Signal lost

Does the thought of managing acute stroke wind you tight like the clock that's tracking your stroke care performance? Take 10 minutes to leverage your AMBOSS resources and work through this module—and save time when it really counts!

You're having the best Friday night of call ever: no codes, no difficult sticks for IVs, and no admissions after midnight. All your notes are done, and there are only 5 minutes left until your relief comes. You treat yourself to a meditative moment. I am composed. I am capable. I am caffeinated.

Unfortunately, your pager resists your zen—vibrating, screaming, and glowing all at once.

Click the pager icon to reveal the message.

Question: How urgently should you assess the patient?

Make your choice, then click on the explanation bubble to reveal the answer.

• Right now
• Well, the new team will arrive in 5 minutes...and they'll be fresh...

This is your last minute of calm before the storm. Take advantage of it and quickly review what you know from the signout.

Signout sheet review

• Age
• Code status
• Admission diagnosis or reason for hospitalization
• PMH, procedures, and interventions
• Medications
• Allergies
• Recent laboratory results

The elevator doors open. You glance at your watch and make a mental note of the time.

Question: What tasks should be accomplished by each time benchmark?

Think about each choice, then click on the explanation bubble to reveal the answer. These benchmarks are consistent with 2019 AHA guidelines; be familiar with local protocols. ^[1]

• ≤ 10 minutes
• ≤ 15 minutes
• ≤ 20 minutes
• ≤ 45 minutes
• ≤ 60 minutes

The nurses' station is in early morning change-of-shift chaos—twice the usual people, four times the usual noise. Time to let go of the zen; this moment is about taking charge. Be loud and authoritative—you are protecting this patient’s brain!

You call out over all the noise, “Who has room 646?” A nurse jumps up, waves, and points down the hallway. Together you quickly walk to the patient's room.

Question: What will you ask the nurse about on the way to the patient's room?

Make your choices, then click on the explanation bubbles to reveal the answers.

• Detailed medical history
• Last time the patient ate
• Any hemodynamic or respiratory instability
• Last time the patient appeared neurologically intact
• Last glucose
• Recent anticoagulation
• Whether neurology has been consulted or a stroke code called

You reach the patient's room. You feel the need, the need for speed.

Question: What are your first steps?

Make your choices, then click on the explanation bubbles to reveal the answers.

• Rapidly assess the ABCs and intervene if necessary.
• Assess for facial droop, abnormal speech, gross motor abnormalities, and arm drift.
• Call a stroke code if any neurological abnormalities are present.

Your rapid screen was positive, so you called a stroke code.

Question: Backup is on the way! Now what?

Until the stroke team arrives, you are the responsible physician. Follow these steps to make sure you perform all the steps recommended by the 2019 AHA guidelines. ^[1] Click on the explanation bubbles for more information.

• Provide airway management if there is respiratory failure.
• Provide oxygen therapy if the patient is hypoxemic.
• Obtain IV access and send laboratory studies.
• Begin fluid resuscitation if the patient is hypotensive.
• Check point of care glucose.
• Use the National Institutes of Health Stroke Scale to assess neurological deficit severity.
• Order an emergency noncontrast CT head or MRI brain.
• Obtain a 12-lead ECG.

Approximately 85% of strokes are ischemic, 10% are hemorrhagic (non-subarachnoid), and 5% are subarachnoid hemorrhages.

Time is running out… Better keep moving!

Question: Which clinical scenario would you like to explore?

Choose an option to continue the module:

• Option 1: Ischemic stroke
• Option 2: Hemorrhagic stroke

You may not have gotten the tranquil moment you hoped for, but you stayed mindful and got your patient the timely treatment they needed. Nicely done! Now you can relax and reflect on what just happened, including what went well.

• You did a great job:
  • Recognizing the need for speed in managing patients with a potential stroke
  • Prioritizing the most important elements of the history and physical
  • Prioritizing POC glucose and neuroimaging over all other diagnostics
  • Taking responsibility for activating the stroke team with only limited information
  • Understanding the different hemodynamic management strategies for ischemic stroke (Option 1) and hemorrhagic stroke (Option 2)
• One of the most pivotal and yet most frustrating elements of caring for patients with acute stroke is the divergence in management for ischemic versus hemorrhagic stroke. Review this flow chart to reduce your stress in the future.

Congratulations on completing this module. Hopefully you now feel more comfortable assessing a patient with acute stroke!

Personal story from an AMBOSS clinician

I was called to evaluate a patient with new aphasia in the post-anesthesia care unit (PACU). He was a 65-year-old retired sailor who had just undergone an uncomplicated cholecystectomy. The PACU course was initially unremarkable except for moderate hypertension (185/100 mm Hg), which was new for him. When the nurse had asked if he was okay, he promptly responded, “Aye aye, sir.”

Several minutes later, the nurse asked him if he was in pain. He again responded, “Aye aye, sir.” When asked how much pain he was in, he again said, “Aye aye, sir.” The nurse realized that all questions provoked the same response. She recognized new aphasia and called for help.

When I examined the patient, I could not identify a facial droop or arm drift, but I called a stroke code based on the new aphasia. A head CT was obtained within 15 minutes and showed no evidence of hemorrhage. The neurologist on the stroke team consulted with the surgeon and the patient's family about the relative risk of fibrinolytic therapy. Since the surgery had been uncomplicated and the bleeding risk was felt to be low, IV alteplase was initiated within 60 minutes of the nurse identifying a neurologic abnormality.

Within 2 hours of the patient receiving fibrinolytic therapy, his aphasia improved markedly. A subsequent head MRI identified moderate changes consistent with ischemia in the superior temporal gyrus.

The lessons I learned: Take any neurological change seriously, even if it is not classic for stroke. Advocate for the patient and include specialists and families in decisions, especially those with potentially life-altering consequences.