Case Study 1 • 72 yo female collapses at home while eating dinner with her daughter. EMS brings the patient to your ER and you note the following: garbled speech, right sided hemiplegia, able to briskly follow commands with left side, and able to write answers to questions. Vitals: BP 177/90, P 88 bpm and irregular, RR 18, O2 95% on room air
What is your FIRST action? • Administer IV tPa • Give 10 mg IV Labetalol • Obtain STAT head CT • Obtain STAT brain MRI
Which artery is likely affected? • Right Middle Cerebral Artery (MCA) • Left Middle Cerebral Artery (MCA) • Right Anterior Cerebral Artery (ACA) • Left Anterior Cerebral Artery (ACA)
What is the name of the patient’s language disorder? • Adam’s Aphasia • Wernicke’s (receptive) aphasia • Broca’s (expressive) Aphasia • Global Aphasia
Case Study 2 Mrs. Liken is a 48 yo female who presents to the ED with “the worst headache of her life”. She states the pain is the worst in the back of her head and her neck. Past medical hx: HTN (noncompliant) and tobacco use. Vitals: 174/88, 103, 99% on room air, RR 22
What is your #1 differential diagnosis? • Intracerebral Hemorrhage • Subdural Hematoma • Epidural Hematoma • Subarachnoid Hemorrhage
Given the confirmed diagnosis of SAH, what is considered the gold standard for diagnosing an aneurysmal SAH? • MRI • MRV • Angiogram • CTA
While awaiting intervention (coiling or clipping), what is the number one priority ? • Make the patient NPO for the procedure • Assure adequate hydration given the large contrast load • Obtain echocardiogram to assess for myocardial stunning • Strict blood pressure control to prevent re-rupture of the aneurysm
Case Study 3 EMS brings a 59 yo homeless male to your Emergency Department. No known past medical history is known. EMS was called when the patient was found in a park on the ground shaking his left arm and leg. Positive loss of consciousness was briefly noted.
Case Study 3 The patient regains consciousness in the ambulance but is substantially weaker on his left side. He states this is new. EMS initiates CODE STROKE per protocol. CT of head is negative for hemorrhage and the patient is unable to receive an MRI 2/2 bullet fragments.
Should you consider the patient for IV tPa? • Yes • No