
You are working at Clerkship General when one of the nurses comes and grabs you. “Hey doc, we need you in bed 10. I think this patient is having a stroke.” 



Initial Vitals:



HR: 51



BP: 201/98



Temp: 98.0F



RR: 18



O2: 99% (Room Air)



Critical Actions:




* Check a Blood Glucose



* Activate a Stroke Alert



* Assess Contraindications to tPA



* Consent for tPA



* Transfer via Air for Thrombectomy


Round 20 (MW) Stroke Symptoms

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You are working at Clerkship General when the next chart is put into your rack. It’s a 76 year-old male who has fallen. 



Initial Vitals:



HR: 101



BP: 138/85



Temp: 98.0F



RR: 20



O2: 99% (Room Air)



Critical Actions:




* Diagnose Retrobulbar Hematoma



* Diagnose Subdural Hematoma



* Reverse Anticoagulation



* Perform a Lateral Canthotomy Procedure



* Administer Tetanus Shot



* Elevate the Head of Bed


Round 21 (MW) Geriatric Fall


Symptoms of stroke – weakness, facial droop, slurred speech. vision loss, vertigo, ataxia, confusion or changes to mental status.   



The “typical” stroke workup – blood glucose level, CTH non-con, CTA head/neck, CT Perfusion, CBC BMP Troponin EKG CXR and Coags.  



Common stroke mimics – hypoglycemia, drug/alcohol intoxication, Bell’s palsy, aortic dissection, complex migraines, and seizure with Todd’s paralysis.  



Management/treatment – thrombolytics (within 4.5 hrs), thrombectomy (within 24 hrs) , and blood pressure control (<185/110 if treating, <220/120 if no treatment).  



Remember that time is brain, so move fast! 



  AAEM tPA Infographic



AHA Stroke – “Getting the Gist Across Is Enough for Informed Consent for Acute Stroke Thrombolytics”

Ischemic Stroke (Deep Dive MW R20)



* Common during the first year of life as well as during puberty



* Presents with nausea/vomiting, abdominal pain, and/or testicular pain



* ALWAYS examine a child for signs of torsion who presents with abdominal pain (especially lower abdominal pain)



* Look for tenderness, firmness, high riding testicle or testicle with unequal lie, swelling, and the absence of a cremasteric reflex   



* Consult Urology IMMEDIATELY if you have high suspicion, otherwise proceed to ultrasound



* Ultrasound is only 85% sensitive, so clinical gestalt can trump even a negative US



* Attempt manual detorsion if there will be a significant delay to surgery


Testicular Torsion (Deep Dive MW R19)


You are working at Clerkship General when the next patient is put into your rack. It is an 8 year-old male with vomiting



Initial Vitals:



HR: 119



BP: 104/63



Temp: 98.0F



RR: 20



O2: 99% (Room Air)



Critical Actions:




* Finger Stick Blood Glucose



* Treat Patient’s Pain



* Diagnose Testicular Torsion



* Immediate Urology Consult



* Perform Manual Detorsion




References:



Mellick LB, Sinex JE, Gibson RW, Mears K. A Systematic Review of Testicle Survival Time After a Torsion Event. Pediatr Emerg Care. 2019 Dec;35(12):821-825. doi: 10.1097/PEC.0000000000001287. PMID: 28953100.

Round 20 (MW) Stroke Symptoms

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