The hallways of the school are a flurry of activity as students discuss the latest Bieber songs while trying to beat the tardy bell by getting to class on time. You and your partner have been called there to care for a 9-year-old girl who isn’t acting right. Entering the nurse’s office you see a young female lying on a cot in the corner. She looks frightened. The school nurse greets you and tells you that soon after the girl, Madison, arrived at school, her friends reported her acting strangely in the restroom. They told the staff she was talking funny, fell to the ground and didn’t seem to be able to walk. Staff carried the girl to her current location. The nurse is unaware of any medical history or medications taken by Madison. The school is attempting to contact her parents.
You kneel next to the cot and begin your assessment. She has no obvious signs of trauma: no bleeding, bruising or obvious deformities. Madison looks at you but doesn’t speak. When you ask her questions, she appears to be attempting to talk but is unable. When you ask yes or no questions she responds by nodding her head. She denies any drug use or recent traumatic events.
On physical exam you note that she’s unable to move the right side of her body. You look at your partner and comment that this looks like a stroke, but she’s only 9. You and your partner get Madison loaded in the ambulance, apply oxygen via cannula, establish an IV and check her blood glucose level, which reads 96 mg/dL. You ask the nurse to let Madison’s parents know she’s being transported to County Regional Medical Center—the local neurology hospital. A computed tomography scan at the hospital confirms that Madison had an occlusive cerebral vascular accident (CVA), commonly known as a stroke.
She received intra-arterial tPA, which is a potent clot busting medication. She had a good outcome and was released four days later with no neurologic deficit. She was referred to a pediatric cardiologist for evaluation of a patent foramen ovale (PFO) discovered during assessment, which is a hole in between the right and left atria. The hole exists normally in uterine circulation (Foramen Ovale) and should close soon after birth.
This case looks at not only the presentation of a CVA but also the presentation of a CVA in a pediatric patient. A CVA or stroke is an acute disruption of neurologic function caused by vascular injury in the brain. Commonly, strokes can be divided into ischemic and hemorrhagic. Most strokes in the U.S. are ischemic in nature, being caused by a thrombus developing in a cerebral vessel or an embolus traveling to the brain from somewhere else in the body. Some ischemic strokes are identified as cryptogenic, which means the cause of the stoke is unknown. Cryptogenic strokes are most common in patients under the age of 45.
The management of CVAs or strokes begins with timely recognition. In EMS, we commonly talk about stroke patients who present with slurred speech and unilateral paralysis. EMS workers should consider any variation in neurologic function as a possible stroke, including changes in gait, acute memory lapses and seizures. Airway and ventilation must be managed to protect against aspiration and to maintain oxygen saturation above 94%.
Establish vascular access and determine the patient’s blood glucose level. Administer Dextrose as indicated by your protocols. Transport the patient to the closest hospital with a neurologic specialty or stroke center. Attempt to establish the exact time of onset for symptoms because much of the definitive care in the hospital is time sensitive with some procedures needing to be completed within three hours of symptom onset. The consideration of stroke must be extended to children as well.
The Children’s Hemiplegia and Stroke Association (CHASA) report that the incidence of stroke in children between 1 and 18 years of age is 11 per every 100,00 children with a mortality rate of 20–40%.1 Many strokes in children are considered cryptogenic; however, in some studies, the incident of PFO in patients with cryptogenic strokes is 40–50%, as compared with a 20% incident in the general population leading to the suspicion there’s some association.2,3 Patients with a PFO may develop a paradoxical embolism, which can travel to the brain and result in an ischemic stroke.
Early recognition, appropriate prehospital treatment and aggressive hospital treatment result in good outcomes for patients experiencing a stroke. This includes patients of all ages, including children.
1. Children's Hemiplegia & Stroke Association. (2010). In Children’s Hemiplegia and Stroke Association. Retrieved Jan. 1, 2012, from www.chasa.org.
2. Horton S, Bunch T. Patent foramen ovale and stroke. Mayo Clin Proc. 2004;79(1):79–88
3. Tobis J, Azarbal B. (2005) Does Patent Foramen Ovale Promote Cryptogenic Stroke and Migraine Headache? In Texas Heart Institute Journal. Retrieved Jan. 1, 2012, from, www.ncbi.nlm.nih.gov/pmc/articles/PMC1336709/.