Cerebrovascular

Question 1

Mimics of CVA

Answer 1

hypoglycemia, seizures, migraine w/ aura, HTN or Wernicke’s encephalopathy, CNS tumor, drug tox (Li, Phenytoin)

Question 2

SBP 220 more or DBP 121-140 (non tPA)

Answer 2

aim for 10-15% reduction in MAP. agents: labetolol, nicardipine

Question 3

Labetolol Dose

Answer 3

10-20 g IV over 1-2 min. May repeat or double q10min. Max 300 mg; cont IV 2-8 mg/min

Question 4

Nicardipine Dose

Answer 4

5 mg/h cont IV. Titrate by 2.5 mg/h q5-15min to max of 15 mg/h

Question 5

DBP 140 more (non tPA)

Answer 5

Aim for a 10-15% decr in MAP, agents: nitroprusside

Question 6

Nitroprusside

Answer 6

0.25-0.5 mcg/kg/min cont IV, inc by same increment, usually up to 2-3 mcg/kg/min; max 10 mcg/kg/min for 10 min, greater - cyanide toxic

Question 7

SBP 185 more, DBP 110 more (tPA)

Answer 7

Labetolol x 2, Nicardipine; aggressive HTN tx excludes fibrinolytic therapy

Question 8

BP fibrinolytic therapy

Answer 8

Goal: less than 180/105; DBP 140 more: nitroprusside; SBP 180-230 or DBP 105-140: labetolol, nicardipine

Question 9

tPA Inclusion

Answer 9

18 yo, acute CVA, timeline est., can begin 3-4.5 hr of CVA onset

Question 10

tPA Exclusion

Answer 10

Evidence/HO intracranial hemorrhage, cranial hemorrhage or edema, deformities of cranial structure/veins, active internal bleed, plt

Question 11

tPA relative Exclusion

Answer 11

NIHSS of 25 more, major surgery or serious trauma in prev 14 d, HO GI or UT hemorrhage in prev 21 d, Acute MI prev 3 mos, prego

Question 12

tPA Exclusion 3-4.5 hrs

Answer 12

80 yo taking oral anticoag regardless of INR, NIHSS or HO both stroke and DM

Question 13

tPA administration

Answer 13

0.9 mg/kg IV, max 90 mg; 10% over 1 min, 90% over 1 hr, door-to-needle time 60; monitor q15min for 2h then q30min for 6h then q1h for 24 hr, no punctures or anti-coag for 24hr

Question 14

ICP Goal

Answer 14

cerebral perfusion press - 60-80 mmHG, CPP = MAP - ICP, agents: mannitol, pentobarbital

Question 15

ICP Supportive Measure

Answer 15

Fluids and/or pressors, packed RBCs (Hct 0-30), PA ctrl, seizure ppx if needed, avoid hyperthermia

Question 16

ICP hyperventilation

Answer 16

Gaol 30-35 mmHg, 25-30 for brief periods may be refractory ICP, effect limited to 24 h

Question 17

Mannitol

Answer 17

1 g/kg IV bolus then 0.25 mg/kg; 5 mcg filter, maintain Osmol under 310-320, C/I in severe renal, effect may be limited to 24 h

Question 18

Pentobarbital Coma

Answer 18

LD: 10 mg/kg over 30 min followed by 5 mg/kg/h for 3 h (total 25 mg/kg), MD: 1-3 mg/kg/h; plasma level 30-40 mg/L, taper if ICP well ctrl for 24-48 h