What to expect when you go to the ED with stroke symptoms

If you or a loved one is experiencing stroke symptoms, it’s time to get to the emergency department—ASAP. That’s because if there’s a blood clot in the brain, the longer the blood flow and oxygenation to the brain are affected, the sooner that tissue can die. When stroke physicians say, “time is brain,” their goal is to get blood flow to the brain restored as quickly as possible.

A 911 call triggers a series of events all aimed at saving brain tissue, starting with the EMS (emergency medical services) team in the ambulance.

Connie Swickhamer, DO, an emergency medicine specialist on the medical staff at Baylor Scott & White Medical Center – Irving, said that EMS professionals are trained to recognize stroke symptoms and will contact the ED en route to the hospital.

“Before they even get to the emergency department with a suspected stroke patient, they contact us so that the nurses and physicians are ready for that patient,” she said.

That means there’s no delay in getting you directly to the CT scanner. Here’s a glimpse at what you’ll experience—and what goes on behind the scenes—if you end up in the ED with stroke symptoms.

First stop: The CT scanner

The most important determinant in quickly treating a stroke is knowing what kind of stroke you are experiencing: ischemic or hemorrhagic.

When a blood clot either forms in the brain or moves to the brain, it triggers an ischemic stroke. Ischemic strokes account for 87% of all strokes and typically can be treated quickly with a clot-busting drug like tPA (tissue plasminogen activator). The other 13% of strokes are hemorrhagic or bleeding strokes. Treatment with tPA can be very dangerous for patients with hemorrhagic strokes, which often require neurosurgical intervention.

A CT scan allows physicians to look for the presence of blood or a large clot to identify the type of stroke.

In addition to a CT scan, within minutes of your arrival, the ED team initiates the CODE STROKE protocol, which notifies neurology immediately to assist in collaborative care of a stroke patient. One of those tasks is for the unit secretary to contact the telestroke team to notify them that a stroke patient is in the department.

Other immediate tasks include a blood draw to check glucose levels to evaluate for hypoglycemia, a common stroke mimic that can be treated with IV dextrose, and a blood pressure check to eliminate that as the cause of symptoms. Other possible tests might include an EKG and chest X-ray.

In addition to vital signs and basic labs, like a complete blood count (CBC) and chemistry test, PT-INR tests are performed to evaluate for abnormal bleeding.

“If there’s any difficulty with clotting, or there are abnormalities in those tests, that may be an indication that the patient shouldn’t get tPA,” Dr. Swickhamer said.

Next, you’ll be assessed by the ED physician to determine the severity of the stroke by performing an NIHSS Stroke Scale. This is an 11-step scale that is used to evaluate the effect of the stroke on your level of consciousness, language, neglect, visual-field loss, motor strength, sensory loss, speech clarity and balance. The score helps clinicians understand the severity of the stroke and what areas of the brain are affected.

The stroke scale is typically repeated, possibly as often as every 15 minutes for the first couple of hours, and then every hour, and eventually every two hours. The scale provides a score that’s reproducible between nurses, emergency physicians and neurologists, so everybody’s speaking the same language to evaluate whether your stroke symptoms are improving or worsening.

Getting your backstory

In order to receive tPA, patients need to get to the ED within three to four and a half hours of the onset of symptoms. ED physicians and nurses will talk to you and your loved one to find out exactly what symptoms you’ve been experiencing and for how long.

“We need to know the last time the patient was seen completely normal to determine their baseline,” Dr. Swickhamer said. “It’s important to tell the physician and nurses what other symptoms are associated such as chest pain, shortness of breath, headache, vomiting or palpitations. Did the patient hit their head recently or did they fall when they had weakness? It’s also important that we have a list of current medications and when each medicine was last taken, because certain medications can make a patient ineligible for tPA.”

If a patient was experiencing waxing and waning symptoms for a few days, for example, that puts them outside of the four-and-a-half-hour window and administering tPA could do more harm than good.

Bring in the tele-expert

Part of Baylor Scott & White’s stroke treatment arsenal is a spoke-and-hub telestroke program. Neurologists trained in stroke care located at Baylor University Medical Center and Baylor Scott & White Medical Center – Temple are able to use telestroke technology to assess patients and help with stroke treatment at many hospitals in the system.

“Our plan is that within 10 minutes of the patient’s arrival in the ED, a neurologist is on the phone hearing exactly what’s going on,” Dr. Swickhamer said.

The neurologist is able to see the patient, speak with the patient and family, and communicate with the treatment team all through video. Each member of the telestroke team is on the medical staff at a Baylor Scott & White hospital, which allows them to electronically access the patient’s medical records and imaging—such as a CT scan—in real time to help expedite treatment.

“It’s a seamless and quick process,” she said. “When you have a specialist group that’s very good at what they do and they can manage it from one location, it really is helpful for our patients in multiple community hospitals across the Baylor Scott & White system.”

Treatment options in the ED

The faster you’re evaluated at a stroke facility, the earlier you can benefit from stroke treatment.

“There is clear evidence showing that tPA is most effective when given early,” Dr. Swickhamer said. “Stroke patients treated with IV tPA may have better long-term functional outcomes.”

The medicine is given intravenously over an hour if the patient arrives at the ED within three to four-and-a-half hours and their symptoms are disabling or affecting your dominant side.

Patients with minor, non-disabling symptoms, or patients outside of the four-and-a-half hour window will generally be admitted for further testing, including a lipid panel and potentially an MRI of the brain. They’ll also be prescribed aspirin and clopidogrel, an antiplatelet drug to try and prevent any further stroke.

If you don’t meet the criteria for tPA, you may be a candidate for a procedure by a neurointerventional specialist on the medical staff at one of the comprehensive stroke centers in the Baylor Scott & White system.

Regardless of what your stroke symptoms or treatment plan look like, our stroke experts are ready to help. Because remember, time is brain.

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