Good Sam Strokes

Question 1

What two medications can be given for an ischemic stroke patient who is not eligible for fibrinolytics?

Answer 1

labetalol

nicardipine

Question 2

In an ischemic stroke case, what are the blood pressure parameters for someone who is not eligible for fibrinolytics?

Answer 2

systolic >220 mmHg

diastolic >120 mmHg

Question 3

ischemic stroke
SBP > 220 mmHg
patient is not eligible for fibrinolytics
what are your optional dosages?

Answer 3

labetalol
IV/IO 5-10 mg
followed by infusion of 2-8 mg/mg

Nicardipine
IVPB 5mg/h IV infusion
titrated to effect by 2.5mg/h q 5 min
[max 15mg/h]

Question 4

ischemic stroke
DBP > 120 mmHg
patient is not eligible for fibrinolytics
what are your optional dosages?

Answer 4

labetalol
IV/IO 5-10 mg
followed by infusion of 2-8 mg/mg

Nicardipine
IVPB 5mg/h IV infusion
titrated to effect by 2.5mg/h q 5 min
[max 15mg/h]

Question 5

In an ischemic stroke patient, what are the BP parameters in the pre-treatment for tPA?

Answer 5

SBP > 185 mmHg

DBP > 110 mmHg

Question 6

In an ischemic stroke patient, what are the BP parameters in the post-treatment for tPA?

Answer 6

SBP > 180 mmHg

DBP > 105-120 mmHg

Question 7

In an ischemic stroke patient, what are the BP parameters in the during the treatment of tPA?

Answer 7

SBP > 180 mmHg

DBP > 105-120 mmHg

Question 8

In an ischemic stroke patient, the pre-treatment of tPA must consider what fluctuation in the BP.

Answer 8

If the BP does not decilne, withhold tPA.

Question 9

In an ischemic stroke patient, what are the optional dosages in the pre-treatment of tPA.

Answer 9

Labetalol 
-10mg IV/IO q 10min 
-max 2 doses 
Nicardipine 
-IVPB 5mg/h IV infusion 
-titrated to effect by 2.5mg/h q 5 min 
-[max 15mg/h]

Question 10

In an ischemic stroke patient, what are the optional dosages in the post-treatment of tPA.

Answer 10

labetalol 
- 5-10mg IV/IO 
followed by infusion 2-8mg/mg
titrated to patient condition
Nicardipine 
-IVPB 5mg/h IV infusion 
-titrated to effect by 2.5mg/h q 5 min 
-[max 15mg/h]

Question 11

It’s important to consider other medications given prior labetalol because decreasing MAP>15% will cause

Answer 11

….rebound increase of ICP.

Question 12

CRITICAL CARE CONTACT MEDICAL CONTROL FOR ORDERS … in adult HTN in an ischemic stroke.

Answer 12

phenytoin 
15mg/kg loading dose 
[max 50mg/min IV] 
mannitol
1 G/kg IV 
[max 200G over <30min]

Question 13

CRITCAL CARE COMMON CONTINUATION MEDICATIONS … in adult HTN in an ischemic stroke.

Answer 13

levetriacetam

500-1500mg IV over 15 min

Question 14

ideal BP for a patient who is on tPA are:

Answer 14

SBP < 185 mmHg

DBP 105-120 mmHg

Question 15

Obvious exclusion criteria for tPA:

Answer 15

1) intracranial/subarachnoid hemorrhage or history
2) uncontrolled HTN
3) witnessed seizure at onset of CVA
4) known or active bleeding diathesis
5) active internal bleeding or acute trauma (fx)
6) labs: plt <100,000/mm3, INR > 1.7, PT>15 sec
7) heparin received within 48h, resulting in PTT greater than upper limit of normal

Question 16

Not so obvious exclusion criteria for tPA:

Answer 16

1) CT shows multi-lobar infarction (hypodensity>1/3 cerebral hemisphere, intracranial neoplasm, arteriovenous malformation or aneurysm)
2) known arteriovenous malformation, neoplasm or aneurysm
3) arterial puncture at a non-compressible site within 7 days
4) hx of intracranial or intra-spinal surgery, serious head trauma, GI bleed,or previous stroke within 3 months

Question 17

tPA administration

Answer 17

.9mg/kg
(not to exceed 90mg total dose)
10% should be given as a bolus over 1 minute

Question 18

reasons to stop tPA

Answer 18

1) signs of intracranial hemorrhage
2) new onset of headache since the beginning of infusion
3) bleeding from previous IV attempts, cuticles, eyes, nose, ears, mucous, membranes or gingiva, hematuria
4) orolingual angioedema
5) changes in neurological status
6) acute pupil changes