ABCDE: Stroke & PE Flashcards
What classification system is used for type of strokes?
The Bamford stroke classification
What does the Bamford stroke classification divide types of stroke into?
Total anterior circulation stroke (TACS)
Partial anterior circulation stroke (PACS)
Posterior circulation syndrome (POCS)
Lacunar stroke (LACS)
What arteries are involved in a total anterior circulation stroke?
Middle & anterior cerebral arteries
What 3 classic features are seen in a TACS?
1) Unilateral weakness (and/or sensory deficit) of the face, arm and leg
2) Homonymous hemianopia
3) Higher cerebral dysfunction (dysphasia, visuospatial disorder)
What features are seen in a partial anterior circulation stroke?
Only 2 of the features seen in a TACS
or
Higher cerebral dysfunction alone
What features can be seen in a posterior circulation stroke?
1) Cranial nerve palsy with a contralateral motor or sensory deficit, or
2) Bilateral motor/sensory deficit, or
3) Conjugate eye movement disorder, or
4) Symptoms of cerebellar dysfunction such as vertigo, nystagmus or ataxia, or
5) Isolated homonymous hemianopia
What is PRESERVED in a lacunar stroke?
Higher cerebral functions e.g. language (as a lacunar stroke is subcortical).
What features are seen in a lacunar stroke?
These can be pure motor, sensory, sensorimotor, or cause ataxic hemiparesis alone.
What are some common stroke mimics?
- Seizures (Todd’s paresis)
- Migraine
- Bell’s palsy
- Vestibular neuritis/BPPV
- Head injuries
- Space occupying lesions e.g. tumours
- Demyelinating disorders (e.g. MS)
- Delirium
- Intoxication with alcohol or drugs
- Hypo/hyperglycaemia
What might you find during ‘circulation’ in a patient with a thromboembolic stroke?
Findings of AF e.g. irregularly irregular pulse
How many boluses of 500ml 0.9% sodium cholride can be administered in hypovolaemic patients?
Up to 4 (i.e. 2000ml) or up to 1000ml in patients at risk of fluid overload.
What tool can be used for assessing stroke-related neurological deficits?
National Institutes of Health Stroke Scale (NIHSS).
The higher the number, the greater the deficit and the bigger the stroke.
What investigation should be requested immediately in all cases of suspected stroke?
CT head
(Also glucose - DONT forget about the glucose!)
Purpose of an immediate CT head in suspected stroke?
To identify intracranial haemorrhage (as as these patients must not receive thrombolysis).
What 2 other imaging may be relevant in suspected stroke?
1) CT angiogram (aortic arch to the circle of Willis): looking for large vessel occlusion, vessel dissection or stenosis.
2) MRI FAST head: sometimes performed in an acute setting, especially in wake-up strokes.
1st line management of an ischaemic stroke once a haemorrhagic stroke has been excluded?
1) Aspirin 300mg (immediately or after 24 hours if thrombolysis has been given).
2) Thrombolysis (e.g. alteplase) –> used in patients who present within 4.5 hours of symptom onset.
What are some contraindications to thrombolysis?
1) Intracranial haemorrhage (a CT head must be performed to exclude a haemorrhage)
2) Anticoagulation
3) Stroke within the last 14 days
4) Serious head injury within the last three months
5) Known intracranial neoplasm, malignancy or aneurysm
6) Intracranial or spinal surgery within the last three months
7) Presence of a risk factor for increased bleeding or clotting disorder
8) Rapidly improving symptoms
What must BP be BEFORE thrombolysis?
Need for a prethrombolytic BP goal of <185/110 mm Hg
What does thrombolysis involve?
Thrombolysis involves the administration of a tissue plasminogen activator (tPA) e.g. alteplase or tenecteplase, to break down a clot.
What are the 2 options for management of an ischaemic stroke?
1) Thrombolysis
2) Thrombectomy
What does mechanical thrombectomy involve?
The endovascular removal of a clot from a large cerebral vessel.
What is the criteria for mechnical thrombectomy in an ischaemic stroke?
