Caesar’s Forum: Stroke patient at the ERI

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DAVE Caesar, clinical director of emergency medicine, Edinburgh Royal Infirmary and St John’s Hospital, Livingston, has a stroke patient to deal with.

IT is the middle of the afternoon and I’m seeing patients in our high dependency majors area, or “HD” as it is known.

The tell-tale tone of the crash box rings out, and the nurse co-ordinating the area scurries off to answer it.

“Royal Infirmary emergency department receiving.”

“Thanks RIE, we have a 67-year-old male, probable CVA (cardiovascular accident or stroke), GCS (Glasgow Coma Score) 12, ETA (estimated time of arrival) two minutes.”

Plenty of time.

The nurse who took the call heads for the tannoy: “Crash call, re-sus one, two minutes,” sounds out around the department.

I head to the re-sus room where I’m joined by a junior doctor, a charge nurse and a registered nurse.

The patients in the waiting room with minor injuries no doubt wonder why some of “their” staff are disappearing.

One of the porters brings in a trolley and a sheet is put on top. Some equipment is prepared and, just then, the patient is wheeled in by the ambulance crew. We transfer the gentleman to our trolley and the whole room listens in to the paramedic.

“This is Michael, 67-years old, found collapsed at home by his son at 1500 hours with right-sided facial droop and arm weakness, some sounds but no words. His son had spoken to him on the phone at 1400 and he seemed fine. Michael has a past medical history of high blood pressure and smoking but nothing else. His son is on the way up by car.”

OK, it’s now 1600hrs – time is of the essence. We get a drip in Michael’s arm and check blood sugar in the first minute or so. This is normal: one less thing on the list of possible causes.

I try to communicate with Michael and it is obvious fairly quickly that he can understand what I am asking him but he is unable to find the words to reply – a condition called expressive dysphasia.

He is able to make some words if carefully prompted but unable to initiate their formation – frustrated doesn’t nearly cover how this must feel.

His physical examination reveals a definite weakness affecting the right side of his face and his right arm and leg. It is like someone has unplugged the wires that connect that part of his body from his brain.

There is little doubt that Michael has had a stroke. Our first priority now is to determine what the cause is – there are a few – and whether there is a possibility of considering clot-busting medicine (thrombolysis) to help improve the chances of Michael’s recovery. This is why the timing is so important in this age group and that there is no other reason on the scan that thrombolysis would be too dangerous to consider.

It is now 1630. Michael may have had his symptoms for two-and-a-half hours, and we know that the beneficial effect of the clot-busting treatment reduces after three hours, leaving only the potential to cause harm. Some hurried, concise conversations are required – never ideal when making such significant decisions – but the clock continues to tick.

We get hold of Michael’s son and, together with Michael, we agree to give thrombolysis.

This is given as a single injection followed by an infusion. All the signs are positive within the first hour, but it will be a nervous waiting game for Michael and his family for the next 48 hours or so.

Medical Russian Roulette

THE use of clot-busting medicine for the treatment of stroke has been somewhat controversial.

There has been much publicity surrounding it but it remains a treatment that requires careful consideration.

It is only recommended in one form of stroke – that caused by a clot in a blood vessel supplying the brain – and only if certain criteria are met.

Probably less than 10 per cent of patients who have had a stroke are likely to be eligible for this treatment.

If you are eligible for thrombolysis and are able to receive it within three hours of symptom onset, then your chances of having an improvement are one in ten.

However, the chances of you having a bleeding complication, which could be fatal, are one in 20. It is like having a 20-barrelled gun with two bullets that will cure you and one which might kill you and spinning the chambers.

The likelihood is that the drug will have no effect (17 out of 20), but that doesn’t make the decision any easier.