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PDAT5 CV > 37 - ACUTE ISCHEMIC STROKE > Flashcards

37 - ACUTE ISCHEMIC STROKE Flashcards

1
Q
  • *Ischemic Stroke**
  • *S/Sx**
A

–SUDDEN–
Weakness / Dizziness / Difficulty Walking
CONFUSION / difficulty Speaking
changes in VISION
Facial DROOP or Numbness
Severe HA

F-A-S-T
Ask to Smile - Face Drooping
Raise Arms - Arm weakness
Talk - Speech Difficulty
Time to call 911

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2
Q

Acute Ischemic Stroke
VS
TIA = Transient Ischemic Attack

A

Ischemic Stroke
Episode of Neurological Dysfunction caused by
FOCAL CNS Infarction

TIA
brief episode of neurological dysfunctioncaused by “
clinical symptoms lasting < 1 hour** & **w/o evidence of Infarction

  • -> treat similarly to stroke!
  • *Major determinant of FUTURE STROKE** esp within few days
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3
Q

Cerebral Vasculature

Different Areas of Brain Circulation

A

Anterior circulation
Internal carotid arteries (ICA)
Anterior cerebral arteries (ACA)

Posterior circulation
Vertebral arteries (VA)
Basilar artery (BA)
Posterior cerebral arteries (PCA)

Hemispheric circulation
Middle cerebral artery (MCA)

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4
Q

Initial Management of Stroke

A

Assess for:
HypoGlycemia - similar sxs, just check BG
Stabilize airway / breathing / circulation
Cardiac Monitoring
Oxygen + IV Access

HISTORY
Ask about:
TIME OF ONSET of SXs = “Last known WELL”
recent: surgery or trauma / MI / stroke / bleeding
HTN or Diabetes?
meds: AC / Insulin / HTN meds

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5
Q

Pertinant Diagnostic Studies
STROKE

A

CT-HEADSCAN
Purpose is to RULE OUT HEMORRHAGE because:
no AC/Alteplase for HEMORRHAGIC STROKE

As Needed:
ECG / EEG / MRI / Chest X-ray

LABS:
BLOOD GLUCOSE - rule out hypoglycemia
Rest are AS NEEDED:
electrolytes / Renal / CBC / PT/INR/PTT / LFT etc

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6
Q
  • *NIHSS**
  • *What is this scoring system for?**
A

NIHSS = NIH Stroke Scale
standardized / validated assessment of:
SEVERITY OF STROKE
0 = normal
<10 = more favorable 1 year outcomes
>20 = severe stroke, less favorable 1 year outcomes

Based on a detailed neurological exam

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7
Q
  • *ABCD2 Score**
  • *What does this assess + Components?**
A
  • *TIA SEVERITY**
  • *High Risk = 6-7** / Medium = 4-5
  • STAY IN ER –> HIGH RISK for ANOTHER STOKE*
  • *Age > 60**
  • *BP > 140/90
  • *Clinical Features (max 2)
  • unilateral weakness / speech difficulty
  • *Duration** (max 2)
  • *- >60min = 2 / 10-59min = 1**
  • *Diabetes**
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8
Q

Outcome Measures in Stroke Care
Measures of:
Disablility / QOL / Function

A

mRS = Modified Rankin Scale
0->6(dead)
degree of disability or dependence

BI = Barthel Index
0-100
daily functions

GOS = Glasgow Outcomes Scale
1(dead)->5
overall functionality

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9
Q

ALTEPLASE DOSING
r-tPA

A

0.9mg/kg IV
Max Dose: 90mg, > 100kg = use 90mg

10% of Dose over 1 MIN

Remainder** infused over **1 HOUR

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10
Q

ALTEPLASE

Post Infusion RESTRICTIONS

A
  • NO OTHER:*
  • *Anti-Thrombotics** or Anticoagulants
  • *for 24 hours**

NO:
Indwelling Bladder Catheters or NG tubes or Arterial Catheters
for 24 hours also

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11
Q
  • *NINDS**
  • *Study Results**
A

Alteplase improved:
30% more patients lives
with no difference in mortality

Safety:

  • *ICH = Intracranial Hemorrhage @ 36 hours was >w/Alteplase**
  • benefit OUTWEIGHS this risk*

