Clinical Decision Making: Acute Ischemic Stroke with Large Vessel Occlusion

This clinical decision-making (CDM) case is intended for emergency medicine (EM) residents of all levels.

About 700,000 patients every year in the United States experience an acute ischemic stroke.1 Morbidity and mortality from an ischemic stroke may be limited from timely diagnosis and acute management, including specialist involvement, appropriate blood pressure control, and evaluation for possible thrombolytic therapy. EM residents should be familiar with stroke management principles whether they work in an academic, community, or rural setting.

By the end of this clinical decision-making case, learners will be able to: 1) demonstrate familiarity with the CDM case format and case play, 2) describe important historical information to obtain when suspecting an acute stroke, 3) outline key diagnostic tests to rule out other causes of acute neurologic deficits, 4) outline acute management strategies for acute ischemic stroke, 5) propose an appropriate disposition plan for patients with an acute ischemic stroke.

This is a clinical decision-making boards case as outlined by the American Board of Emergency Medicine (ABEM). Each learner was paired with one instructor for the case, a scoring checklist by the instructor was used, structured debriefing time was incorporated into the assessment, and learners were given the opportunity to provide qualitative feedback after the case.

Each CDM case session lasted approximately 25 minutes, with 15 minutes for the case and 10 minutes for debriefing and feedback. A 26-point critical action checklist was developed to evaluate each learner's performance, with each point reflecting an equally weighted item. Learners then provided verbal feedback on the cases to the examiners at the conclusion of their assessments.

Thirty-nine categorical emergency medicine residents participated as learners for this clinical decision-making session, including 10 third-year residents, 12 second-year residents and 17 first-year residents. The average overall score was 17.3 of 26 possible points. Performance with respect to postgraduate year (PGY) is as follows: 17.7 for PGY-3s, 18.8 for PGY-2s, and 15.9 for PGY-1s. One resident had a perfect score.

Performance of our learners varied and unexpectedly, our second-year residents outperformed our third-year residents. This is likely due to our PGY-2 learners being responsible for the primary care of stroke patients in our department, which makes their identification and management of acute ischemic stroke patients likely more recently retrievable.

Emergency medicine, neurology, acute ischemic stroke.