Jimmy and his wife arrive at the Emergency Department of the thrombectomy hub. There is a local protocol for the management of patient’s arriving with a suspected stroke which should be followed. Protocols provide a clear written description of appropriate action required under specific circumstances.
- Taken into area defined locally for hyperacute assessments (perhaps Resus in ED, or a specific bay, or in some hospitals into the scanning dept
- Met by doctor and nurse
- Rapid assessment to confirm diagnosis of probable stroke – determine deficits with the National Institutes of Health Stroke Scale (NIHSS) – all medical and nursing staff involved in hyperacute stroke care should complete training in this
- Assess for eligibility for thrombolysis and thrombectomy (onset time, severity warrants hyperacute treatment)
- Insert iv cannula to allow injection of contrast for CTA, and administration of thrombolysis if appropriate
- Arrange immediate CT and CTA (if eligible for both thrombolysis and thrombectomy)
- If imaging ready take patient through, don’t wait for porters!
How do you elicit an accurate onset time? Answer True or False to each of the questions below:
How do you go about eliciting an accurate onset time?
1. To determine the onset time ask when they first noticed the symptoms? – False – ask them when they were last free of the symptoms?
2. If patient wakes from sleep – use time when they woke as the onset time? – False – use the time they went to sleep.
3. If a patient is unable to tell when symptoms came on (for instance because of aphasia) one needs to talk to a witness? – True – to be eligible for hyper-acute treatment was must either have a reliable onset time, or the results of advanced brain imaging.
4. If another healthcare professional tells you the onset time, you should believe it without question? – False– if you are making the decision to treat or not you should ask how they know that? Often it is based on hearsay, and needs to be checked with the patient or another witness.
5. Patients with neglect may provide unreliable onset time because they may not be aware of all of their stroke symptoms – True – the time they fell (due to neglect) might be reported as the onset time, whereas the stroke may have started hours earlier, for instance if they were in bed.
6. In patients with neglect it is useful to establish when they were last carrying out complex tasks, such as preparing a meal, or dressing, or showering? – True – patient with neglect may have difficulties with such tasks even though they may not have any weakness that they recognise
7. Even I f the brain scan shows a well defined acute infarct, one should always believe the onset time? – False – if the appearance on the brain scan don’t seem to be compatible with the onset time you need revisit the time of onset to check it is accurate.
8. If the onset time is unknown, or more than 4.5 hours ago, one can consider using advanced imaging to determine if patient likely to benefit from hyper-acute treatment – True – Mismatch between the imaging appearances and the clinical severity, or mismatch between an imaging measure of infarct size and the volume of brain with inadequate blood supply (using CT or MRI) can be used to guide hyper acute treatment.
