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ERcast Lite

Welcome to ERCast, a focused discussion on the questions, quagmires and known unknowns we face everyday in the emergency department.

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Sep 23, 2016

When you are calling a consultant, whatever the specialty, what are you really doing? You are presenting an argument, making a case for what you think should be done, or making the best case for what you think is going on and seeking the benefit of their expertise. One area where this gets a little short circuited is in the acute stroke consult. The short circuit has its roots in the early days of TPA in stroke literature. When the NINDS study came out, my neurologist friends were beyond belief excited. Finally a therapy for stroke! 

At the same time, there was a counter argument. The legendary emergency physician and skeptic, Jerry Hoffman, said, "This data does not support using thrombolytics in stroke, in fact quite the opposite." Therein began the divide that has only grown since and therein began the stroke treatment narratives within neurology and emergency medicine.  For the most part, neurologists favor TPA and many ED docs do not. We read the same studies, all went to medical school and want the best for our patients. I’m not going to debate the merits and dangers of TPA here. I bring this up because this dichotomy leads to stress at the wrong time.

The decision of whether or not lytics are going to be part of your stroke practice needs to be decided before you see an acute stroke patient. Once you make that consult, you are already on the path of potentially giving lytics and if you are going to do it, you should do it it the most expeditious way possible. Not that you can’t advocate for the patient, because you absolutely should. So when you call the neurologist for a patient with an acute stroke stroke patient, be professional and be economical with the presentation, no BS and no unneeded information.

Elements of a Stroke Consult

  • Age
  • Last normal
  • Onset of symptoms and type of symptoms if witnessed
  • Blood sugar
  • Are they on anticoagulants
  • What is the blood pressure
  • NIH stroke score and specific deficits that gave the patient points
  • Where is the patient is on their path to CT



Now, the consult. This is not a full chitty chat long form conversation, this is a condensed bolus of vital information. 

  • This is a 70 year old male, last seen normal at 9am. At 10 am, family heard some noise in the living room and found the patient stumbling around, weak on the left side. Paramedic blood sugar was 100, normal. Patient is on aspirin but not anticoagulants. Last blood pressure 200/100. Eam shows an NIH stroke score of 6. All points are given for left sided weakness. There is a partial left  facial palsy, left arm and leg cannot resist gravity. We are now 90 minutes after last seen normal and the patient is being packaged for a stat CT.


There will be questions after this, there always are. You have the benefit of a tremendous amount of information: you’ve met the family , shared the same air as the patient, your consultant is only getting the picture you’re painting. There will be talk of heart rhythm, comorbidities, potential exclusion criteria. etc. But that is the initial call. Short, sweet and to the point. 


NIH Stroke score training video