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*Neuro Block Pharm > ischemic stroke > Flashcards

ischemic stroke Flashcards

1
Q

on Initial Assessment of Ischemic Stroke, what is the first thing you need to determine?

A

Determine if patient it candidate for thrombolytic therapy

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2
Q

on Initial Assessment of Ischemic Stroke, you need to do a Rapid but thorough exam. what should the exam include?

A

o VS: BP, temperature
If BP is too high and you put them on thrombolytic is increases brain bleed risk. If BP is to low may have problems with perfusion.
Increased temperature due to stroke has detrimental outcomes. Tylenol is good choice.

o Neuro: for deficits
Variety of scales to assess risk of stroke (e.g., NIH Stroke Scale)

o CV: peripheral pulses, murmurs
Check for A fib, peripheral pulses may be indication for atherosclerosis.

o Neck: vascular bruits (for carotid stenosis)

o Pulm: adequate respirations

o Eye/funduscopic: neuro deficits, papilledema

o Head: trauma

o Extremities: assess for DVT

o Skin: purpura, ecchymosis, cyanosis
Cyanosis can give you idea of clotting as well as peripheral blood flow

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3
Q

n Initial Assessment of Ischemic Stroke, it is Critical to distinguish other disorders in differential. what are some of these disorders?

A 
o	Seizure
o	Syncope
o	Migraine
o	Hypoglycemia
o	Drug toxicity
o	Many others
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4
Q

Initial Assessment: what are some immediate Diagnostic Testing needed?

A

o Oxygen saturation
o Noncontrast head CT or brain MRI
o Blood glucose (finger stick)
o Accurate body weight (if planning to use alteplase)

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5
Q

besides the immediate diagnostic needed, what are some other diagnostic tests that can/should be ordered?

A 
o	ECG
o	CBC
o	Cardiac enzymes and troponin
o	E-lytes, BUN, Cr
o	PT and INR
o	aPTT

Others to consider if fever present
o UA, blood cultures, CXR

Other tests for select patients:
o	Liver function
o	Toxicology
o	Blood EtOH
o	Pregnancy test
o	ABG
o	LP (if suspect subarachnoid hemorrhage with negative head CT)
o	EEG
o	Thrombin time or ecarin clotting time (if known/suspected direct thrombin or factor Xa inhibitor therapy)
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6
Q

what should be used for Fluid management in ischemic stroke patients?

A

o Usually best treatment is normal saline (0.9%) vs. hypotonic and fluids containing glucose
o If someone is dehydrated, need to maintain isotonic solution. Want to avoid extremes so we won’t use hypotonic or hypertonic solutions because that can change fluid shifts in brain.

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7
Q

after patients experience a stroke, what assessment should be performed before they eat or drink?

A

Swallowing assessment

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8
Q

when someone has a stroke, there is guidelines that glucose control should be maintained at ______.

A

140-180

If it is above this we want to get that down as part of their stroke management.

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9
Q

why is BP control an important part of stroke management

A

need to maintain high enough for perfusion pressure and low enough to where it won’t cause hemorrhage.

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10
Q

what are some Management Issues for patients with ischemic stroke?

A
  • Use of antiplatelet drugs as part of antithrombotic therapy
    2 phases of management: acute management and preventive management.
  • Prophylaxis for DVT/PE
  • Secondary prevention with antithrombotic therapy (at discharge)
  • Statin therapy
  • BP reduction following acute phase
  • Behavioral/lifestyle interventions
    Smoking cessation, weight management, exercise, diet
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11
Q

Strict BP control is critical prior to and during first 24 hours after _______ therapy

A

thrombolytic

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12
Q

BP should be at or below ____ before administration of alteplase and remain below _____ for at least 24 hours

A

185/110

180/105

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13
Q

can we use alteplase if BP is above 185/110 ?

A

no

If it is above that we can’t use thrombolytic therapy, need to do something to BP to get it down.

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14
Q

why does the BP need to stay below 180/105 for at least 24 hours after alteplase therapy?

A

Maintained at least for 24 hours because that is when they are most at risk for hemorrhage.

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15
Q

Suggested first-line drugs (all IV) for lowering BP in ischemic stroke?

A

labetalol, nicardipine, clevidipine

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16
Q

should you use IV or PO BP drugs when managing acute ischemic stroke?

A

IV

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17
Q

what is the BP Monitoring schedule during first 24 hours- following administration of alteplase infusion.

A

o Q 15 minutes for first 2 hours
o Q 30 minutes for the next 6 hours
o Q 1 hour until 24 hours after administration

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18
Q

Must be vigilant AGAINST excessive lowering of BP due to _______

A

hypoperfusion

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19
Q

If not using thrombolytic therapy, usually don’t treat BP unless extreme, such as ___ or if patient has certain underlying conditions

A

> 220/>120

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20
Q

If not using thrombolytic therapy, usually don’t treat BP unless extreme (i.e., >220/>120) or if patient has certain underlying conditions.

what are some of these conditions?

