Grand Rounds Recap 6/22

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Morbidity and Mortality Conference with Dr. Denney

Stroke Chameleons

  • Stroke chameleons are atypical presentations of stroke and are associated with delays in diagnoses and failure to administer intervention when otherwise indicated
  • Maintaining a diagnosis of stroke on the differential is paramount to being able to diagnose a chameleon. Characteristics of chameleons that we most frequently miss are:
    • Atypical presentations (we miss 4% of typical vs 64% of atypical) 
    • Strokes in the young
    • Cerebellar strokes
  • Stroke syndromes to keep in mind that can be particularly tricky in terms of diagnosis
    • Tip of the basilar: ischemia to the pons can result in "locked in" syndrome. Look closely for extensor posturing, which may be transient on exam
    • Occlusion of the anatomical variant Artery of Percheron in the posterior circulation can lead to ischemia to the bilateral thalami, resulting in inability to awaken due to inactivation of the bilateral Reticular Activation System
    • Expressive aphasia can be difficult to diagnose as patients cannot follow commands nor adequately convey their thoughts. This also can lead to a significant amount of frustration/panic which may be misconstrued as confusion on the part of the provider.
    • Frontal-parietal of the non-dominant circulation may manifest as delerium
    • Seizure-like activity can present at stroke onset, particularly in younger patients
  • As a rule of thumb the best way to prevent mis-diagnosing a chameleon is to ask yourself FOR EVERY UNDIFFERENTIATED AMS PATIENT WHO ARRIVES WITHIN THE TPA WINDOW if this presentation could be consistent with acute ischemic stroke

The Beers List

  • The Beers List details medications that are relatively contraindicated in the elderly due to potential adverse reactions
  • Promethazine is relatively contraindicated in the elderly as it may induce significant anticholinergic symptoms and alterations in mental status. Ondansetron is preferred in the elderly for nausea and emesis.

Coagulopathy 

  • Bleeding, even trace bleeding, from multiple sites should trigger a serious consideration of serious coagulopathy such as DIC
  • Many factors may account for coagulopathy and must all be taken into account such as medications (ASA, plavix), intrinsic clotting factor dysfunction (liver disease, heparinization), and intrinsic platelet dysfunction (thrombocytopenia, uremia, ASA, etc). 

AMA and High-Risk Discharge

  • Patients who leave AMA can be challenging, as the provider's goals of care may not align with the patient's in such circumstances
  • AMA is associated with a higher association with bad medical outcomes and litigation
  • Regardless of a patient's motives for leaving AMA, the bedside discussion with these patients is incredibly important and should be accompanied by documentation of these discussion. It is essential that physicians fully inform their patients of the risks and benefits of leaving AMA and providers cover themselves by documenting these discussion adequately. 
  • For a review of the pertinent points for discussion with patients leaving AMA and a guide to the associated documentation, check out this post from ALiEM.