new-onset-aphagia part 3

Standard Approach
Suggested Approach

• Evaluate the airway; patient may be at risk of aspiration, especially with altered mental status
• Have airway equipment ready in case it is needed; if snoring respirations are noted, a nasopharyngeal airway is often adequate and well tolerated
• Oxygen by nasal cannula is not essential but is acceptable; if the patient is not oxygenating well, give 15L by mask and assess for adequate ventilation and possible need for intubation
• Position head of gurney greater than 30 degrees, prop the patient up to prevent leaning due to weak trunk muscles, and fasten seatbelts to secure in safe position for transport; it may also be necessary to position the patient in left lateral recumbent to allow for airway drainage
• Consider trauma for any patient with a history of fall or bruising on their head or neck; spinal precautions are controversial and may not be helpful, so consult your medical director or local protocols before immobilizing routinely.
• Any time stroke is considered, check a glucose.
• Note the time the patient was last seen normal. This may be when the neurologic deficit was witnessed to happen; but if it was not witnessed, then the last time anyone saw the person normal.
• Try to establish a current medication list. Anticoagulants (aspirin, warfarin or Coumadin, clopidigrel or Plavix, dabigatran or Pradaxa, and rivaroxaban or Xarelto are a few of the more common ones) are risk factors for hemorrhagic strokes.
• Establish IV access
• Obtain a 12-lead ECG if able and if it will not significantly delay transport.
• Notify the receiving hospital you are concerned about a stroke.
• Transport expeditiously; lights and sirens only if patient is hemodynamically unstable, signs of increased intracranial pressure or has airway compromise that cannot be managed with basic techniques including suction, positioning, manual maneuvers or basic airway adjuncts.

Notes

• Stroke is a cerebrovascular accident (CVA). Either there is a clot that is preventing blood flow to part of the brain (ischemic stroke), or there is bleeding in the brain (hemorrhagic stroke).
• Strokes can be very subtle, and any new neurologic deficit should be considered a stroke until proven otherwise. Use the Cincinnati Prehospital Stroke Scale to evaluate rapidly for neurological deficits. Any deficit should be presumed to be new.
• The Cincinnati Prehospital Stroke Scale:
• Facial droop: Have the person smile or show his or her teeth. If one side doesn’t move as well as the other, such that it seems to droop, that could be sign of a stroke.
• Normal: Both sides of face move equally
• Abnormal: One side of face does not move as well as the other (or at all)
• Arm drift: Have the person close his or her eyes and hold his or her arms straight out in front for about 10 seconds
• Normal: Both arms move equally or not at all
• Abnormal: One arm does not move, or one arm drifts down compared with the other side
• Speech: Have the person say, “You can’t teach an old dog new tricks,” or some other simple, familiar saying
• Normal: Patient uses correct words with no slurring
• Abnormal: Slurred or inappropriate words or mute
• Glucose should be checked in every person with neurologic deficits Hypoglycemia can manifest itself with neurologic symptoms
• In a stroke, time is of the essence. Minimizing time on scene can maximize the patient’s chance of getting to a hospital in a time frame that it is safe to attempt to reverse their stroke.
• Thrombolysis or fibrinolysis is the key non-surgical intervention that may reverse a stroke; however, use of thrombolytics (fibrinolytics) is very controversial and has many absolute and relative contraindications. There is some evidence that prehospital administration of TPA (tissue plasminogen activator, a thrombolytic) may be safe and effective; however, it should only be given in strict adherence to local protocol or in direct consultation with an emergency medicine physician or stroke specialist. The patient in this video was most likely not a candidate for receiving TPA.
• In a hemorrhagic stroke, there is bleeding in the brain. That cannot be determined without a CT scan. Avoid giving aspirin or other anticoagulant medications.
• In a hemorrhagic stroke, the bleeding can be so great that it can push on the brain, resulting in a herniation (or protrusion) of the brain down the spinal column. This also can happen due to edema in a large ischemic stroke. Increased intracranial pressure manifests with high blood pressure, low heart rate, and irregular breathing (known as Cushing’s triad). This is a bad sign. If you carry it, you can consider giving mannitol or hypertonic saline, or expediting transport with lights and sirens.
• It is important to note when the patient was last seen normal. That is the time that the stroke team will base their time of onset on, and will determine what treatment options are available to the patient.
• Patients with prior strokes can have recurrence of their symptoms (known as recrudescence) in the context of metabolic stresses like infections.
• A transient ischemic attack is a cerebrovascular accident that resolves fully within 24 hours.
• Some patients may not be able to provide an accurate history even if they appear to understand what you are asking. Be sure to gather as much relevant documentation or available medical records as possible and have a high index of suspicion for pain, difficulty breathing, or confusion, regardless of what the patient tells you. If they look like they are in pain or having difficulty breathing, they are, even if they say they are not.
• This patient had evidence of recent trauma, which may increase the possibility of bleeding. Spinal precautions were not indicated in this patient, and may have actually caused harm, due to airway compromise, breathing difficulty, and supine position. However, it is important to assess for signs of trauma and evaluate for signs of head injury.

Suggested references

• Delirium, Dementia, and Amnesia in Emergency Medicine Treatment & Management
• New Stroke Management Guidelines: A quick and easy guide
• Time Is Brain in Prehospital Stroke Treatment