Scenario: Another boring transfer

[scubanurse]

So question.... why would this be hemorrhagic vs ischemic? Just based on the history of tPA? I didn't think you would see a BP THAT high with hemorrhagic. I'm not really seeing any signs of cushing's triad either indicating to me that the ICP isn't rising as it would with a hemorrhagic right?

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.

[ERDoc]

Just because you have bleeding doesn't mean you will have increased ICP so you won't see Cushing's triad.

It's not exactly peer reviewed science but gives a good explanation:

http://stroke.about.com/od/strokesignsandsymptoms/a/stroknathistory.htm

That being said, I am at a loss for the tachycardia. Could it be afib? Sure. Could the pt throw a clot and have a second stroke? Sure.

[scubanurse]

But why would you then think it's hemorrhagic? http://hyper.ahajournals.org/content/43/2/137.full I always thought hemorrhagic wouldn't have a super high BP where ischemic is usually associated with hypertension....

I understand why the patient is at an increased risk for a hemorrhagic, but not why you think it is that in this case given what information is provided.

Either way this patient is super sick and shouldn't be transported yet, but just trying to understand why y'all are classifying is has hemorrhagic?

[MariB]

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Either way this patient is super sick and shouldn't be transported yet, but just trying to understand why y'all are classifying is has hemorrhagic?

I'm classifying it as a no way, no how am I transporting this patient until he is more stable and I have a medic on board

[ERDoc]

An ischemic stroke is caused by interruption of blood flow to a part of the brain. The most common cause is from a blood clot, such as when someone with untreated afib throws a clot and it ends up in the brain. The going theory, last I checked, is that the hypertension you see with an ischemic stroke is from the body trying to increase perfusion to the ischemic brain by using more pressure. In the days after someone has had an ischemic stroke, the part of the affected brain becomes mush (for a lack of a better term). The vessels are leaky and weak and the tissue itself is not very durable. On top of that, you have added a drug that prevents clotting so you have leaky vessels that have lost a good portion of their ability to clot. You are now set up for badness. If you add to that a high pressure such as the one in this case, those vessels are going to bleed and you end up with a hemorrhagic stroke from those vessels bursting. Bleeding is a known and possibly fatal complication of tPA administration. It is not the wonder drug that the neurologists would have you believe it is.

[scubanurse]

Right, but once the vessel ruptures, wouldn't the blood pressure decrease since it no long is trying to force blood past the occlusion?

[ERDoc]

Don't forget, in theory the clot is no longer there since we gave tPA. Look at the whole picture and try not to focus on one number. The hypertension may have nothing to do with the brain. There is a cardiac issue at play here too.

[scubanurse]

I'm just trying to work my brain on this one... I just have a very narrow experience with strokes so understanding more of the pathophys of all this can only help? Sorry

[ERDoc]

Don't apologize. It's always good to ask when you don't understand, that is why we are all here.

[scubanurse]

Would you want to treat this with a beta blocker IV or some nitro to get the pressure down then? Adenosine to slow the rate and maybe some amiodarone or lido for the dysrhythmia?