Adv Acls Casestudies

Copyright © 2012 by Mosby, an imprint of Elsevier Inc.

Case Studies

Copyright © 2012 by Mosby, an imprint of Elsevier Inc. 2

Case 1

3 Copyright © 2012 by Mosby, an imprint of Elsevier Inc.

Scenario

Your patient is a 42-year-old woman who was pulled out of a backyard swimming pool. It is a warm July day. The time is 1523.

You have four other advanced life support (ALS) personnel available to assist you.

Emergency equipment is immediately available.

The scene is safe to enter.


Case 1

You are putting on personal protective equipment as you approach the patient

What are the general impression ABCs?


General Impression ABCs

Appearance

Mental status, muscle tone, and body position

(Work of) Breathing

Body position, visible movement of chest and abdomen, ventilatory rate, ventilatory effort, and audible airway sounds

Circulation

Skin color


General Impression: Decision

On the basis of your general impression, decide if the patient is sick (unstable) or not sick (stable).


Case 1

Your patient is a 42-year-old woman who was pulled out of a backyard swimming pool.

It is a warm July day.

The time is 1523.


Case 1

You see a woman supine on a stretcher.

Her eyes are closed, and her hair and clothing are wet.

You see no signs of breathing.

Her skin looks pale.


Case 1

What memory aid can you use to evaluate the patient’s level of responsiveness?


Assess Responsiveness

A = Alert

V = Responds to Verbal stimuli

P = Responds to Painful stimuli

U = Unresponsive


Case 1

The patient is unresponsive.

What should be done next?


Primary Survey

Perform a primary survey that starts with the assessment of the patient’s airway: A = Airway B = Breathing C = Circulation D = Defibrillation/disability E = Exposure


Case 1

How will you open the patient’s airway?


Airway

Unresponsive patient

Use the head tilt–chin lift maneuver to open the airway if no trauma is present.

Use a jaw-thrust without head-tilt maneuver if there is known or suspected trauma.


Case 1

You see a small amount of pink fluid in the patient’s mouth.

What should be done now?


Case 1

What is the maximum length of time for a suctioning attempt?


Case 1

The patient’s airway is clear.



Case 1

The patient is not breathing.

How should you proceed?


Case 1

Size and insert an oral airway. Begin positive pressure ventilation. Continue the primary survey.


Case 1

How will you determine the properly sized oral airway for this patient?


Oral Airway: Sizing


Case 1

Name two possible complications of oral airway insertion.


Oral Airway: Complications

Too long Too short


Case 1

Describe two methods for the insertion of an oral airway in the adult patient.


Oral Airway: Insertion


Case 1

An oral airway has been inserted.

The patient is still not breathing.

Should a nasal cannula be considered at this point?


Case 1

When the use of a nasal cannula is indicated, what liter flow is recommended for use with this device?

What is the approximate oxygen concentration that can be delivered with a nasal cannula?


Nasal Cannula

0.25 to 8 L/min flow

Oxygen concentration of approximately 22% to 45% (actual amount of inspired oxygen depends on ventilatory rate and depth)


Case 1

Should a simple face mask be considered at this point?


Case 1

When the use of a simple face mask is indicated, what liter flow is recommended for use with this device?

What is the approximate oxygen concentration that can be delivered with a simple face mask?


Simple Face Mask

5 to 10 L/min flow

Inspired oxygen concentration of approximately 35% to 60%

The patient’s actual inspired oxygen concentration will vary, because the amount of air that mixes with supplemental oxygen is dependent on the patient’s inspiratory flow rate.


Case 1

What percentage of oxygen can be delivered with a bag-mask device?


Bag-Mask Ventilation


Case 1

What are the most frequent problems associated with bag-mask ventilation?


Case 1

An oral airway has been inserted, and the patient is being ventilated with a bag-mask device.

You see gentle chest rise with bagging.

At what rate should this patient be ventilated?


Case 1

The patient is being ventilated as instructed.



Case 1

Although it is difficult to feel, a slow carotid pulse is present. You estimate the rate to be about 40 beats/min.

