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Clinical Scenario: Man weak, falls, possible occlusive stroke

A careful and thorough EMS stroke assessment can make a difference in ED management

By Patrick Lickiss

As you finish checking out in line at the grocery store, dispatch calls over the radio, “Engine 2542, Medic 2552, respond Priority 3 to 226 1st Street on a 66-year-old male who fell from his wheelchair.”

You go en route to the call and half way to the address dispatch updates “2542 and 2552, upgrade Priority 1, caller states the patient is not responding.”

You arrive at a small house in an older part of the city. Bystanders meet you at the curb and urge you to come inside. You walk through the front door and are directed upstairs to a bedroom down a small hallway. A woman identifies herself as the 911 caller and the patient’s daughter. When asked what happened she replies:

“My father lives alone and I come over in the afternoons to visit and make him dinner. Today I found him sitting in his wheelchair instead of his recliner. When I tried to help him out of the chair he couldn’t stand and he slid to the floor. I thought he was just weak from being in his chair all day but I called 911 back when he couldn’t answer my questions. He was fine when I talked to him on the phone a few hours ago!”

You approach the patient and notice that he is tracking you visually as you walk up. You introduce yourself and see that the patient is moving his lips trying to respond but is unable. You notice that his face is crooked and obviously weaker on one side. You ask him to lift his arms with his palms up and he is unable to lift his right arm.

Your partner checks the patient’s vital signs and finds:

  • BP 152/90
  • HR 88, irregular
  • RR 16

The patient’s daughter says that he has a history of high blood pressure, irregular heartbeat and COPD. He takes atenolol, Coumadin, digoxin and several inhalers. She reports that he is in charge of taking his own medications.

Discussion: Differing between hemorrhagic and occlusive stroke

The standard procedure for evaluating stroke symptoms is the Cincinnati Prehospital Stroke Scale. In order to perform the stroke scale, a provider will ask the patient to perform several simple tasks: lift both arms and hold them up, palms upright, smile showing their teeth and recite the phrase “The sky is blue in Cincinnati.” If the patient is unable to perform one or more these tasks, he has positive findings for a stroke.

There are two types of stroke: occlusive and hemorrhagic. An occlusive stroke occurs when blood flow to an area of the brain is blocked by a clot. These clots may have several causes but frequently result from an underlying heart rhythm like atrial fibrillation.

A hemorrhagic stroke, on the other hand, is caused by a ruptured blood vessel in the brain. As the patient bleeds, pressure increases in the skull resulting in changes to the patient’s neurological status.

There are a few findings that indicate whether a patient is having an occlusive stroke or hemorrhagic stroke. In a study published in 2011, researchers found that three types of patient presentation were associated with an occlusive stroke:

  • Atrial fibrillation
  • Diastolic BP < 100 mmHg
  • No change from baseline level of consciousness 1

With a cardiac condition like atrial fibrillation, patients are at a much higher risk of developing blood clots in the heart due to decreased blood flow in the atria. Once these clots form, they can leave the heart and lodge in the brain.

Baseline hypertension (> 100 mmHg diastolic) can weaken the walls of blood vessels in the brain. As the walls weaken the vessels are more likely to form aneurysms. If an aneurysm bursts, the bleeding can increase pressure in the skull causing the patient to develop stroke symptoms.

This study found the opposite correlation as well: patients not suffering from extreme hypertension were more likely to have an occlusive stroke.

In a hemorrhagic stroke, pressure in the brain from bleeding into a closed space (the skull) causes the brain to be pushed downward, towards the largest opening in the skull. This puts pressure on the midbrain located above the brain stem.

The midbrain controls alertness and sleep cycles. Since a hemorrhagic stroke can causes changes in level of consciousness, the researchers were also able to show that no loss of consciousness indicates a higher likelihood of occlusive stroke.

By understanding the differences between occlusive and hemorrhagic stroke, providers of all training levels can collect valuable information to pass on to hospital staff. When a patient suffering from a stroke arrives at the emergency department, the report from EMS responders sets a series of events in motion based on two particular pieces of information: Whether the stroke appears to be caused by a clot; and how long has the stroke been occurring.

One of the most important pieces of information an EMS provider can collect is when a stroke patient was last seen normal, and by whom. If a patient can be given “clot busting” drugs within 4 and a half hours of the time of symptom onset, their chance of recovery increases greatly.

Treatment: Possible diagnosis of occlusive stroke

Based on the patient’s positive stroke scale findings, the fact that he has a history of atrial fibrillation and does not have a diastolic blood pressure greater than 100 mmHg, you conclude that he probably has an occlusive stroke. You ask further questions of his family and learn that the patient spoke with his daughter on the phone approximately two hours earlier and that everything was okay. You record the daughter’s name and phone number to bring to the hospital.

You also learn that the patient has not been taking his Coumadin regularly because he “doesn’t like all the bruises”. The transporting unit arrives and you assist in packaging the patient for transport.

Resolution

The ambulance crew contacts your station several days later. The patient arrived at the hospital approximately three hours after he was last witnessed acting normally. He was taken directly to the CT scanner in the ER and it was confirmed that he did not have a hemorrhagic stroke.

The patient and his family consented to drug therapy and his symptoms began resolving by the next morning. He is expected to be discharged for rehabilitation in the next day or two. It is anticipated that he will regain 95% of function back.

References:

  1. Yamashita S, Kimura K, Iguchi Y, et al. Kurashiki Prehospital Stroke Subtyping Score (KP3S) as a means of distinguishing occlusive from hemorrhagic stroke in emergency medical services. Eur Nerol. 2011; DOI: 10.1159/000324025.
  2. Jauch EC, Saver JL, Adams HP, et al. Guidelines for the early management of patients with acute occlusive stroke: A guideline for healthcare professionals from the American Heart Association/American Association/ Stroke. 2013; DOI:10.1161.

An EMS practitioner for nearly 15 years, Patrick Lickiss is currently located in Grand Rapids, MI. He is interested in education and research and hopes to further the expansion of evidence-based practice in EMS. He is also an avid homebrewer and runner.

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