Case Summary:

An ALS crew responded to 50s woman with concern for a possible stroke.  They arrived to find the patient in bed with left sided facial droop, left sided arm and leg weakness, and slurred speech.  The crew learned from family that the patient’s last known well was ~12 hours prior when she went to bed the previous night since no one had seen her at her neurologic baseline that morning.  The crew checked a glucose level and it was 62.  The crew placed an IV and gave a bolus of 10% dextrose.  While it was infusing, they checked a full set of vitals:

Vitals: BP 142/82,  HR 75,  RR 18  O2 sat: 92%

The crew checked a glucose level after the infusion, and it was now 112.  The crew attempted to get more history from the patient and the patient was found to no longer have slurred speech as a well as had resolution of her facial droop and left sided weakness.  The patient informed the crew that she has had an upset stomach and had not been eating very well.  Despite this, she had still been taking her insulin but not also checking her glucose levels. 

The patient remained stable for the rest of the trip to the receiving hospital and did not have return of her stroke-like symptoms. 

Highlights of the case:

Hypoglycemia can cause stroke symptoms

The reason that most stroke protocols involve checking a patient’s glucose level is because hypoglycemia in itself can cause stroke-like symptoms.  One of the main treatments for an acute stroke is the use of thrombolysis to break down the clot and reperfuse the injured brain.  Thrombolysis can cause significant complications, such as major bleeding, since it breaks down clots everywhere in the body, not just the blood vessels of the brain.  We do not want to subject patients to this risk of bleeding unless they are having a true ischemic stroke and stand to benefit from it.  This is why we want to correct hypoglycemia as soon as possible since if their symptoms do not resolve with correcting the glucose level, then they likely are having an ischemic stroke and still might benefit from treatments such as thrombolysis.  If we fail to check for and then correct hypoglycemia, the patient might be given thrombolytics inappropriately.  After we begin treatment of hypoglycemia, we should still transport the patient to a stroke center since it is still possible that they are having a stroke and need further treatment and evaluation.

A key part of stroke care is determining last known well (LKW).

One of the most important pieces of information we can gather on a potential stroke patient is what the patient’s last known well time is.  This is the last time that the patient or their family are sure that they were at their neuralgic baseline (which for many patients will be no stroke symptoms at all).  Families/patients often mention the time that they first see something wrong as the LKW since that is the trigger for calling EMS, however, that is the "first known abnormal" time which is a term I made up and is not useful in stroke care.  We need to confirm and document that the family saw the patient at their neurologic baseline at X time and that they were found in their new neurologic state at Y time.  This makes it clear that the time we are reporting is correct.  If a patient is witnessed to go from normal to abnormal at a specific time, then X and Y might be the exact same time, and this should be documented as such.  Determining an accurate LKW time is paramount since it dictates what care can be offered to these stroke patients.  Patients who present within 4.5 hours of the LKW might be candidates for thrombolysis to try and break up the clot, while patients who present within 24 hours of LKW might be candidates for thrombectomy which is where a wire is fed through arteries into the brain to directly pull out the clot.  If we incorrectly pick a time that is earlier than the true LKW, then patients might not be considered for treatments that they should have been offered.  If we incorrectly pick a time that is later than the true LKW, patients might be offered thrombolysis or thrombectomy when the risk of brain bleeding is much higher increasing the chance of these bleeds which can be devastating and even fatal.  In addition, many strokes affect a patient’s ability to communicate making it difficult if not impossible for the receiving facility to determine an accurate LKW if we do not since family might not accompany the patient.  For these reasons, it is important that we do our best to hash this out with patients and families and it is often worth it to delay transport a little longer to figure this out.  We should also consider getting contact information so that if the receiving facility needs to get in touch with family that they can do so since much of the care for acute stroke patients is incredibly time sensitive.