1) Terminal internal carotid, middle cerebral artery (M1 or proximal M2) occlusion or basilar artery occlusion
2) NIHSS score of 6 or more
3) Presenting within 6 hours of onset
4) No significant early ischaemic changes on imaging
How soon after symptom presentation must mechanical thrombectomy be performed?
Together with thrombolysis –> Within 6 hours of onset
On its own –> Within 24 hours of onset
For patients with an ischaemic stroke (not due to AF) who do not fit the criteria for thrombolysis/thrombectomy, what is the management?
Asprin 300mg for 2 weeks, followed by clopidogrel 75mg lifelong
2ary prevention of ischaemic stroke?
1) Aspirin for 2 weeks following the stroke
2) Then clopidogrel 75mg lifelong
3) If cholesterol >3.5 mmol/l –> statin
If clopidogrel is contraindicated in the lifelong 2ary management of ischaemic stroke, what can be given?
Aspirin + dipyridamole
What are the 2 key contraindications of clopidogrel?
1) Active pathological bleeding, such as peptic ulcer or intracranial haemorrhage.
2) Severe hepatic impairment.
What does the general management of an intracranial haemorrhage involve?
1) Anticoagulant reversal
2) BP lowering –> use labetalol 10mg IV, then consider GTN infusion
3) Referral to neurosurgery for advice regarding potential surgical intervention.
What are some risk factors for DVT?
- pregnancy
- cancer
- immobility e.g. recent surgery, long haul flight, recent fractures
- drugs e.g. COCP, HRT
- coagulopathy (PMH or FH)
- obesity
- infection
Symptoms of a PE?
- SOB
- pleuritic chest pain
- dizziness or syncope
- haemoptysis
- cough
Signs of a PE?
- tachypnoea
- tachycardia
- hypotension: suggestive of right ventricular strain.
- evidence of DVT
- pleural rub
- cyanosis (late sign)
What is a pleural rub?
A squeaking or grating sound caused by ischaemic lung tissue coming in contact with the pleura.
Assessment, investigations & interventions in PE?
Assessment: RR, O2 sats, cyanosis, work of breathing, trachea position, auscultation, percussion, expansion
Investigations: ABG, CXR, Wells score
Management: oxygen, assisted ventilation, PE treatment
What are some CXR findings in a PE?
In most cases of PE, CXR will be completely normal
CXR findings:
- pleural effusion
- area of atelectasis (where a small area of lung tissue has collapsed)
- consolidation: may represent an established area of infarcted lung tissue.
What Wells score indicates that a PE is likely?
> 4
What Wells score indicates that a PE is unlikely?
≤4
What is next step in suspected PE if Wells score is >4?
CTPA (or V/Q scan is CTPA is contraindicated)
If positive –> PE diagnosed
If negative –> consider a proximal leg vein US scan if DVT is suspected
If a CTPA or V/Q scan cannot be performed immediately in a PE, what is next step?
Offer interim anticoagulation with apixaban or rivaroxaban (if no contraindications are present).
What is next step in suspected PE if Wells score is ≤4?
D-dimer test
If negative –> likelihood of PE is low
If positive –> CTPA or V/Q scan
What are 3 key contraindications to a CTPA (indicates the need for a V/Q scan instead)?
- renal impairment
- contrast allergy
- pregnancy
1st line management of PE without haemodynamic instability?
Anticoagulant therapy e.g. apixaban or rivaroxaban.
Provoked –> 3 months
Unprovoked –> 6 months
Management of a massive PE with haemodynamic instability?
Continuous unfractionated heparin infusion +/- thrombolysis (seek expert review).
What are some signs of a massive PE?
These occur 2ary to right ventricular strain:
- hypotension
- raised JVP
- HF
- cardiac arrest
What is the most common ECG finding in PE?
Sinus tachy
What ECG findings may be seen in a PE?
- T wave inversion
- New-onset atrial fibrillation
- Right bundle branch block
- Right axis deviation
- S1Q3T3: S waves in lead I, Q waves in lead III, T wave inversion in lead III
What ‘circulation’ findings might there be in PE?
- tachycardia
- HTN
- hypotension: aconcerning sign in the context of PE and most likely represents cardiac failure secondary to right heart strain (i.e. massive PE)
- JVP: raised indicates massive PE
- hypotension may cause prolonged CRT
