Don’t miss strokes: Be on the lookout for atypical symptoms and patients
You may be surprised by the next stroke patient you see in your ED
While working at her office job, a 27-year-old woman suddenly felt weakness in her left arm and leg, and she experienced facial droop. Alarmed, her co-workers rushed her to the ED. Upon arrival, she was alert, but her speech was slurred.
At first, ED nurses suspected her symptoms were due to an overdose, based on her age and her likely access to opioids as a sickle cell anemia patient. However, based on the woman’s slurred speech and hemiparesis, nurses quickly placed her in a room, alerted the ED attending, and paged the stroke team.
A brain attack computerized tomography scan was ordered, which was negative for intracranial bleeding. Only 40 minutes after she arrived at the ED and 90 minutes after the onset of symptoms, the patient began receiving peripheral tissue plasminogen activator (t-PA). She was admitted to the neurosurgical intensive care unit and discharged three days later with no neurologic deficits.
The above scenario is a success story that underscores the importance of having a high index of suspicion for stroke even in young patients, urges Rebecca A. Steinmann, RN, MS, CEN, CCRN, CCNS, clinical nurse specialist for the ED. She notes that 25% of all strokes occur in patients younger than 65 years of age.1
"Skilled triage clinicians are truly the key to good outcomes in all patients, particularly atypical presenters," she says.
Women have different symptoms
The age of your next stroke patient may not be what you expect, but the way they present also may surprise you.
Multiple studies have shown that women report different symptoms than men when having a myocardial infarction, says Lauren Brandt, RN, MSN, CNRN, clinical director of neurosciences for the Brain & Spine Center at Brackenridge Hospital in Austin, TX.2
According to new research, these differences also are seen in patients presenting with stroke, she says. A recent study found that women presented more often with atypical stroke symptoms. Of 1,189 patients with acute stroke, nontraditional stroke symptoms were reported by 28% of women and 19% of men. These symptoms include pain, change in level of consciousness, disorientation, and non-neurologic symptoms.3
Men more commonly present with the traditional stroke symptoms of weakness or numbness on one side of the body, slurred speech, loss of balance, or gait disturbance, says Dawn K. Beland, RN, MSN, CCRN, CS, stroke center coordinator at The Stroke Center at Hartford (CT) Hospital.
"The presenting symptoms for women with stroke may be subtler than this, and therefore need a more focused assessment to detect," she says. She points to another study that shows that female stroke patients present with more headache and facial sensory deficits.4
Brandt urges you to consider the study’s findings as strong evidence that you always should evaluate women for stroke if they present with nontraditional stroke symptoms. "The rapid identification and treatment of the patient who is having a stroke affects outcomes," she stresses. "Any delay may increase morbidity and mortality."
Here are items to consider:
• Be suspicious, even if patients don’t report specific symptoms.
Any change from baseline functioning could be due to an acute ischemic stroke, Beland emphasizes. "The patient or possibly the significant other may simply state the patient just isn’t right,’" she says.
Help to identify a potential stroke patient by obtaining a brief past medical history, says Beland. She says to ask the following questions:
- Has this ever happened before? If so, when and for how long?
- What time did these changes start today?
- What was the patient’s level of functioning before this change? Was he able to take care of himself independently?
- Is the patient diabetic, or does he or she have heart disease?
These two disease states significantly increase the risk for stroke, Beland emphasizes. "Quickly ruling out changes in blood sugar, heart rate, rhythm, and blood pressure will help narrow the differential diagnoses to stroke," she says.
Your neurological assessment should include level of consciousness, orientation, and motor movement at a minimum, says Beland. An expanded assessment should include an assessment of drift, facial weakness, changes in sensation, and language, she adds.
"Women have more developed language abilities, so go beyond orientation questions to assess for clarity, and assess reading ability for fluency," she advises. "Ask the patient if her speaking ability is normal for her or difficult in any way." You also should define time of symptom onset, Beland says. "If the patient was found changed, when were they last seen well?" she says. "Thrombolytics can only be given up to three hours after a known onset."
• Know signs of hemorrhagic stroke.
Women have a higher incidence of hemorrhagic stroke, either from intracerebral hemorrhage or subarachnoid hemorrhage, notes Brandt. This subset of stroke differs in presentation from ischemic stroke in that the chief complaint is typically headache, change in level of consciousness, and non-neurologic symptoms, says Brandt. "These nontraditional symptoms may delay the identification of stroke," she adds.
Regard with a high level of suspicion any onset of new headache with other symptoms, such as disorientation, change in level of consciousness, or non-neurologic symptoms such as nausea and vomiting, says Brandt. Assess the characteristics of the headache, and note that the classic presentation of hemorrhagic stroke is the thunderclap headache or "the worst headache ever," she adds. "The only way to accurately diagnose ischemic versus hemorrhagic stroke is to perform CT imaging as soon as possible," says Brandt.
• Use the NIH Stroke Scale.
Because patients won’t always present with classic stroke symptoms, the use of a standardized assessment tool can help with rapid triage and treatment, such as the National Institute of Health Stroke Scale, Brandt says. This scale assesses 11 areas that are consistent with the diagnosis of stroke, and it measures severity based on the number and type of deficits, explains Brandt.
"Incorporate this into your routine assessment whenever a patient comes in with suspected stroke," she advises.
References
1. American Heart Association. 2002 Heart and Stroke Statistical Update. Dallas: American Heart Association; 2001.
2. National Heart Attack Alert Program. The physician’s role in minimizing prehospital delay in patients at high risk for acute myocardial infarction: Recommendations from the National Heart Attack Alert Program. Ann Intern Med 1997; 126:645-651.
3. Labiche LA, Chan W, Saldin KR, et al. Sex and acute stroke presentation. Ann Emerg Med 2002; 40:453-460.
4. Rathore SS, Hinn AR, Cooper LS, et al. Characterization of incident stroke signs and symptoms: Findings from the atherosclerosis risk in communities study. Stroke 2002; 33:2,718-2,721.
Sources
For more information on acute stroke, contact:
• Dawn K. Beland, RN, MSN, CCRN, CS, Stroke Center Coordinator, The Stroke Center at Hartford Hospital, 80 Seymour St., Hartford, CT 06106-5037. Telephone: (860) 545-2183. Fax: (860) 545-5062. E-mail: [email protected].
• Lauren Brandt, RN, MSN, CNRN, Clinical Director, Neurosciences, Brain & Spine Center, Brackenridge Hospital, 601 E. 15th St., Austin, TX 78701. Telephone: (512) 324-7782. Fax: (512) 324-7051. E-mail: [email protected].
• Rebecca A. Steinmann, RN, MS, CEN, CCRN, CCNS, Emergency Department, Northwestern Memorial Hospital, 251 E. Huron St., Chicago, IL 60611. Telephone: (312) 926-7069. Fax: (312) 926-6288. E-mail: [email protected].
While working at her office job, a 27-year-old woman suddenly felt weakness in her left arm and leg, and she experienced facial droop. Alarmed, her co-workers rushed her to the ED. Upon arrival, she was alert, but her speech was slurred.
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