A 
o	Ischemic coronary disease
o	HF
o	Aortic dissection
o	Hypertensive encephalopathy
o	ARF
o	Preeclampsia/eclampsia
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21
Q

Alteplase (Activase, Cathflo Activase) MOA

A

o Recombinant tissue plasminogen activator (tPA)

o Binds to fibrin to convert plasminogen to plasmin

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22
Q

what time from onset of symptoms to treatment of alteplase will result in the best outcomes?

A

Less than 3 hours (from onset of symptoms)

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23
Q

a patient is no longer eligible for alteplase if they have had stroke symptoms for how long?

A

4.5 to 6 hours

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24
Q

when is a patient eligible for mechanical thrombectomy?

A

6 to 24 hours after onset of symptoms

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25
Q

when is a patient Not eligible for IV alteplase or mechanical thrombectomy, just supportive care.

A

beyond 24 hours

26
Q

what is the Inclusion Criteria for giving alteplase? (3)

A
  • Clinical diagnosis of stroke causing measurable neurologic deficit
  • Onset of symptoms <4.5 hours before beginning treatment- If onset is unknown, define as last time patient was known to be normal
  • Age >18 years
27
Q

what are some examples of HISTORICAL Exclusion Criteria for alteplase? (5)

A
  • Stroke or head trauma in last 3 months
  • Previous intracranial hemorrhage
  • Intra-axial intracranial neoplasm
  • GI malignancy or hemorrhage in last 21 days (3 weeks)
  • Intracranial or intraspinal surgery in last 3 months -surgical lacerations may not have healed well and can have increased risk for bleeding.
28
Q

what are some examples of CLINICAL Exclusion Criteria for alteplase? (6)

A
  • Symptoms suggestive of subarachnoid hemorrhage
  • Persistent blood pressure elevation ( ≥185/≥110)
  • Active internal bleeding
  • Presentation consistent with infective endocarditis
  • Known or suspected association with aortic arch dissection–> will bleed a lot from alteplase very quickly and die.
  • Acute bleeding diathesis, including but not limited to conditions defined in “Hematologic” (ex:hemophilia)
29
Q

what are some examples of HEMATOLOGIC Exclusion Criteria for alteplase? (5)

A
  • Platelet count <100,000/mm3
  • Current anticoagulant use with an INR >1.7 or PT >15 seconds
  • Therapeutic dose of LMWH in last 24 hours
    Does NOT apply to prophylactic doses
  • Heparin use within 48 hours and an abnormally elevated aPTT
  • Current use of a direct thrombin inhibitor or direct factor Xa inhibitor with evidence of anticoagulant effect by laboratory tests (e.g., aPTT, INR, ECT, TT, or appropriate factor Xa activity assays)
30
Q

what are some examples of HEAD CT SCAN Exclusion Criteria for alteplase? (2)

A
  • Evidence of hemorrhage

- Extensive regions of obvious hypodensity consistent with irreversible injury (significant infarction).

31
Q

what are some examples of RELATIVE exclusion criteria for alteplase? (13)

A
  • May receive IV alteplase despite one or more of below based on risk-to-benefit
  • Only minor and isolated neurologic signs or rapidly improving symptoms
  • Glucose 10 mm), untreated, unruptured intracranial aneurysm
  • Seizure at the onset of stroke with postictal neurologic impairments
  • Pregnancy
  • Untreated intracranial vascular malformation
  • Alteplase appears to be safe and may be beneficial for patients below
  • Other relative exclusion criteria for treatment from 3 to 4.5 hours from symptom onset
    o Age >80 years
    o Oral anticoagulant use regardless of INR
    o Severe stroke (NIHSS score >25)
    o Combination of both previous ischemic stroke and diabetes mellitus
32
Q

what things do you need to confirm before administering IV alteplase?

A
  • Treatment commencing within the required 4.5 hour time window after onset of symptoms
  • Persistent, measurable neurologic deficit
  • Eligibility criteria are met
  • Noncontrast head CT or brain MRI is without hemorrhage or other CI
  • BP parameters are met
  • Two IV lines are placed (preferably large bore)
    o One dedicated for alteplase and other for support
  • Accurate body weight
  • Glucose check to rule out hypoglycemia
33
Q

what two organ systems do you need to closely monitor after alteplase administration?

