Basic Laceration Repair

Question 1

Modifiable stroke risk factors?

Answer 1

HTN
Smoking
DM
AFib
Poor diet or sedentary lifestyle
Obesity
PAD
Heart disease
Drug and alcohol abuse

Question 2

Interventions targeting stroke risk factors that reduce risk?

Answer 2

Lifestyle modifications (diet, exercise, smoking cessation)
BP management
Antithrombotic therapy for people with AFib
Statins

Question 3

Major stroke subtypes and possible interventions?

Answer 3

Ischemic stroke - IV tPA if candidate, endovascular therapy

Hemorrhagic strokes - hemostasis

Question 4

FAST acronym for stroke recognition?

Answer 4

Facial dropping
Arm weakness (pronator drift)
Speech difficulty
Time to call 911/activate stroke code/time since last well

Question 5

Initial assessment of patient presenting with stroke-like symptoms?

Answer 5

ABCs
CC and HPI
Baseline deficits?
Establish time last known well (patients with ischemic stroke may be eligible for IV tPA within the 0 to 3-4.5 hour window) and/or endovascular intervention
Check vitals and glucose
Neuro exam/NIHSS

Question 6

List 9 stroke mimics.

Answer 6

Hypoglycemia
Psychogenic
Seizures (with post-ictal paralysis)
CNS infections
Brain tumors
Drug toxicity
Demyelinating disorders
Complicated migraine
Hypertensive encephalopathy

Question 7

If a stroke is suspected, what is the next step?

Answer 7

Non-contrast CT to evaluate for intracranial bleeding

Question 8

NINDS recommendations regarding target treatment care windows?

Answer 8

Door to expertise <10 minutes
Door to CT initiation <25 minutes
Door to CT interpretation <45 minutes
Door to needle time (decision to give tPA) <60 minutes

Question 9

Review initial team treatment summary

Answer 9

1. Establish CC/HPI, time last known well
2. Place on monitor, check vitals and glucose
3. Establish peripheral IV x2
4. Code stroke and stroke kit (proper lab tubes, order sets, medication dosing, education tools, etc.)
5. Critical labs - BMP, CBC, PT/INR, PTT (consider need for T&S, ETOh, tox screen, troponin, lipid panel, A1C, LFTs, pregnancy test)
6. 12-lead EKG
7. Do not delay CT, but ensure patient is stable enough for transport

Question 10

BP recommendations in stroke?

Answer 10

AHA/ASA:
Treat BP for patients presenting w/extreme HTN (SBP >220 or DBP >120)

For IV tPA candidates, treat SBP >185 or DBP >110

Question 11

Explain the theory behind BP parameters

Answer 11

During cerebral ischemia, cerebral auto-regulation is lost in ischemic regions. Precipitious BP lowering may aggravate brain ischemia, moreover permissive HTN may help maintain collateral perfusion

Extremely elevated BP has been associated with cerebral edema, hemorrhagic transformation, and death

Elevated BP has been associated with intracranial bleeding following IV tPA administration

Question 12

BP Rx for IV tPA candidates?

Answer 12

Labetalol 10-20 mg IV over 1-2 minutes, may repeat 1x

OR

Nicardipine 5 mg/h IV, titrate up by 2.5 mg every 5-15 minutes to max dose of 15 mg/hr

Question 13

Once tPA has been administered, what monitoring is needed?

Answer 13

VS Q15 minutes for 1st 2 hours, maintain SBP <180 and DBP <105

Question 14

IV tPA (alteplase) treatment window?

Answer 14

0 to 3-4.5 hours of time since last known well

Question 15

Absolute contraindications for tPA?

Answer 15

CT evidence of hemorrhage, hypodensity >1/3 hemisphere
BP >185/110 mmHg (may attempt to control)
Glucose <50
Hx of ICH, stroke, or major head trauma within 3 months
Seizure at onset (unless thought to be 2/2 stroke)
Non-compressible puncture of artery or organ such as organ biopsy <7 days
INR >1.7
Recent heparin use with increased PTT
Platelet count <100,000

Question 16

Relative contraindications to tPA use?

Answer 16

Recent surgery or major trauma <14 days
Pregnancy
GI or urinary tract hemorrhage <21 days
MI <3 months
Rapidly improving or minor neuro deficits likely to result in minimal or no deficit

Question 17

Additional exclusion criteria in candidates who fall in the 3-4.5 hour time frame

Answer 17

Age >80
Any warfarin use
NIHSS >25
Previous stroke AND DM