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What Would I Do Next? | Transient Ischemic Attacks (TIA)

Mizuho Morrison, DO and Jaime Hope, MD
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24:10

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Mizuho interviews Jaime Hope on the topic of TIA identification and management from the UC setting. They discuss nuances and subtleties of a thorough neurologic exam and practical tips of pre-EMS transfer to the emergency department.

Pearls:

  • If a patient with a suspected TIA comes to you urgent care, defer aspirin administration or blood pressure control to the physician at the nearest stroke receiving center

 

CASE: A 64-year-old woman with a pmhx of DM, HTN, HLD presents to the urgent care after last night she had right arm weakness, left facial numbness and tingling of the tongue lasting for 40 minutes.

 

ROS:

Denies changes to her medication or new medication

Denies recent travel

Denies recent illness or fever

Denies trauma or falls

 

EVALUATION

  • Evaluate the patient’s mental status by assessing for orientation:

    • Can you tell me your full name?

    • Can you tell me what year it is?

    • Can you tell me where you are now?

  • Assess for function of the cranial nerves:

    • CN II: Assess all four quadrants of each visual field for subtle deficits. Evaluate pupillary function by shining a light in each eye and looking for pupillary response

    • CN III/IV/VI: Have the patient move their eyes in all four directions by following a finger

    • CN V: Touch to patients forehead, cheeks and chin to assess for intact and symmetric sensation in a V1-V3 distribution

    • CN VII: Have the patient elevate both eyebrows, squeeze their eyes shut against resistance and smile to evaluate for symmetry

    • CN X: Have the patient open their mouth and say “Aw” in order to look for symmetric elevation of the palate

    • CN XI: Have the patient shrug both of their shoulders and turn their head from side to side

    • CN XII: Ask the patient to stick their tongue out and move it from side to side

  • Assess for coordination by performing the finger-to-nose test by having the patient touch your finger then touch their nose repeatedly.

  • Systematically evaluate sensation in the upper extremities by checking if sensation is intact and symmetric in each dermatome.

  • Evaluate strength in the upper extremity at the elbow in flexion, extension, and then at the wrist by having them grip your hand and also spread their fingers against resistance.

  • Evaluate strength in the lower extremity by having the patient first raise their leg up off the bed and then have them kick their leg out towards you. Have them push their feet down against resistance (as if pushing on the gas) then point their toes to the ceiling .

  • Lastly check for a down going babinski reflex to rule out an upper motor neuron lesion.

 

CASE CONTINUES: The patient’s neurologic exam is completely normal. Whats next?

 

ACEP Clinical Guidelines On TIA

  • Patients with suspected TIA should be referred for emergent imaging

  • A non-contrast head CT, even if available in an urgent care, should not be used to identify patients at an elevated short-term risk of stroke - patients with suspected TIA need additional advanced imaging such as MRI, carotid doppler, echocardiography etc.

 

Treatment

  • Defer management of elevated blood pressure for asymptomatic patients while they are awaiting transfer to a higher level of care.

  • It is impossible to rule out hemorrhagic stroke as a cause TIA so defer aspirin administration as well.

  • Patients who present with an acute stroke with deficits should be a 911 transfer to a stroke center. Do not delay transfer if you have a CT scan at your urgent care center because doing so will delay definitive management.

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Better Put A Ring On It Full episode audio for MD edition 196:02 min - 92 MB - M4AHippo UC RAP May 2018 Written Summary 367 KB - PDF

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