The patient’s skin is cool, pale, and wet.



Case 1

The patient remains unresponsive and apneic.

Breath sounds with bag-mask ventilation are clear and equal.

The patient’s heart rate is 44 beats/min.

Her blood pressure is 86/54 mm Hg.


Case 1

The patient has been placed on the cardiac monitor. What is the rhythm?



SAMPLE HistorySigns/symptoms Submersion incident

Allergies None

Medications Unknown

Past medical history Depression

Last oral intake Unknown

Events prior The patient was retrieved from the swimming pool by her husband. He estimates that she was in the water for less than 10 minutes.

What should be done now? What should be done now?


Physical Examination Findings

Head, ears, eyes, nose, and throat

Pink fluid initially present in the mouth (cleared with suctioning)

Neck Trachea midline, no jugular venous distention

Chest Breath sounds clear and equal with bag-mask ventilation

Abdomen No abnormalities noted

Pelvis No abnormalities noted

Extremities No abnormalities noted

Posterior body Unremarkable


Case 1

A tracheal tube has been inserted and the cuff inflated.

An IV has been established with normal saline.

What methods can be used to verify the proper placement of the tracheal tube?


Confirming Tube Placement Visualizing the passage of the tracheal tube between

the vocal cords Auscultating the presence of bilateral breath sounds Confirming the absence of sounds over the epigastrium

during ventilation Adequate chest rise with each ventilation Absence of vocal sounds after tracheal tube placement End-tidal carbon dioxide measurement (waveform

capnography is preferred) Verification with an esophageal detector device Chest radiography


Case 1

Describe how you will auscultate the patient’s chest to confirm tracheal tube placement.


Confirming Tube Placement


Case 1

There are no sounds heard over the epigastrium.

Breath sounds are diminished on the left side of the chest with bag-mask ventilation. They are clearly heard on the right.



Case 1

On the basis of these findings, you should suspect a right primary bronchus intubation.

Ask the airway team member to deflate the cuff, pull back slightly on the tracheal tube, re-inflate the cuff, and reassess the patient’s breath sounds.


Case 1

Breath sounds with bag-mask ventilation now reveal clear and equal breath sounds.

What would you like to do now?


Case 1

Capnography confirms the presence of CO2. The tracheal tube has been secured.



Case 1

The patient is attempting to breathe spontaneously at a rate of 6 to 8 breaths/min.

Her vital signs are now as follows: Blood pressure: 112/74 mm Hg Pulse: 75 beats/min, strong and regular Ventilatory rate: 10 breaths/min via bag-mask

device SpO2: 97% with bagging


Case 1

What is the rhythm on the cardiac monitor?



Case 2


Scenario

Your patient is a 52-year-old woman who was found unresponsive on her kitchen floor by a neighbor. The time is 1442.

You have four other ALS personnel available to assist you.



General Impression

A woman is supine on a stretcher.

Her eyes are closed.

You do not see any signs of breathing.

Her skin is pale, and her lips are blue.



Case 2


How would you like to proceed?


Case 2




Case 2

There is no pulse.

You note that the patient’s skin is cool, pale, and dry.



Case 2

Compressions are being performed as requested.



Case 2




Case 2

An oral airway has been inserted.

The patient is being ventilated with a bag-mask device. You see gentle chest rise with bagging.

What would you like to do next?


Case 2

The AED pads are in place on the patient’s chest.

The power to the AED is on.

How do you want to proceed?


Case 2

While waiting for the machine to analyze the patient’s rhythm, should you ask your assistants to insert an advanced airway or start an IV?

Why or why not?


Case 2

The AED advises a shock.

What do you want to do now?


Case 2

Everyone is clear of the patient.

The defibrillation team member has delivered the shock.



Case 2

The AED states, “No shock advised.”



Case 2

A strong carotid pulse is present.

The patient is waking up and breathing on her own at a rate of about 12 breaths/min.



Case 2

The patient’s heart rate is strong and regular at a rate of 80 beats/min.

Ventilations are occurring at a rate of 12 breaths/min.

