Get certified in ACLS for just $195.00.
To view this video please enable JavaScript, and consider upgrading to a web browser that supports HTML5 video
In this scenario, you're going to have a patient with a suspected stroke. You're an ACLS team leader who has a 70-year-old female patient. Her friend said she was watching television when she started to feel weak, then suddenly had some difficulty speaking while her left side became very weak. When her friend tried to help her stand up, she was unable to walk on her own. The patient is conscious and breathing normally, but appears agitated. As you ask your patient questions, she has difficulty speaking and giving appropriate answers. Your patient's friend said she noticed the difficulty speaking about 30 minutes ago. Now, because the initial signs indicate a possible stroke, you should perform a stroke assessment. Prehospital providers might perform an abbreviated assessment known as the Cincinnati Prehospital Stroke Assessment. It consists of facial droop, arm drift, speech and time. If you're a hospital provider, you may perform a more detailed full NIH stroke score to document neurological status. In our patient assessment, we found that she is conscious and alert. However, the patient does have facial droop, left arm drift and speech difficulty. This is enough information to call for the stroke team to respond and order an emergency CT scan. Now, the next step is to get a set of vitals. You direct a team member to place the BP cuff and the O2 sat monitor. The team member tells you that the pulse is 78, respirations are 18, she has a blood pressure of 124 over 100, her skin is warm and dry, and the O2 sat is 96. Based on the vital signs, the patient does not need oxygen at this time. At this time, you would attach the monitor and get a 12 lead EKG. As you look at the 12 lead, you see a normal sinus rhythm. You direct a team member to continue checking the blood pressure every five minutes and keep a close eye on any changes in her breathing. Now, an important diagnostic tool for potential stroke is blood glucose. Hypoglycemia, or low blood glucose, can mimic stroke symptoms, such as confusion and slurred speech. You direct the assistant to check the glucose level, and it's normal at 90. In order to consider fibrinolytic therapy, we need to determine the time since the symptoms started. Since she arrived at the emergency room, it has been just about 15 minutes. The symptoms started 30 minutes before arriving to your care. Since the patient's blood pressure, O2 sat, and glucose levels are within normal limits, and the symptoms started less than three hours ago, the patient may actually be a good candidate for rtPA. If the patient has no history of previous strokes, is not on blood thinners or other contraindicated medications or other contraindications, then the CT scan will be the determining factor. Now, if the CT scan shows no hemorrhage, we'll be able to go with our rtPA. To be ready for potential drug therapy, this is the time to start an IV. You direct the assistant to start an IV, 18-gauge antecubital with normal saline. We're gonna keep this at a TKO rate. The goal is to recognize potential stroke signs early and get the patient appropriate fibrinolytic therapy or the most appropriate reperfusion strategy in a timely manner.
In this lesson, we're going to let you play the role of team leader during a stroke emergency. From start to finish, you'll be in charge of assessing the patient and providing therapy and treatment recommendations.
In this scenario, you've been presented with a 70-year-old female patient. A friend of hers told you that she was watching TV when she started to feel weak and suddenly had difficulty speaking. Her left side also became very weak.
When her friend tried to help her stand up, as told to you by the friend, your patient was unable to walk on her own. She is conscious and breathing normally but appears agitated.
As you ask the patient a few questions, you notice that she's having difficulty speaking and also giving appropriate answers. Her friend said that she noticed the difficulty of speaking about 30 minutes ago.
Your initial assessment recap:
Because the initial signs indicate a possible stroke, you should perform a stroke assessment. If you're a pre-hospital provider, you might want to perform an abbreviated assessment, known as the Cincinnati Prehospital Stroke Scale (CPSS).
This abbreviated stroke assessment consists of four elements:
If you're an in-hospital provider, you might want to perform a more detailed full NIH stroke score to more completely document the patient's neurological status.
During your patient's assessment, you found her to be conscious and alert. However, the patient does have facial droop, left arm drift, and has trouble speaking. This is enough information to call for a stroke team to respond and also order an emergency CAT/CT scan.
The next step is to obtain a full set of vitals for this patient. So, you direct one of your team members to place a blood pressure cuff on the woman and also an O2 saturation monitor.
The team member now has the patient's vital signs and tells you the following:
Based on your patient's vital signs, you determine that she does not need oxygen. At this time, you attach the monitor and get a 12-lead ECG. And as you look at the 12-lead printout, you see a normal sinus rhythm.
You then direct the team member to continue checking the woman's blood pressure every 5 minutes and keep a close eye on any changes in her breathing.
Pro Tip #1: An important diagnostic tool for potential stroke is blood glucose. Hypoglycemia or low blood glucose can mimic stroke symptoms, such as confusion and slurred speech, so it's important to rule this out.
You direct a team member to check the patient's glucose level and find that it's normal at around 90.
In order to consider fibrinolytic therapy, you need to determine the time since the onset of symptoms. And since the woman arrived at the emergency room, it's been another 15 minutes. Remember, symptoms began 30 minutes before the woman arrived into your care.
Since the patient's blood pressure, O2 saturation, and blood glucose levels are all within normal limits, and since symptoms started less than 3 hours ago, you decide that this patient may be a good candidate for rtPA.
Pro Tip #2: rtPA, also known as recombinant tissue plasminogen activator, includes specific medications like alteplase, reteplase, and tenecteplase. These are often used in clinical medicine to treat embolic or thrombotic stroke.
Indications for rtPA include:
If the patient has no history or previous strokes, isn't on blood thinners or contraindicated medications, or has other contraindications, then the CT scan will be the determining factor. If the CT scan shows no hemorrhage, you'll be able to go with rtPA.
To get ready for this potential drug therapy, this would be the time to start an IV. You direct a team member to start an IV – 18 gauge antecubital with normal saline. And you'll keep this at a TKO rate.
Remember, the goal is to recognize the patient's potential stroke signs early and get her the appropriate fibrinolytic therapy, or the most appropriate reperfusion strategy, in a timely remember.