Earlier Treatment = Better Results

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12
Q

ALTEPLASE

CONTRAINDICATIONS

A

Onset of Sxs > 3 hours
now OKAY to do <4.5 hours

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13
Q

ALTEPLASE

Monitoring Guidelines

A
  • *Neurological Assessment**
  • *q15min** during infusion
  • *q30min** for 6 hours
  • *q60min** until 24 hours passed
  • *Blood Pressure < 180/105**
  • CI is when BP > 185/110*
  • *q15min** during infusion for 2 hours
  • *q30**min for 6 hours
  • *q60min** until 24 hours passd
  • *CT after 24 hours**
  • before starting antithrombotic or AC*

Monitor for:
ANGIOEDEMA** / **AIRWAY OBSTRUCTION

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14
Q

STROKE

BP Treatment / Management

Alteplace Contraindicated w/
BP > 185/110

A
  • *“PERMISSIVE HYPERTENSION”**
  • we want to LET the BP be HIGH for PROPER PERFUSION*

If INELIGIBLE for ALTEPLASE:
we allow for BP < 220/120

Intermittent Therapy:

  • *Labetalol** 10mg IVP q10min prn (max 300mg)
  • *Hydralazine** 10-20mg IVP q15min prn

Continuous Infusion:

  • *NICARDIPINE** 5-15mg/hr
  • *Nitroprusside** 0.25-10mcg/kg/min
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15
Q

INTRACRANIAL HEMORRHAGE = ICH

Symptoms / Treatment

A
  • *SUDDEN** worsening of:
  • *Neuro Exam / HA / NV / ACUTE HTN**

STOP ALTEPLASE** –> **CT SCAN STAT

LABS:
PT/INR/PTT - Platelets - Fibrinogen - CBC

Give BLOOD PRODUCTS:
6-8 units of FPP
if platelets < 100,00 –> give 6-8 units of Platelets

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16
Q

INTRACRANIAL HEMORRHAGE = ICH

RISK FACTORS

A

not following strict thrombolytic protocols

High Dose of Alteplase

↑Blood GLUCOSE

Poor HTN Control

Early Ischemic Changes on CT

Stroke Severity

Adv AGE

17
Q

ALTEPLASE

Main ADR + Risk Factors

A

ANGIOEDEMA
acute swelling of tongue / lips –> potential airway compromise

Risk Factors:
prior ACE INHIBITOR USE
Insular** / **Frontal Cortex Stroke

18
Q
  • *TREATMENT**
  • *Alteplase-Induced ANGIOEDEMA**
A

Antihistamines
Diphenhydramine 50mg IV
AND
FAMOTADINE 20mg IV OR RANITIDINE 150mg IV

Corticosteroids
MPD 80-100mg IV OR Hydrocortisone 100mg IV

MAY NEED SYMPATHOMEMETIC:
Epinephrine 0.1% 0.3mL SQ or 0.5mL by neb
VV
Consult ENT or Anesthesiology STAT

19
Q
  • *ECASS 3**
  • *Trial Outcomes**
A

Outcomes at 3 Months:

  • ALTEPLASE DOES NOT SAVE LIVES*
  • *Alteplase = IMPROVED FAVORABLE OUTCOMES**
  • death was similar*

ICH was Increased w/ Alteplase

EXCLUSION CRITERIA:

  • *>80 y/o** // Diabetes // Prior Stroke
  • *any form of AC** // NIHSS >25 (severe stroke)
20
Q

Alternative Treatments for Acute Ischemic Stroke

IntraArterial (IA) Thrombolysis (Alteplase)

FIRST LINE >
> Stent Retriever & Cerebral Angioplasty

A

NOT FDA approved

Used for patients ineligeble for IV Alteplase

  • *3-6 hours from onset**
  • *High Grade Stroke / PREGNANCY**

Recommended for:
MCA or Vetebro-basilar Artery occlusions

21
Q

Aspirin in ACUTE stroke

A

Aspirin 325mg
can be started within 24-48 hours of stroke onset
NOT a substitute for ALTEPLASE or Mech. Thrombectomy

HOLD ASPIRIN for 24 HOURS
AFTER
ALTEPLASE ADMIN

↓ death / ↓ recurrent stroke
No change in bleeding

PDAT5 CV (30 decks)

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