The patient’s blood pressure is 98/60 mm Hg.


SAMPLE History

(History obtained from neighbor)

Signs/symptoms Found unresponsive by neighbor

Allergies Unknown

Medications Azithromycin (Zithromax), alendronate (Fosamax)

Past medical history “Intestinal problems”


Events prior Found unresponsive on the kitchen floor by a neighbor who had last spoken to the patient about 25 minutes prior




Cyanosis of lips noted on initial examination


Chest Breath sounds clear and equal with positive pressure ventilation




Posterior body No abnormalities noted


Case 2



Case 3


Scenario

Your patient is a 58-year-old man who collapsed while having lunch.

The patient was helped to the floor by his coworkers.

It has been 5 minutes since the patient collapsed.

You have five other ALS personnel available to assist you.

Emergency equipment, including a biphasic manual defibrillator, is immediately available.


General Impression

The patient’s eyes are closed.

He does not appear to be breathing.

His skin looks very pale.



Case 3

You have determined that the patient is unresponsive and not breathing.



Case 3

There is no pulse.

The patient’s skin is cool, pale, and dry.



Case 3




Case 3

An oral airway has been inserted. The patient is being ventilated with a bag-

mask device. You see gentle chest rise with bagging. Breath sounds are clear and equal with positive

pressure ventilation. Combination pads are in place on the

patient’s chest.



Case 3

A biphasic defibrillator is within arm’s reach.




Case 3

Will you be performing synchronized cardioversion or defibrillating this patient?


Case 3

What initial medications do you want the IV team member to prepare?


Case 3

What energy setting will you use for your initial shock?


Case 3

The shock is delivered.



Case 3

An IV has been started with normal saline in the patient’s left antecubital vein.

Epinephrine has been given intravenously.



SAMPLE History

(History obtained from the patient’s wife)

Signs/symptoms Collapsed about 15 minutes ago

Allergies Codeine, penicillin

Medications Divalproex sodium (Depakote)

Past medical history Epilepsy, substance abuse


Events prior Sudden collapse




No abnormalities noted


Chest Breath sounds clear and equal with positive pressure ventilation

Abdomen No abnormalities notedPelvis No abnormalities notedExtremities No abnormalities notedPosterior body No abnormalities noted


Case 3

You observe the following rhythm on the cardiac monitor.



Case 3

The IV team member requests clarification regarding the amiodarone order. What dosage should be administered at this time?


Case 3

Amiodarone has been given as instructed.

The patient’s cardiac rhythm remains unchanged, and CPR is ongoing.



Case 3

The shock has been delivered. A team member calls your attention to a

rhythm change on the cardiac monitor. What is the rhythm?



Case 3

The patient is unresponsive but breathing shallowly at a rate of approximately 4 breaths/min.

A strong pulse is present at a rate of approximately 80 beats/min.

His blood pressure is 88/62 mm Hg.

His color is improving.



Case 4


Scenario

Your patient is a 24-year-old man who was found unresponsive in his home by his girlfriend.

She told law enforcement personnel that he was fine about 15 minutes ago and then she heard a gunshot.

The time is 1415.

You have four other ALS personnel available to assist you.



General Impression

You see a young man supine on a stretcher. He is unaware of your approach. There is no obvious rise and fall of his chest. His skin is pale. You observe minimal bleeding from a chest

wound on the patient’s right sternum. What would you like to do now?


Case 4




Case 4

There is no pulse.




Case 4




Case 4

An oral airway has been inserted. Two-person bag-mask ventilation is being

performed. You see gentle chest rise with bagging. Breath sounds are clear and equal with positive

pressure ventilation.

Combination pads are in place on the patient’s chest.

A biphasic defibrillator is within arm’s reach. What should be done now?


