Stroke? Or what?

[adamjh3]

BLS unit dispatched to a vascular access center at 1412 info en route states you have an 81 yo M hypoglycemic. No further info available.

You arrive on scene at 1432 to find an 81 yo M sitting upright in a wheelchair, unresponsive but breathing. Story from the nurses and correlating paperwork states he came in at approximately 1200 for a declotting of his fistula. You are unable to obtain a history on the patient other than he's normally a&oX1 but always alert.

At about 1230 s/p scheduled procedure the patient goes unresponsive. Facility nurses then recorded a bgl of 45 and administered 2 amps of D50 via IV. bgl rechecked at 1345 and is recorded at 234, pt remains unresponsive. Facility calls pts son to authorize bls transport to a hospital 15 minutes away.

Pts vitals are as follows
P:110 with a fib/flutter on the facilities monitor. Palpated pulse correlates and is strong at the radial site
R:12 full and effective w/clear lungs W/spO2 @98% on room air.
BP: 126/58
Eyes PERRL @ 3
Skins are pink cool and dry.

Contact with your base hospital (the aforementioned hospital 15 minutes away) to activate a stroke code ends up with them requesting you transport l&s but go directly to an ED room. No stroke code is activated.

My thinking with calling a stroke code was a clot could moved into the brain during the declotting of the fistula. The ED staff seemed unworried and pretty much brushed us off.

Offload was about ten minutes shy of three hours from the onset of symptoms.

Your thoughts?

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[NomadicMedic]

Could be a CVA. When was his last dialysis?

 

[adamjh3]

Could be a CVA. When was his last dialysis?

48 hours prior to the procedure

Forgot to mention, pt has bilateral BKAs if that's important here.

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[NomadicMedic]

Why was no stroke code activated? Did the PT go right to CT? Any sign of hyperk on the 12 lead? Did you see any labs or an ABG?

 

[adamjh3]

Why was no stroke code activated? Did the PT go right to CT? Any sign of hyperk on the 12 lead? Did you see any labs or an ABG?

I called to request a stroke code, the radio nurse requested we go to an ED bed. Pt did not go to CT as of when we cleared which was about 30 minutes post arrival.

No 12 lead available, this was a BLS truck, we used the three lead at the vascular center that was already hooked up. EKGs are out of my scope.

No labs provided.

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[JPINFV]

It doesn't sound like a stroke. Assuming he's a dialysis patient, I'd like a chem 7 and a CBC and maybe a CT.

In regards to the fistula causing a stroke, what are the 2 big organs with lots of capillaries that stands between the fistula and the brain?

 

[adamjh3]

It doesn't sound like a stroke. Assuming he's a dialysis patient, I'd like a chem 7 and a CBC and maybe a CT.

In regards to the fistula causing a stroke, what are the 2 big organs with lots of capillaries that stands between the fistula and the brain?

Lungsband heart.

Someone already called me out on that via PM (which I'll reply to when I get home, its a pain to quote segments on my phone).

I didn't even think about that until they brought it up.

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[NomadicMedic]

As a BLS truck, you did the right thing.

Can't tell anything without any additional diagnostics, stuff that you don't have.

I'm still guessing a CVA, close second is an electrolyte imbalance. Again, can't tell without CT and labs.

 

[JPINFV]

Specifically the lungs unless some other disorder (such as a septal defect or patent ductus arteriosus) is present. Clots from the veins causes PEs, clots in the arteries causes organ infarct (spleen, kidneys, heart, brain).

 

[JPINFV]

I'm still guessing a CVA, close second is an electrolyte imbalance. Again, can't tell without CT and labs.

Unless the issue with the fistula is being treated as a red herring, what is making you think CVA?

 

[Handsome Robb]

It doesn't sound like a stroke. Assuming he's a dialysis patient, I'd like a chem 7 and a CBC and maybe a CT.

In regards to the fistula causing a stroke, what are the 2 big organs with lots of capillaries that stands between the fistula and the brain?

Seeing as chronic afib is a recognized risk factor for a CVA I'm not seeing your point. Not arguing just wondering if there's something I'm missing. I don't foresee a clot from the fistula getting caught in the heart unless it gets caught in the turbulent flow in the atria from the afib and with what I said before about chronic afib and CVAs a clot could definitely make it through the lungs.

 

[NomadicMedic]

A suddenly unresponsive PT who's normally alert? I'm going to guess a CVA, especially if he was alert when he came in, he has Afib and is undergoing treatment for a clot. ;/

CT him. If its not a clot (or a bleed, made worse by those 2 amps of D50) great. Then we can look for a secondary cause.

Now, is he septic? Maybe. Is it hyperkalemia? Maybe. A simple UTI? Maybe. Who knows without diagnostics that the OP can't provide. Maybe some follow up from the call will come.

Until then it's just a guessing game.

 

[adamjh3]

As far as sepsis, the patient would generally have a fever, yes? Sublingual temp was 98.3

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[Handsome Robb]

As far as sepsis, the patient would generally have a fever, yes? Sublingual temp was 98.3

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Generally but not always. Wouldn't be the first time a septic patient was afebrile.

 

[NomadicMedic]

As far as sepsis, the patient would generally have a fever, yes? Sublingual temp was 98.3

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Not necessarily.

 

[JPINFV]

Seeing as chronic afib is a recognized risk factor for a CVA I'm not seeing your point. Not arguing just wondering if there's something I'm missing.

You're missing that I missed that the patient was in a-fib.

 

[Akulahawk]

JP: It still could very well be a CVA. Given that there's known Atrial Fibrillation... Who knows if the patient is on some anticoagulant, and even then he could have developed a clot, which dislodged, and floated to the brain.

I'm certainly not getting the feeling that that this is/was a PE. To me,this "sounds" more like a CVA, and that close to the 3 hour mark, that patient would have run out of time well before reaching the CT scanner...

Just my thoughts.

 

[DV_EMT]

Well Afib and fistula de-clot make me think Neuro, maybe they did have a stroke/CVA. Its hard to tell though since they're unresponsive. Did you see any facial droop and was the patient leaning even while in bed as though motor function was lost.

Could also be a clot that manifested elsewhere, but the vitals dont really show a good indication that it might be a PE.

As everyone has stated, Labs/CT would be the best course of action given the presentable info. Stroke Code was a good call (even my wife, a neuro RN of 6 years, agreed).

Whats the PT History? why the BTK Amputation? ESRD (assuming since they are dialysis)? Diabetic?

 

[JPINFV]

A suddenly unresponsive PT who's normally alert? I'm going to guess a CVA, especially if he was alert when he came in, he has Afib and is undergoing treatment for a clot. ;/

Clots because of a surgical vascular anomaly (what he's being treated for) and clots because of a-fib aren't really the same. A clot generated from a fistula isn't going to cause a stroke without a right to left shunt.

 

[JPINFV]

JP: It still could very well be a CVA. Given that there's known Atrial Fibrillation... Who knows if the patient is on some anticoagulant, and even then he could have developed a clot, which dislodged, and floated to the brain.

I'm certainly not getting the feeling that that this is/was a PE. To me,this "sounds" more like a CVA, and that close to the 3 hour mark, that patient would have run out of time well before reaching the CT scanner...

Just my thoughts.

In this thread, a page of "But he's in a-fib you stupid med student." :wacko:

I agree that there's no indication that the patient is having a PE. I'm guessing/assuming that the shunt is for dialysis access, which makes me concerned about the patient's electrolytes and RBC count.