ITS A MIRACLE X 2

1
ITS A MIRACLEX 2

• CASE STUDY
• FOR
• THROMBOLYSIS PATIENT
• BY JOANNE SAYLES

2
56 YEAR OLD MALE

• JIM - SAT IN CAFÉ WITH WIFE, WENT DIZZY, PALE AND
  COLLAPSED NO LOC/NO LIMB SHAKING, TIME 10.30
• PARAMEDICS CALLED FAST TEST POSITIVE, GCS 14/15
  CONTACTED WARD ON DIRECT LINE 11.10AM AND
  BROUGHT TO AE

3
AE

• REVIEWED BY DR CHADHA
• PMH OCCASIONAL CONFUSION
• DENSE RIGHT HEMIPLEGIA
• MILD TO MODERATE DYSPHASIA
• FACIAL DROOP
• DECREASED SENSATION
• GCS 15
• BLOOD SUGAR 5.6 MMOLS, INR 0.9
• BP 150/89
• NIHSS 16

4
PLAN

• URGENT CT HEAD 11.32AM - There is minor ischaemic
  change within the right occipital lobe. No other
  findings of note and in particular, there is no
  haemorrhage and no abnormality is shown within
  the left cerebral hemisphere.
• WEIGHT ESTIMATED, CONTACTED WARD TO DRAW UP
  ALTEPLASE

5
WARD

• WARD STAFF PREPARED ALTEPLASE FOR ARRIVAL TO WARD
• DR CHADHA DISCUSSED WITH WIFE AND JIM TREATMENT
• CONNECTED TO MONITOR, BASELINE NEURO OBS AND
  VITAL SIGNS COMMENCED
• WEIGHT ESTIMATED AT 85KG (WAS 94KG)- 8ML BOLUS
  GIVEN STAT AT 11.49AM FOLLOWED BY REMAINING 68ML
  GIVEN OVER 1 HR INFUSION

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OBSERVATIONS

• 1 HR POST LYSIS JIM COULD MOVE RIGHT HAND AND
  SPEECH BEGAN TO IMPROVE
• 2 HR POST ABLE TO MOVE RIGHT LEG AND HOLD RIGHT
  ARM UP WITH SLIGHT DRIFT
• 2.5 HR POST ABLE TO FULLY MOVE RIGHT ARM,
  SLIGHT WEAKNESS IN RIGHT LEG, PASSED SWALLOW TEST
  AND USING RIGHT ARM ENJOYED A DRINK, SPEECH NOW
  RESOLVED
• VITAL SIGNS NAD THROUGHOUT

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24 HOUR POST LYSIS

• NIHSS 0
• REPEAT CT HEAD POST 24 HOURS -Appearances have
  not changed from the previous scan
• REVIEWED BY PHYSIO MOBILE WITH SUPERVISION FOR
  24 HOURS THEN INDEPENDANTLY
• FEELS GREAT
• LENGTH OF STAY 4 DAYS
• DISCHARGED HOME INDEPENDANTLY

8
2nd CASE STUDY
9

• 75 YEAR OLD LADY APRIL
• CURRENTLY IN HOSPITAL
• ADMITTED WITH SOB
• O/A AF (NEW), IHD AND CInf, AND OCCASIONALLY
  CONFUSED
• COMMENCED WARFARIN (STOPPED ON DAY 4 DUE TO 2
  FALLS ON WARD)
• CONTACTED ON DAY 8 BY WARD STAFF RE POTENTIAL
  THROMBOLYSIS

10

• APRIL FOUND SLUMPED IN CHAIR AFTER BREAKFAST
  TIME 915 AM, LAST SEEN WELL 830
• RIGHT SIDED WEAKNESS
• ABLE TO FOLLOW COMMANDS
• EXPRESSIVE APHASIA/DYSARTHRIA
• PARTIAL (R) GAZE PALSY
• AGITATED
• (R) HEMINOPIA
• BLOOD SUGAR 7.9MMOL BP 146/72
• NIHSS 16 / GCS 14

11

• 0933 ATTENDED CT SCAN There is patchy low
  attenuation in both internal and external
  capsules and in the periventricular white matter
  in keeping with small vessel ischaemic change
• URGENT INR REQUESTED PREVIOUS WAS 1.3, NOW 1.2
  (DELAY)
• 1014 - 5ML BOLUS GIVEN,
• 1019 - 44ML OVER 1HR INFUSION
• 2 HOURS POST - NO WEAKNESS DETECTED AND SPEECH
  NORMAL
• 6 HOURS POST H20 TEST - NORMAL

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• 24 HOURS POST LYSIS
• REPEAT CT HEAD SCAN No haemorrhage. No
  significant change compared with the previous CT
• NIHSS 0 / GCS 15
• ATTENDED VASCULAR FOR CAROTID DOPPLER Left CCA
  totally occluded, retrograde flow in the left ECA
  filling to the left, extensive plaque in the
  right unusual scan discussed with April not
  keen for surgery so consented for oral
  anticoagulation.

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• DISCHARGED 34 DAYS POST LYSIS
• LOTS OF CONCERNS REGARDING CONFUSION RE DISCHARGE
  HOME
• FAMILY FELT CONFUSION NO WORSE AND HAD MANAGED
  PREVIOUSLY INDEPENDANTLY, FAMILY ONLY LIVE 2
  DOORS AWAY AND WOULD INCREASE VISITS
• DISCHARGED HOME WITH INCREASED FAMILY SUPPORT,
  SOCIAL INPUT DECLINED