Case 4




SAMPLE History

Signs/symptoms Found unresponsive by girlfriend after she heard a gunshot; minimal bleeding from chest wound on right sternum

Allergies None

Medications None

Past medical history None

Last oral intake Lunch 2 hours ago

Events prior Last seen 15 minutes ago; law-enforcement personnel report that the patient shot himself in the chest with a .45-caliber gun; an estimated 1 to 2 L of blood have been lost at the scene





Neck Trachea midline, jugular veins flatChest Gunshot wound present on the right

of the sternum; breath sounds diminished on the left with positive pressure ventilation

Abdomen No abnormalities notedPelvis No abnormalities notedExtremities No abnormalities notedPosterior body Large exit wound lateral to the left

scapula


Case 4



Case 4

The airway team member has successfully inserted a Combitube.

The IV team member has successfully placed an IV in the right antecubital vein.


Case 4

Waveform capnography confirms the proper placement of the Combitube.



Case 4

The Combitube has been secured.

The IV fluid bolus that you ordered is infusing, and 1 mg of 1:10,000 epinephrine has been given.

CPR is ongoing, and the rhythm on the cardiac monitor is unchanged.

Does the placement of an advanced airway necessitate any changes in bag-mask ventilation?


Case 4

After 40 minutes of high-quality CPR, the rhythm on the cardiac monitor is unchanged.

Epinephrine has been given every 3 to 5 minutes, and one dose of vasopressin was administered.



Case 5


Scenario

Your patient is a 53-year-old woman who has been found unresponsive by her husband.

The time is 1700.




General Impression

You see a middle-aged woman lying supine on a stretcher.

You estimate that the patient weighs approximately 100 kg.

Her eyes are closed, and you do not observe any rise and fall of her chest.

She is blue from her chest up.



Case 5




Case 5

There is no pulse.




Case 5

Compressions are being performed, and combination pads have been applied to the patient’s chest.



Case 5




Case 5

An oral airway has been inserted. Two-person bag-mask ventilation is being

performed. You see gentle chest rise with bagging. Breath sounds are clear and equal with positive

pressure ventilation. The defibrillator that you requested is within

arm’s reach. What would you like to do next?


Case 5

You see this rhythm on the cardiac monitor. What is the rhythm?



SAMPLE HistorySigns/symptoms Unresponsive, apneic, pulseless

Allergies Unknown

Medications Unknown

Past medical history Unknown


Events prior According to the patient’s husband, the patient told her daughter that she was not feeling well and went to take a nap in the bedroom about 2 hours ago. The husband went to awaken his wife for dinner but could not arouse her. He reports that his wife has had no recent surgery or trauma. They returned from a 6-day stay in Mexico yesterday.




Upper body blue


Chest Breath sounds clear and equal with positive pressure ventilation; blue from the chest up






Case 5



Case 5

The airway team member has successfully inserted a tracheal tube.

The IV team member has successfully placed an IV in the left antecubital vein, and epinephrine was administered as ordered.



Case 5

The proper placement of the tracheal tube has been confirmed with an esophageal detector and waveform capnography.

A cardiology consult has been ordered.



Case 5

The tracheal tube has been secured.



Case 5

High-quality CPR is continuing.

The patient’s cardiac rhythm is unchanged.



Case 5

Epinephrine is being given intravenously as instructed.

What memory aids can be used to help recall the possible reversible causes of cardiac arrest?


PATCH-4-MD

Pulmonary embolism

Acidosis

Tension pneumothorax

Cardiac tamponade

Hypovolemia

Hypoxia

Heat/cold (hyperthermia/hypothermia)

Hypokalemia/hyperkalemia (and other electrolytes)

Myocardial infarction

Drug overdose/accident


The Five Hs and Five Ts

1. Hypovolemia

2. Hypoxia

3. Hypothermia

4. Hypokalemia/

hyperkalemia

5. Hydrogen ions (acidosis)

1. Tamponade, cardiac

2. Tension pneumothorax

3. Thrombosis: lungs

4. Thrombosis: heart

5. Tablets/toxins: drug overdose


Case 5

On the basis of the information available to you, what possible causes of this patient’s cardiac arrest have you considered?


Case 5

You observe a change on the cardiac monitor. What is the rhythm?

Does the change in the patient’s cardiac rhythm necessitate any changes in the management of the patient at this time?


Case 5

High-quality CPR is ongoing.

