Setting the Scene
The elderly patient in this case, attended the Emergency Department (ED) after calling 111 due to a sudden onset of visual disturbance. They complained of blurring, loss of sight in one eye and a headache. In the ED it was noted that the patient had sudden onset blurring of vision lasting 30 seconds followed by a headache and persisting blurred area.The patient was advised that this was probably due to a migraine and discharged home. The patient’s visual disturbance was persisting.
On the trip home the patient’s condition worsened. An ambulance arrived to find the patient on the pavement with the following symptoms: lowered GCS (The Glasgow Coma Scale) is the most common scoring system used to describe the level of consciousness in a person following a traumatic brain injury. It is used to help gauge the severity of an acute brain injury) ; slurred speech and a right side hemiplegia (Hemiplegia is a condition caused by brain damage or spinal cord injury that leads to paralysis on one side of the body. It causes weakness, problems with muscle control, and muscle stiffness). On return to the hospital by ambulance, the patient was diagnosed as having a stroke.
The patient was treated with antithrombotic medication (which is used to prevent blood clots) but they suffered significant brain injury, as a result of the stroke.
How to help reduce the risk of incident recurrence and improve patient safety
TMLEP wishes to raise awareness of the issues surrounding this case to help reduce incident recurrence and the potential for litigation by enhancing patient safety. It is important that clinicians are mindful of the following;
Patients who show symptoms of migraine should be questioned on their history. The patient in this case should have been asked about previous migraines and whether there was any family history. Elderly patients should not be discharged with the diagnosis of a migraine when persistent abnormal neurological symptoms are present. Other potential sinister causes of these symptoms (such as a stroke) should be excluded.
Elderly patients presenting with a first episode of headache and visual disturbance, with persistent neurological symptoms and/or signs should receive a full neurological examination, blood tests and further imaging (e.g. a CT scan or MRI scan) to exclude a central neurological cause for their symptoms. The history taken should include the presence of: scalp tenderness, vomiting, fever and neck stiffness to exclude more sinister causes of symptoms. In this case, had the patient not been discharged but had been awaiting further tests in the ED when their symptoms worsened, they may have received scans and treatment sooner, potentially preventing brain injury.
- With strokes and brain injuries “time is of the essence” to begin anti-thrombotic therapy. The earlier intervention takes place, the better the outcome, in terms of ongoing permanent brain damage.
Elderly patients who present to the ED with symptoms of a migraine for the first time, including visual disturbance and a headache, should be questioned on their history to ensure diagnosis is made with supporting information. Further to this, they should undergo a full neurological assessment, blood tests and further imaging should their symptoms persist. Doctors experienced in Emergency Medicine would normally be aware of these standard procedures.