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Jaymazing

Scenario: Another boring transfer

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You and your partner are working in a rural community, about 2 hours from any major centers
You are called to your local health center for a BLS transfer of a 60 year old male, going for a Head CT. It's a patient you've already been acquainted with, since two days ago one of the other crews brought her to the nearby stroke facility (~75 km away) for a suspected CVA, and after being given TPA and receiving 24hrs of monitoring, you and your partner brought her back for continued care.
It's been ~48 hours since TPA was given. Thrombolytics were unsuccessful, and the patient was left with right-sided paralysis and significant aphasia (he can only say "Yes", "No", and something that sounds like "bipisa").
When the nurses came this morning to give the patient his AM meds, the patient was found to have lost the ability to swallow or chew (new finding), and seemed increasingly confused. The attending physician has now requested a repeat head CT at a center ~1.5 hours away.
When you arrive at the nurses station to receive a report, you find that all of the nurses are missing. When you look around, you discover that all of the nurses are in the room where your patient currently is. They're moving around frantically, and they've just finished administering adenosine.
The patient appears significantly distressed, is not responding to questions, and appears acutely ill. He's on a NRB at 15 lpm, has a 20g IV in his left wrist running at 75 ml/hr, and has cardiac monitoring showing a rate of ~190bpm.
What would you like to know? What would you like to do? What do you think is going on?

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You'll have to excuse the typos. For some reason I'm not able to go back and fix them....I dont have permission.

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Well, I'd like him stable before I consider transporting bls.

What's him bp. O2 before and after the non rebreather.

The ct is 1.5 hours away. Have they even done one yet? Before the TPA was given? After?

How is his conscious level?

I think he needs a bird, not a bls crew

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Well, I'd like him stable before I consider transporting bls. A wise decision!

What's him bp. O2 before and after the non rebreather. BP is 198/124, SpO2 on NRB is 92% and decreasing. I, unfortunately, do not know what the RA Sp02 was.

The ct is 1.5 hours away. Have they even done one yet? Before the TPA was given? After? They completed an emergency headCT prior TPA and ruled out hemorrhage. There was no tumor or mass. There was no repeat CT scan completed.

How is his conscious level? Not opening his eyes, not answering questions, withdraws from pain on the left, making incomprehensable sounds.

I think he needs a bird, not a bls crew Unfortunately, there's no option for flight right now. The heli and fixed wing crews are already on other runs.

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I'd like to just note; it's a BLS transfer, but you don't have to be a BLS crew if you don't want to be. It's a scenario! Let's have some fun!

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What/when was the last CBC, PT/INR? What rhythm does it look like at that rate? Any response to the adenosine? What dose of the adenosine? Possibility of cardioverting?

Why are there no physicians in the room??? A RRT should have been called and a stroke alert at the first notice of change in symptoms...but I'm guessing this is a small hospital with no such resources which brings me to the question of why in the world would he be brought back to podunkville just 48 hours after tPA?!? He should have been in a major hospital with CT capabilities...

On to care....

I'd like to get that BP down, so like IV beta blocker to get that pressure and heart rate down...

Anyone else feeling like RSI and knocking this patient down for a bit? With the O2 saturation decreasing and his altered LOC, I'm not too happy with him controlling his own airway as he's stroking out and possibly going to code on us with a BP and HR that high.

He's likely having another ischemic stroke (doubt hemorrhagic d/t pressure)... What meds is he on? What have his vitals trended?

ETA: Any presence of corotid bruits? Patient Temperature?

Edited by scubanurse

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You said the heart rate on the monitor is 190...what is it on his wrist?

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Hello,

First, thank you for posting a scenario.

It is a little crazy that a CVA patient was transfer back to a small community hospital from the stroke centre so fast.

Thrombolytic CVA can convert to a hemmorrhage hemorrhagic at the 24-48 hour mark. Basically, the ischemic tissue dies and a bleed can result. This is the same reason the ischemic changes do not show on a Head CT for the first 24 hours. This could explain the new neurological finding and the HTN.

HR=190 What dose the monitor show?

Also, what is the code status/ level of intervention?

lastly, this is not a BLS transfer.

Thank you,

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Well... hopefully you can cancel from the job since the patient has deteriorate but is in hospital and it’s not what you’ve been called for… If they want your involvement then:

Is he maintaining his airway? If not, triple airway manoeuvre and OPA as primary intervention. I’d like to provide positive pressure ventilation with an SP02 of 91% on high flow oxygen with a GCS of 8.

What are pupils doing?

What’s happening on ECG? Are they giving adenosine for SVT?

What’s BGL doing?

I’d like bigger IV access than a 20g at this stage.

A total summary of IV fluids.

Recent pathology results.

Further respiratory status assessment, auscultation, skin colour etc.?

Were the doc?

Can we get a better history on the situation, how long ago did the symptoms start, has there been a rapid deterioration, what treatment has the patient received since being admitted to the rural hospital including what the nurses have done since the patient started to deteriorate? I’d still like to get a full past history and list of current or new medications.

Treatment is really dependant on what your skills level is and what the hospital can provide?

Sounds like the patient will need to be intubated…

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As a former BLS provider I would say, "Thanks but no thanks." This pt is sick and not stable for transport. He needs ALS transport. He is probably having a hemorrhagic stroke after the ischemia/tPA.

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