There is gentle chest rise with bagging.

Breath sounds are clear and equal bilaterally with positive pressure ventilation.


Case 5

Forty-five minutes have now elapsed since resuscitation efforts began.

So far, 8 mg of epinephrine have been given in 1-mg doses.

The patient’s ECG rhythm and condition remain unchanged.


Case 5



Case 6


Scenario

Your patient is a 52-year-old man who is complaining of shortness of breath and substernal chest discomfort.

The time is 0719.




General Impression

You see a 52-year-old anxious-looking man sitting in a chair.

His breathing does not appear to be labored.

His skin is pink.


Primary Survey

Airway: clear; patient states that he is short of breath and has severe chest discomfort

Breathing: 22 breaths/min, unlabored Patient completes sentences without hesitation

Circulation Radial and carotid pulses strong and regular Heart rate of approximately 60 beats/min Warm, pink, and moist skin



SAMPLE History Signs/symptoms Shortness of breath and substernal chest discomfort

OPQRST Symptoms began at rest; patient describes his chest discomfort as “pressure” with radiation down his left arm and rates his discomfort at 10/10; the symptoms have been present for about 1 hour

Allergies None

Medications Nitroglycerin, chlorzoxazone (Parafon Forte), imipramine (Tofranil), alprazolam (Xanax), hydrochlorothiazide (Hydrodiuril)

Past medical history

Depression, hypertension, angina pectoris; patient is 5’9” and weighs 190 pounds

Last oral intake Dinner last evening

Events prior The patient states that he was watching the morning news on television when his symptoms began; he denies nausea, vomiting, and dizziness






Chest Breath sounds clear bilaterally






Case 6

Blood pressure: 127/88 mm Hg

Heart rate: 58 beats/min

Ventilations: 22 breaths/min

SpO2: 98% (nasal cannula at 4 L/min O2)



Case 6

An IV has been started.

Aspirin has been given.

The patient still rates his discomfort at 10/10.

A 12-lead ECG has been obtained as ordered.


Case 6 Are there any significant findings on this 12-lead

ECG?

I Lateral aVR ------------ V1 Septum V4 Anterior

II Inferior aVL Lateral V2 Septum V5 Lateral

III Inferior aVF Inferior V3 Anterior V6 Lateral


Case 6



Case 6

The loading dose of clopidogrel was given as instructed.

The patient rated his chest discomfort as 10/10 after the first dose of NTG. The patient’s blood pressure remained stable, and

a second NTG dose was given. The patient’s discomfort was subsequently noted as 8/10.

A third dose of NTG was given, with no change in the patient’s rating of his discomfort (i.e., 8/10).



Case 6



Case 6

The patient’s blood pressure is now 131/91 mm Hg, his heart rate is 66 beats/min, and his ventilatory rate is 18 breaths/min.

After two doses of IV morphine, the patient rates his discomfort as 0/10.



Case 7


Scenario

Your patient is a 76-year-old woman who is complaining of dizziness. The time is 1121.




General Impression

You see an ill-appearing woman lying on a stretcher.

Her eyes are closed.

You can see equal rise and fall of her chest.

Her skin is pale.


Primary Survey

Airway: “I feel dizzy”

Breathing: 18 breaths/min, unlabored

Circulation Carotid pulse weak but regular Heart rate of approximately 30 beats/min Cool, pale, and dry skin

Defibrillation: biphasic defibrillator available


Case 7



Case 7

Blood pressure: 64/42 mm Hg

Heart rate: approximately 30 beats/min

Ventilations: 18 breaths/min

Breath sounds clear and equal

SpO2: 90% on room air


SAMPLE History

Signs/symptoms Sudden onset of severe dizziness

Allergies None

Medications Furosemide (Lasix), aspirin, olanzapine (Zyprexa), pantoprazole (Protonix), paroxetine (Paxil)

Past medical history Arthritis, osteoporosis, heart failure, schizophrenia, gastroesophageal reflux disease, depression

Last oral intake Breakfast 3 hours ago

Events prior Sudden onset of dizziness; symptoms started approximately 30 minutes ago while at rest


Case 7

The patient has been placed on the cardiac monitor.

