Book 09 · Page 1010 / 15

Exhibit: the thrombolytic clock

Focal and generalized seizures, with the nursing actions during a seizure and the one thing never to do. — Fig 10.10 · pending clinical review

TAB 1 · TRIAGE NOTE `` 0712 68-year-old male brought to the emergency department by a neighbor. Neighbor reports going to check on the patient at 0640 after he did not answer his phone. Found him seated, face drooping on the right, speech slurred and effortful. 0714 Neighbor states she spoke with the patient on his porch at 2130 the previous evening. He was walking, talking, and behaving normally at that time. No one saw him between 2130 and 0640. 0715 Arrival time to emergency department: 0700. Triage complete 0715.

TAB 2 · NEURO CHECKS `` TIME LOC MOTOR SPEECH NIHSS 0718 Alert, follows R facial droop; R arm Expressive 9 commands drifts to bed in 8 sec aphasia 0733 Alert, follows R facial droop; R arm Expressive 9 commands drifts to bed in 8 sec aphasia 0748 Alert, follows R facial droop; R arm Expressive 9 commands drifts to bed in 8 sec aphasia

TAB 3 · DIAGNOSTICS `` 0731 Noncontrast head CT: No acute intracranial hemorrhage. No early ischemic changes identified. 0720 Bedside capillary glucose (nursing note): 118 mg/dL. 0716 Blood pressure 196/104 mm Hg, pulse 88, irregularly irregular. 0731 Blood pressure 192/100 mm Hg. 0746 Blood pressure 188/98 mm Hg. 0740 International normalized ratio 1.3.

TAB 4 · MEDICATIONS AND HISTORY `` HOME MEDICATIONS warfarin 5 mg by mouth daily; last dose 2100 yesterday metoprolol succinate 50 mg by mouth daily atorvastatin 40 mg by mouth daily HISTORY hypertension; atrial fibrillation; former smoker

The reading task. Name the three assessments that gate intravenous thrombolysis, name the one finding on this chart that closes the gate on its own, and say why the anticoagulant row does not close it. Then state which recorded time you would report to the stroke team and why the other two are distractors.

The answer. The gate is the noncontrast head computed tomography scan excluding hemorrhage, the stroke severity score, and the bedside glucose. All three are present and all three are favorable: no hemorrhage, a documented score, and a glucose that rules out hypoglycemic mimicry. The finding that closes the gate is the last known well time of 2130 the previous evening, roughly 9.5 hours before arrival and far outside even the extended window. The warfarin does not close it by itself, because the international normalized ratio of 1.3 is inside the acceptable range under the cited guideline. The blood pressure is elevated but treatable, which makes it a barrier rather than an exclusion.

Margin notethe chart tells you when he was found, not when it started. Exhibit anatomy is → BOOK 01 · P61. Thrombolytic dosing is → BOOK 05 and → BOOK 06.

Takeawaythe exam hides the eligibility clock in a different tab from the deficit, and the time that counts is the last time the patient was known to be well.