Acute Stroke & Status Epilepticus Flashcards
Stroke symptoms
Sudden onset of FOCAL, UNILATERAL neurological deficit
- dysphagia (diff swallowing), dysarthria (diff speaking)
- hemianopia (half-blindness)
- weakness
- ataxia (decreased coordination)
- sensory loss
- neglect
NIH stroke scale 0
no stroke symptoms
NIH stroke scale 1-4
Minor stroke
NIH stroke scale 5-15
Moderate stroke
NIH stroke scale16-20
Moderate-severe stroke
NIH stroke scale > 20
severe stroke
Recommended acute treatment: Within 4.5h of sx onset
Fibrinolysis +/- thrombectomy
Recommended acute treatment: 4.5-24 h after sx onset (large vessel occlusion)
Thrombectomy
Recommended acute treatment: 4.5-24h after sx onset (small vessel occlusion + permissive hypertension)
Heparin infusion
Absolute CI to fibrinolytics
< 18 yo
ischemic stroke within 3 months
intracranial/intraspinal surgery w/in 3 months
GI bleed in last 21 days
LMWH within 24 h
Infective endocarditis
Intra-axial intracranial neoplasm
unclear time of onset or > 4.5 h after
current intracranial hemorrhage
severe head trauma in last 3 mo
platelet < 100,000
INR >/= 1.7
aPTT > 40
DOAC within 48 h
Aortic arch dissection
Fibrinolytic agents
Alteplase
Tenecteplase
Alteplase dosing
0.9 mg/kg (max 90 mg)
Bolus 10% over 1 minute
remaining 90% as infusion over 60 min
Tenecteplase dosing
0.25 mg/kg (max 25mg)
IV push
more specific than alteplase
BP required for thrombolytic bolus
< 185/110
BP goal for thrombolytic infusion
< 180/105
if patient meets exclusion criteria and alteplase is not given, BP is not treated unless
> 220/110
First line agents for BP control in acute stroke setting
IV Labetalol
IV Nicardipine (preferred if HR < 55)
Fibrinolytic complications
symptomatic intracranial hemorrhage
angioedema
Symptomatic intracranial hemorrhage management
1.) DC fibrinolytic
2.) Cryoprecipitate 10 U infused over 10-30 min
3.) anti-fibrinolytics
- tranexamic acid 1000 mg IV
- E aminocaproic acid 4-5 g IV
Angioedema management
Maintain airway
hold ACEi
Methylprednisolone 80-100 mg IV
Diphenhydramine 50 mg IV
Ranitidine 50 mg IV or famotidine 20 mg IV
Epinephrine 0.3 mL
Post-stroke regimen
close monitoring for first 24h
dysphagia and aspiration risk assessment
high dose statin
antiplatelets
- aspirin
- dual antiplatelet for low NIH stroke scale or intracerebral stent x 21 d
DVT prophylaxis
Anticoagulation if cardioembolic stroke or hx of A Fib)
Risk factors for breakthrough seizures
Intoxication
Withdrawal
Trauma
Meningitis
Psychiatric
Metabolic derangements
First line agents to stop an acute seizure
Benzos:
Lorazepam 0.1-0.2 mg/kg IV
Diazepam 0.15 mg/kg IV
Midazolam IM (if no IV access)
Benzodiazepine ADE
impaired consciousness
hypotension
respiratory depression
(Fos)Phenytoin
Loading dose: 20 mg/kg IV
Maintenance dose: 4-6 mg/kg/day in 2-3 div
highly protein bound
ADE:
- CV risks (hypotension, bradycardia, QTc P, usually correlated with high infusion rate)
- extravasation
Phenytoin ADRs (PHENYTOIN-RN)
P-450 interactions
Hirsutism/hypertrichosis
Enlarged gums
Nystagmus
Yellow-browning of skin (hepatitis)
Teratogenicity
Osteomalacia - VitD deficiency
Interference with folate metabolism (anemia)
Neuropathies: vertigo, ataxia, HA
Rashes/fever: SJS
Neutropenia, thrombocytopenia
(Fos)Phenytoin Monitoring
Goal level: 10-20 mcg/dL (total phenytoin)
if seizing may target 15-25
levels > 30 = seizures
must correct level for low albumin (< 3.5) and poor renal function (CrCL < 30)
Levetiracetam
SE dose:
- LD: 20 mg/kg IV bolus
- MD: 1000 mg IV BID
levels do not correlate with efficacy
ADE
- agitation
- drowsiness
Valproic acid
Dose:
- LD 40 mg/kg
- MD 5 mg/kg IV Q8H
Goal level:
- 50-100 mcg/mL
ADE:
- drowsiness, HA
- thrombocytopenia
- pancreatitis (pediatrics)
- hyperammonemia
DDI:
- phenytoin -> increased free phenytoin levels -> increased toxicity
Lacosamide
Dose: 100-200 mg IV BID
ADE:
- dizziness, abnormal vision, diplopia, ataxia
- generally well tolerated
Refractory SE
If there is no response to initial anticonvulsants
OR
seizures lasting > 2hrs
OR
seizures recuring at a rate of 2 or more episodes per hour with no recovery to baseline between seizures, despite treatment
Paralyzed patients
paralytics used during intubation in refractory SE -> cannot physically observe seizures
start an IV antiepileptic (propofol or midazolam)
long term EEG (LTM) monitoring
Phenobarbital/Pentobarbital Coma
Pentobarbital
- 5-10 mg/kg IV x1
- 0.5-5 mg/kg/hr IV infusion
Phenobarbital:
- LD 20 mg/kg IV
- MD 1-2 mg/kg IV BID
ADE:
- respiratory depression (intubation required)
- hypotension (may need vasopressor)
- lethargy
- nystagmus
- thrombocytopenia
- suppressed immune system
- decreased GI motility
Super Refractory Status Epilepticus
Ketamine infusion
- LD 1.5-3 mg/kg IV
- MD 0.1-4 mg/kg/hr