What is the rhythm?



Case 7

The patient has been placed on O2, and an IV has been started.

A 12-lead ECG has been ordered.

Your defibrillator has transcutaneous pacing capability.



Case 7

Atropine has been given as ordered.

Laboratory work and a chest radiograph have been ordered.

A cardiology consult has been ordered.

A reperfusion checklist has been started.



Case 7

The patient’s heart rate has increased to 48 beats/min (i.e., junctional rhythm).

The patient’s blood pressure is now 74/53 mm Hg, and her ventilatory rate is 16 breaths/min.



Case 7 A second dose of atropine has been given as

ordered.

The patient’s blood pressure is now 110/66 mm Hg, her heart rate is 80 beats/min, and her ventilatory rate is 16 breaths/min.

Her skin is now warm, pink, and dry.

The patient states that she is feeling much better.



Case 8


Scenario

Your patient is a 37-year-old man who states that he was awakened by “heart palpitations.”

The time is 0023.

You have five other ALS personnel to assist you.



General Impression

You see a man supine on a stretcher.

He is awake, and his skin looks very pale.

You can see the rise and fall of his chest.


Primary Survey Airway: clear

Breathing: 16 breaths/min

Circulation

Unable to feel radial pulse

Weak carotid pulse present

Heart rate of approximately 150 beats/min

Cool, pale, and moist skin

Defibrillation: biphasic machine available


Case 8



Case 8

The patient’s blood pressure is 50/24 mm Hg, his heart rate is 150 beats/min, and his ventilatory rate is 16 breaths/min.

Breath sounds are clear and equal.

The patient’s SpO2 is 88% on room air.


SAMPLE History

Signs/symptoms Heart palpitations

Allergies Codeine, sulfa

Medications Albuterol (Proventil), ipratropium (Atrovent)

Past medical history Asthma

Last oral intake Dinner at 1800

Events prior Awakened from sleep by “heart palpitations”; symptoms present for 1.5 hours


Case 8


What is the rhythm? Is the patient stable or unstable?


Case 8



Case 8



Midazolam has been given as instructed.

The cardiologist is en route.

Will you be performing synchronized cardioversion or defibrillation?


Case 8

A biphasic manual defibrillator is available.

What initial energy setting will you use?


Case 8

A synchronized shock was delivered using 100 joules.

You see the following rhythm on the monitor. What is the rhythm?


Case 8



Case 8

Strong carotid and radial pulses are present.

The patient’s ventilatory rate is 14 breaths/min.


The patient’s blood pressure is BP 108/88 mm Hg, and his SpO2 is 99%.

The cardiologist is here.



Case 9


Scenario

A 19-year-old man presents with a complaint of a “rapid heartbeat” and chest discomfort.

You have four ALS personnel available to assist you.

Emergency equipment is available.


General Impression

You see a nervous-appearing young man sitting upright on a stretcher.

His breathing is unlabored.

His skin is pink.


Primary Survey

Airway: “My heart is racing and feels like it is going to pound out of my chest.”

Breathing: 18 breaths/min, unlabored Circulation

Strong radial and carotid pulses that are too fast to count accurately

Heart rate of approximately 200 beats/min Warm, pink, and moist skin



Case 9



Case 9

The patient’s vital signs are as follows: Blood pressure: 134/90 mm Hg Heart rate: 214 beats/min Ventilatory rate: 18 breaths/min


The patient’s SpO2 on room air is 99%.


Case 9


What is the rhythm shown on the monitor?


SAMPLE History Signs/symptoms Rapid heartbeat and chest discomfort

OPQRST Symptoms began when the patient was at rest; he describes his chest discomfort as “pressure” and rates his discomfort at 1/10; his symptoms have been present for about 25 minutes

Allergies None

Medications None

Past medical history None

Last oral intake Caffeine-free soda 1 hour ago

Events prior Patient was sitting in the college library when his symptoms began


Case 9

An IV has been started in the right antecubital vein.


