated - serious trauma or major surgery within 14 days - prior history of GI/GU bleeding ~ seizure - pregnancy - large intracranial aneurysm or vascular matformation, untreated Additional relative exclusion criteria (3-4.5 hrs): ~ age >80 - anticoagulant use (regardless of INR) ~ severe stroke ~ history of prior stroke AND diabetes References: http://www.strokeahaorg Wardlaw, Joanna M., et al. "Thrombolysis for acute ischemic stroke, update August 2014.” Stroke 45.11 (2014): €222-e225.