American Medical Response and Las Vegas Fire and Rescue are summoned to a suburban residence after an elderly man was found unresponsive in his garage. On arrival, paramedics found a 73-year-old man lying supine on the floor of his garage. A fallen ladder was nearby, and a large amount of emesis was on the garage floor.
A roommate reported that the patient had gone out to the garage to change a light bulb, but still hadn’t returned to the house after about 30 minutes. The roommate went out to check on him 30 minutes later and found him lying on the floor.
The patient was breathing adequately but responded to painful stimuli by wincing. Paramedics performed a detailed assessment and found no apparent injury. His blood pressure was 139/75, pulse 57, respirations 16. His saturation of SpO2 was 98% on room air and Glasgow Coma Scale (GCS) score is 9 (E=2, V=2, M=5). A C-collar was placed on the patient, and full spinal motion restriction was applied.
While the patient was being packaged, EMS providers surveyed the scene again and concluded the injury was most likely a fall. Because of the patient’s altered mental status, closed head injury was the presumptive prehospital diagnosis, and the patient was transported to the trauma center at University Medical Center (UMC) in Las Vegas. Based on the prehospital providers’ findings, a full trauma activation was called at the trauma center.
On arrival, the patient immediately went to the trauma resuscitation area, and a full trauma assessment began. The patient’s vital signs seemed regular. His GCS remained at 9, and no obvious trauma was noted although providers noticed he had a left gaze preference, right-sided weakness, and he didn’t follow commands.
He was immediately taken to the CT scanner, where a CT of the head (without contrast) and cervical spine were completed. He also received chest and pelvic X-rays.
The emergency physician’s initial reading of the imaging studies didn’t reveal any evidence of trauma. No fractures or hemorrhage were noted; however, the reading did reveal evidence of brain edema on the left side in the distribution of the left middle cerebral artery.
Based on these findings, the trauma activation was cancelled, and a presumptive diagnosis of stroke was made. A CT angiogram of the head and neck was obtained in the trauma center, which revealed a complete occlusion of the left internal carotid artery and a 50% stenosis of the right internal carotid artery. While the patient was in the scanner, his roommate and partner arrived. Emergency physicians were able to document that the patient was well approximately 60 minutes prior to trauma center arrival. Thus, he was within an interventional window for stroke.
The stroke team promptly evaluated the patient and agreed with the emergency physician’s assessment and administered recombinant tissue-plasminogen activator (rt-PA). The patient did well and was subsequently admitted to the neuro intensive care unit in stable condition. He showed some improvement with the rt-PA, but he didn’t show a total reversal of signs and symptoms.
We later learned from the patient’s roommate that the patient had recently been evaluated in Minnesota, and surgery on the right carotid artery was planned.
EMS textbooks often address trauma and medical conditions separately. But in many situations, like this one, what appears to be a trauma-related problem is actually a medical problem. Another example is a patient who has a heart attack while driving and runs into a pole.
Likewise, some patients may present with an apparent medical condition that is later found to be trauma related. For example, a patient presents with altered mental status and later it’s found he has a subdural hematoma from a fall.
Prehospital providers are often limited in their ability to determine whether a patient has a medical or traumatic condition. Thus, as occurred in our case, they assume the worst—a closed head injury in an elderly male—and transported the patient to a Level I trauma center. There, the patient was able to obtain immediate assessment and diagnostics.
One of the biggest advances in emergency care over the past decade has been the care of stroke patients. A stroke occurs whenever blood supply to a part of the brain is interrupted by either a blood clot (thrombus) or hemorrhage. Immediate imaging of the brain with CT technology can usually exclude hemorrhage as a cause.
Thus, in cases where patients have an obstruction (as in this case), administering a drug to break down the clot and open the blocked artery may be beneficial. These drugs, called fibrinolytics, can be effective, but they can also be dangerous. To be effective, they must be quickly administered after the onset of symptoms. Traditionally, the interventional window for administration of fibrinolysis has been three hours, but the American Heart Association (AHA) has extended this to 4.5 hours.1,2
EMS providers must practice medicine in the austere prehospital environment. It would be easy to retrospectively criticize prehospital providers for not recognizing a stroke in this patient. However, it took full trauma activation and complex imaging studies before the diagnosis became apparent.
In EMS and emergency medicine, decisions are made based on the best information available at the time. Unlike the flow-sheet algorithms commonly used in EMS, signs, symptoms and clinical information don’t present themselves in an orderly, linear fashion.
The initial information you receive on an emergency scene can be random and nonlinear. You must organize it in your mind to process it. The more you see a particular pattern or variations in a pattern, the easier it will be to recognize it. EMS providers will analyze a situation, gather additional data (history, physical examination, scene assessment) and organize it until they recognize a known and defined pattern. Physicians use the same process.
The pattern is often less clear. Certainly, our patient’s presentation was consistent with both a closed-head injury and a stroke. However, prehospital providers didn’t have the tools to determine the actual problem. But, they identified the highest level of risk and acted accordingly, thus helping to mitigate the risk for the patient.3
It’s not necessary for EMS providers, and in some cases emergency physicians, to determine a final, binding patient diagnosis. In most cases, we must look for and exclude the most severe life-threatening conditions. When we can’t exclude those, we must assume they exist until proven otherwise.
With the advent of stroke centers and interventional neurology, stroke victims are now offered a treatment option in selected cases. The stroke care system works best when strokes are promptly identified and transported to an accredited stroke center.
In emergency medicine and EMS, we’re often presented with chaos, and our job is to restore order. Trying to follow a flow-chart algorithm is problematic in situations like this.
The modern prehospital practitioner must, in essence, become a diagnostician. But, unlike the emergency department, the primary goal is to detect life-threatening injuries and illnesses and get the patient to the proper facility for definitive care.
This case involved a victim of a fall who actually suffered a massive stroke. Although the stroke wasn’t diagnosed in the field, the patient was transported to a facility, where a prompt diagnosis was made and the appropriate treatment provided. The ultimate outcome for the patient might have been quite different had he been transported to a non-trauma center or a facility that didn’t have interventional neurology capabilities. JEMS
This article originally appeared in December 2010 JEMS as “Mixed Signals: The complexities of recognizing stroke patients.”