Note: Your progress in watching these videos WILL NOT be tracked. These training videos are the same videos you will experience when you take the full ProACLS Recertification program. You may begin the training for free at any time to start officially tracking your progress toward your certificate of completion.
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:
- 70-year-old female
- Difficulty speaking
- Left side weakness
- Conscious and breathing normally
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:
- Facial droop
- Arm drift
- Speech
- Time
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:
- Pulse: 78 beats per minute
- Respiratory rate: 18
- Blood pressure: 124/100
- Skin: warm and dry
- O2 saturation: 96 percent
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:
- Symptom onset less than 3 hours
- No history of strokes
- Normal blood glucose levels
- No blood thinners
- No contraindicated medications
- No other contraindications
- A clear CT scan
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.