Is this patient stable or unstable?



Case 9

The patient has complied with your instructions, but no change is observed on the cardiac monitor.



Case 9

Adenosine has been given as ordered.



Case 9

A cardiology consult has been requested. The cardiologist is en route and is expected to arrive in about 20 minutes.

The patient’s chest discomfort has resolved.

His blood pressure is now 122/70 mm Hg, his heart rate is about 40 beats/min, and his ventilatory rate is 16 breaths/min. His skin is warm, pink, and dry.

The patient states that he feels “much better.”


Case 9

What is the rhythm on the monitor?



Case 10


Scenario

A 73-year-old woman presents with a sudden onset of slurred speech. The patient’s son is present. The time is 0906.

You have four ALS personnel available to assist you.

Emergency equipment is available.


General Impression

You find the patient awake and supine on a stretcher.

You see equal rise and fall of her chest.

Her skin is pink and looks dry.


Primary Survey

Airway: Patient attempts to speak, but her speech is garbled and unintelligible

Breathing: 18 breaths/min, quiet and unlabored

Circulation Strong and regular radial and carotid pulses Heart rate of approximately 70 beats/min Warm, pink, and dry skin



Case 10



Case 10

The patient’s vital signs are as follows: Blood pressure: 217/93 mm Hg in the left arm and

208/90 mm Hg in the right arm Heart rate: strong and regular at 74 beats/min Ventilatory rate: 18 breaths/min


The patient’s SpO2 is 98% on room air.


Case 10


What is the rhythm?


SAMPLE History

Signs/symptoms Patient awoke at 0730 with slurred speech; it is apparent that the patient can understand you, although you cannot understand her

Allergies None

Medications Niaspan (Niacin), lisinopril with hydrochlorothiazide (Zestoretic), gabapentin (Neurontin)

Past medical History

Seizures, hypertension, pacemaker, high cholesterol

Last oral intake Dinner about 1900 last evening

Events prior The patient’s son states that his mother has complained of heartburn and not feeling well for about 24 hours; she awoke this morning with slurred speech and said that she was “feeling sick,” with nausea, dizziness, and sweating


Physical Examination FindingsHead, ears, eyes, nose, and throat

Pupils equal and reactive but sluggish; right-sided facial droop present


Chest Breath sounds clear bilaterally; pacemaker noted in left pectoral region



Extremities Pulses, movement, and sensation equal bilaterally



Case 10



Case 10



The patient’s serum glucose level is 143 mg/dL.

Why is it important to determine the serum glucose level of a patient with a suspected stroke?


Case 10

After obtaining the SAMPLE history, what are three questions that you should ask about a patient who presents with signs and symptoms of an acute stroke?


Case 10

The patient’s son states that his mother complained of heartburn and not feeling well for about 24 hours.

She awoke at 0730 this morning with slurred speech (which is new for this patient) and said that she was “feeling sick,” with nausea, dizziness, and sweating.


Case 10

The patient does not have a headache, chest pain, or shortness of breath.

Although the patient has a history of seizures, her last seizure was 4 months ago.

There is no history of recent trauma.



Case 10

What areas are assessed with the use of the Cincinnati Prehospital Stroke Scale?


Case 10

Facial droop is present on the right.

The patient is unable to repeat a phrase clearly.

The upper extremities move equally.

The patient has not been feeling well for 24 hours.

She awoke at 0730 today with slurred speech.


Case 10



Case 10

What is the time target for a possible stroke patient evaluation by a physician?

What are the time targets for obtaining and reading a computed tomography scan?


National Institute of Neurological Disorders and Stroke (NINDS) Recommended Stroke Evaluation

Targets for Potential Fibrinolytic Candidates

Activity Target

Door to physician evaluation 10 minutes

Door to access to neurologic expertise (in person or by phone)

15 minutes

Door to computed tomography completion 25 minutes

Door to computed tomography read 45 minutes

Door to drug/intervention 60 minutes

Door to neurosurgical availability (on site or by transport)

2 hours

Door to admission to monitored bed 3 hours


Questions?

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