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Stroke Only the Beginning of Patient’s Problems


You’re dispatched as a MICU crew to a BLS sick person call at a skilled nursing facility (SNF). En route to the scene, additional information is provided from the communication center that the patient is hypoxic and on oxygen, and no other information is available. The patient is in the stroke rehabilitation unit and, on arrival, a nurse directs you to the patient’s room. You enter the room and find a 78-year-old female lying in semi-Fowler’s position in a hospital-type bed being attended to by a nurse and a physician. The physician begins to offer a report.

Doctor’s Report
This patient was admitted to the facility this past evening from a hospital that’s primarily a stroke center after being treated there for a non-hemorrhagic stroke. The patient was treated with tissue plasminogen activator (tPA) there without much change in her condition and wasn’t a candidate for interventional radiological procedure interventions. As a result of the stroke, the patient has right-sided hemiparesis, right-sided facial droop, aphasia and dysphasia. The patient was additionally treated for her uncontrolled hypertension and atrial fibrillation. The previous evening, upon the patient’s admission to the SNF, she was noted to be extremely hypertensive at 190/136 and was also noted to have an elevated white blood cell count. The patient was treated with Lopressor and Cardizem. This morning, the patient was found to be still moderately hypertensive at 160/100, with no other changes in her condition noted.

During afternoon rounding, the patient was found by a nurse to be semi-conscious and is responsive to verbal stimulation with slight eye-opening and incomprehensible speech. Vital signs were BP 60/40, HR 118 and irregular, RR 44 and shallow, Sp02 76% on room air, blood glucose of 101 mg/dL. The attending physician was summoned and 9-1-1 EMS activated. The RN started a 22-gauge IV with normal saline and administered a 250 cc fluid bolus without any change noted in the patient’s blood pressure. The patient was administered supplemental oxygen at 4 lpm via nasal cannula.

Assessment & Treatment
Your assessment reveals a 65 kg, elderly female who appears to be in moderate distress. The patient is semi-conscious and responds to light tactile stimulation with eye opening. The patient has garbled and incomprehensible speech after being stimulated. The patient has shallow rapid respirations at 40 breaths per minute and no palpable radial pulses. A weak, irregular carotid pulse is palpated at 122 bpm. The patent has cool, pale and dry skin. A BP is obtained at 68/38 and a SpO2 reading of 82% on 4 lpm of oxygen. The SpO2 readings are sporadic and seem to be inaccurate due to the patient’s cool extremities. You also note that the patient has a right-sided facial droop and complete right-sided hemiparesis.

Initial treatment includes assessment of the patient’s airway to ensure patency and protection, and the patient is noted to have an intact gag reflex at this time. The patient’s husband requests that the patient be transported to the original hospital she was treated at, which is an approximately 45-minute transport. Due to the instability of the patient’s condition, it’s agreed upon that she should be transported to a closer hospital that’s approximately six minutes away. Oxygen is increased to 15 lpm via a non-rebreather mask, and the patient is moved to the EMS stretcher and transport initiated.

The IV is opened to a wide-open rate and a second IV is established with normal saline at a to-keep-open rate. The cardiac monitor is attached and atrial fibrillation noted with an occasional unifocal PVC (fewer than five per minute). Blood glucose testing is obtained and a reading 96mg/dL noted.

Secondary assessment reveals no trauma or injuries to the entire body. Lung sounds are diminished in the bases bilaterally with no other abnormal sounds noted. The abdomen is soft and the patient is noted to have a questionable grimace upon palpation to the upper quadrants, and when asked if she feels pain, she doesn’t respond. The extremities are cool to the touch and the patient’s feet are mottled bilaterally. A stroke scale couldn’t be completed due to the patient’s recent stroke having left her with a right-sided facial droop and right hemiparesis.

Continuing transport, medical command is contacted at the receiving hospital, and the case is discussed. No additional treatment orders are given by the medical command physician. The patient’s level of consciousness continues to decrease throughout transport, and the patient’s work of breathing continues to become more labored. The patient is now unresponsive to all stimuli but retains an intact gag reflex. A nasopharyngeal airway is placed and bag-valve ventilations are initiated (local protocol doesn’t allow medication-facilitated intubation for ground EMS providers). The receiving hospital is contacted and requested to prepare for immediate intubation of the patient upon EMS arrival. Additional vital signs remain unchanged with only a slight increase in the patient’s blood pressure to 78/56, no change in the patient’s heart rate and an increase in the patient’s SpO2 reading to 90%.

Hospital Care
Upon arrival at the hospital, the patient is immediately prepared for intubation with the standard rapid sequence induction medications and successfully intubated by the respiratory care technicians. During intubation, the patient begins to vomit coffee ground emesis. The patient remains acutely hypotensive with readings remaining below 90 systolic. A CT scan of the head is inconclusive. After placement of a nasogastric tube, approximately 700 cc of dark coffee ground contents are removed. The patient is admitted to the ICU with a diagnosis of aspiration pneumonia and a gastrointestinal bleed of unknown origin. The patient is treated with broad-spectrum antibiotics, and IV blood pressure support medications are initiated for continued hypotension and then subsequently discontinued after two days of continuous administration.

After two days of admission, the patient develops abdominal tenderness and is diagnosed with ischemic colitis. The patient is then noted to have decreased kidney function and begins to have multi-organ failure. The patient is made a DNR after five days of admission to the hospital. She is extubated and palliative care is initiated. She subsequently passes 12 hours later.


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