E4 Stroke (pause) Flashcards
2 classes of stroke we talk about
ischemic and hemorrhagic
where do atheroscletoric and cardioembolic strokes fall?
under ischemic
which type of stroke has headache as a clinical presentation more often?
hemorrhagic (cause its the brain duh)
what scale is used for sx evaluation
National Institutes of Health Stroke Scale (NIHSS)
has a score 0-42
if ischemic stroke with _______ or _______ usually cardioembolic
Afib, valvular abnormalities
if ischemic stroke with _______ usually atherosclerotic
normal sinus rhythm
what two tests are used to assess stroke
ECG
echocardiogram
what 4 labs are used in assessment of stroke
BG
BMP
CBC
INR/aPTT
what two vital signs are used in assessment of stroke
BP
o2 sat
what two imaging things are used for assessment of stroke
Head CT
MRI
can cause neurological changes mimicking a stroke
A. Hypoglycemia
B. Hyperglycemia
A
treat with carbs
A. Hypoglycemia
B. Hyperglycemia
A
if hyperglycemic when presenting treat with insulin in BG > ___
180
when to use insulin drip in pts presenting with hyperglycemia and stroke
only if patient is in acidosis *
acute BP goals:
check BP how often?
q15 min x 2h, then q30 min x 6h, then q1 h for 16 hours
damn
BP goals within first 48 hours:*****
no tPA:
tPA admin:
<220/110
<180/105
do i need to know the details from slide 31? ( i think its 31 but its the flow chart)
spencer pls
3 drugs for acute htn tx options in acute ischemic stroke
labetalol
nicardipine
sodium nitroprusside
all are quick onset
dont need doses
htn management after 48 hours:
if BP elevated after 48 hrs, do what
start po meds if able to take OR resume home antihypertensives
2 tPA drugs
alteplase
tenecteplase
what do tPAs activate and what does that do
plasminogen -> breaks clots
T or F:
thrombolytics (tPAs) improve mortality and neurologic function
false, no impact on mortality
what are the 3 inclusion criteria for tPA eligibility
diagnosis of ischemic stroke
sx onset of <4.5 hours*
age >18 yo
Based on the mechanism of action, which type of stroke would you use a thrombolytic? Select all that apply.
A. Hemorrhagic
B. Ischemic – atherosclerotic
C. Ischemic - cardioembolic
B and C
what BG level is considered hypoglycemic
<50
for tPA eligibility you need to meet ALL inclusion and NO exclusion criteria
yes
what BP value is in exclusion criteria for tPA eligibility ***
BP >185/110 at time of admin
what are some of the tPA exclusion criteria things that might pop up based on his practice questions
active internal bleed
MI in last 3 months
platelets <100k
any current anticoag use
alteplase dose and max
0.9mg/kg
max 90mg
tenecteplase dose and max
0.25mg/kg
max 25 mg
alteplase dosing regimen (ignore actual dose for this)
10% given as bolus
90% given over 1 hour
tenecteplase dosing regimen (ignore actual dose for this)
all IV bolus
2 SEs of tPA agents
bleeding duh
cerebral edema
after giving tPA keep BP at what value to reduce risk of bleeding/hemorrhagic stroke***
<180/105
what should you avoid for 24 hours after tPA admin *
ALL antiplatelets and anticoags
antiplatelets decrease activation of?
P2Y12
4 antiplatelet options for acute ischemic stroke management
aspirin mono
aspirin+clopid
ticagrelor
aspirin +ticag
T or F:
aspirins inhibition of COX is reversible
false, irreversible
inhibiting COX reduces formation of ?
thromboxane A2 -> reduces platelet agg
aspirin utility:
- __ line for acute mgmt of ischemic stroke
- studies show a decrease in early recurrent ischemic stroke with ?
1st
high dose aspirin for 2-4 weeks*
2 monitoring for aspiri
bleeding
stroke
who gets aspirin for a stroke
ALL ischemic stroke pts unless CI’d
what are 2 CI’s of aspirin use
active bleeding or high bleeding risk
when to give aspirin if tPA administered and if not administered
> 24 hours with tPA
immediately if not*
use aspirin+clopid ONLY in ?
minor strokes (NIHHS <4)
how long to use aspirin + clopid combo
3 weeks or 90 days but 90 days increases bleed risk
ticagrelor only used in?
minor strokes (NIHHS <5)
T or F:
aspirin + ticagrelor is better than ticagrelor alone
true
if pt has a true aspirin allergy what do you use?
ticagrelor (yes even over clopid)
what do we do if a pt came in on anticoags already when they came for ischemic stroke
d/c and transition to aspirin
if cardioembolic ischemic stroke or other indication for anticoag, start > __-__ days after stroke *(quiz question)
2-14 days but his quiz said after 7 so just use that range
distinguishing sx of hemorrhagic stroke
severe headache
T or F:
worse prognosis with hemorrhagic stroke
true duh
warfarin reversal agent
IV vitamin K
heparin products reversal agent
protamine
dabigatran (DOAC) reversal agent
idarucizumab
other DOAC reversal agent
Andexxa
antiplatelet reversal agent
none
management is mostly surgical
A. cardioembolic
B. Atherosclerotic
C. Hemorrhagic
C
stroke guidelines recommend to treat with IV antihtn if SBP > ___
180
goa BP in first 24 hours for hemorrhagic stroke
<180/100*
goal BP in hospital AFTER 24 hours for hemorrhagic stroke
<160/90
outpatient BP goal for hemorrhagic stroke
<140/90
what type of stroke gives pts a risk of cerebral vasospasm
subarachnoid hemorrhagic stroke
what to give to minimize complications from cerebral vasospasm
nimodipine (DHP CCB)
T or F:
prophylactic anticonvulsants are recommended by stroke guidelines after a hemorrhagic stroke
false, lack of benefit
anticonvulsants only used if pt has?
documented seizure history
atherosclerotic stroke pts receive what to prevent future strokes
antiplatelets
cardioembolic stroke pts receive what to prevent future strokes
anticoag
1st line for secondary stroke prevention in atherosclerotic stroke
aspirin, high dose 2-4 weeks then 81 indefinitely
my bad theres another 1st line for secondary stroke prevention in atherosclerotic stroke what is it
dipyridamole + aspirin
dipyridamole inhibits ?
adenosine phosphodiesterase
1 niche side effect for dipyridamole aspirin combo
headache
2nd line for secondary stroke prevention in non-embolic ischemic stroke (mod/sev)
clopidogrel + aspirin
1st line for secondary stroke prevention in non-embolic ischemic stroke (minor)
clopid+aspirin
drug that is CI’d in secondary prevention
prasugrel
when to give warfarin/rivaroxaban in cardioembolic stroke
if mechanical mitral valve/LV thrombus
high dose aspirin for >2 days
A. Atherosclreotic
B. Cardioembolic
B, A is 2-4 weeks
long term BP goal for all pts w/ hx of stroke
<130/80
first line antihypertensives:
black people
CCB, thiazide
first line antihypertensives:
CKD
ACE/ARb
first line antihypertensives:
CAD
BB + ACE (or ARB)
first line antihypertensives:
diabetes
ACE or ARB
first line antihypertensives:
HF
ARNI, ACE, ARB + BB + spiro (duh)
first line antihypertensives:
Afib
BB or non-DHP CCB
after an atherosclerotic stroke, all pts should be initiated on ?
high intensity statin
LDL goal
<70
do not use a statin if what or what?
cardioembolic or hemorrhagic stroke
? have been shown to improve neurological functioning after a stroke
SSRis, just avoid paroxetine