A

Close neurologic and cardiac monitoring

34
Q

5 important things for First 24 Hours of Alteplase

A
  • VS and neurologic status
    o Every 15 minutes for 2 hours then q 30 minutes for 6 hours, then q 60 minutes until 24 hours
  • BP maintained <180/105
  • Anticoagulant and antithrombotic agents should NOT be administered for at least 24 hours after infusion is complete
  • Placement of intra-arterial catheters, indwelling bladder catheters, and NG tubes should be avoided for at least 24 hours if at all possible
  • Follow-up head CT after alteplase is initiated and before starting antiplatelet or anticoagulant therapy
35
Q

what are three Complications of Thrombolytic Therapy

A

**Symptomatic Intracerebral Hemorrhage (ICH)

Systemic bleeding
Angioedema (~1-8%)

36
Q

Suspect Symptomatic ICH in any patient with (especially within first 24 hours) what symptoms?

A 
o	Sudden neurologic deterioration
o	Decline in level of consciousness
o	New headache
o	Nausea or vomiting
o	Sudden rise in BP
37
Q

if you suspect ICH in your pt, how should you manage it?

A

o Discontinue alteplase infusion (if applicable) (if they are still in hour window of infusion)
o STAT noncontrast head CT or brain MRI
o Type and cross (some recommend doing this before starting alteplase)
o Labs: PT, aPTT, platelet count, fibrinogen

38
Q

if ICH is confirmed in your patient after administering alteplase, what should you do? (5)

A
  1. Cryoprecipitate (increase fibrinogen and factor VIII)
    o Prothrombin complex concentrate as adjunct if on warfarin
    o Fresh frozen plasma (FFP) as adjunct if on warfarin
    o Vitamin K as adjunct if on warfarin
  2. Antifibrinolytic agents:
    o Aminocaproic acid IV (only used when pts have ICH)
    o Tranexamic acid IV (only used when pts have ICH)
  3. Platelets if evidence of thrombocytopenia
  4. Protamine (if receiving UFH (heparin) for any reason)
  5. Recombinant factor VIIa
39
Q

Management of Systemic Bleeding- when does bleeding require cessation?

A
  • Mild bleeding usually do NOT require cessation of treatment
    E.g., oozing from IV catheter sites, ecchymoses, gum bleeding
  • More serious bleeding MAY require cessation
    E.g., GI/GU–>GI bleed, defecating blood, hematuria.
40
Q

if Angioedema occurs, it is Usually mild, transient, and _______ to ischemic hemisphere

A

contralateral

41
Q

if angioedema is severe and might compromise the airway, what management is needed?

A

May need to stop tPA, administer antihistamines/corticosteroids, and intubate

42
Q

Everyone that has ischemic stroke should be offered _______ acutely within the first 24-48 hours

A

Antithrombotic Treatment

43
Q

what are Options for patients who are NOT treated with thrombolytic therapy

A

o Antiplatelet agents
o Heparin
o LMWHs

44
Q

IF alteplase used, Antiplatelet Agents (ASA +/- dipyridamole or Plavix) should NOT be initiated until______ after completion of infusion

A

24 hours

45
Q

Antiplatelet Agents (ASA +/- dipyridamole or Plavix) Can be used with LMWH or UFH for ______.

A

DVT prophylaxis

46
Q

regarding Antiplatelet Agents,______ is only effective agent in very early treatment

A

Aspirin (160-325 mg/d)

47
Q

_____ (or ticlopidine) is an alternative for those intolerant to ASA

A

Clopidogrel

48
Q

Dual antiplatelet therapy remains unproven in early management but might benefit patients with _____disease

A

large vessel

49
Q

For cardioembolic TIA,

Anticoagulants such as______ should be used

A

warfarin or dabigatran

50
Q

For non-cardioembolic TIA and ischemic stroke, Antithrombotic Therapy options are?

A 
o	ASA (50-325 mg/day)
o	Clopidogrel
o	ASA + extended release dipyridamole (Aggrenox)
51
Q

name four Major Treatable Atherosclerotic Risk Factors

A
  • HTN
  • DM
  • Smoking
  • Dyslipidemia
52
Q

what is the Single most important treatable risk factor for stroke

A

hypertension

o CV mortality increases as BP rises above 110/75
o ~60% of strokes attributed to HTN

53
Q 
2014 AHA/ASA guidelines:
Resume treatment (after first several days) in patients with \_\_\_\_\_\_.
A

previous HTN

54
Q

2014 AHA/ASA guidelines: initiate treatment (after first several days) in all patients with ischemic stroke or TIA with baseline BP______ no matter of PMH

A

≥140 systolic or ≥90 diastolic

55
Q

according to UpToDate, you should Initiate HTN treatment in all patients with ischemic stroke or TIA of atherothrombotic, lacunar, or cryptogenic type with baseline ______no matter of PMH

A

BP >120/70

56
Q

according to UpToDate, you should Initiate HTN treatment in all patients with ischemic stroke or TIA of atherothrombotic, lacunar, or cryptogenic type with baseline BP >120/70 no matter of PMH. the Exception is nonhypertensive patients (i.e., <140/90) with etiology of _______

A

cardioembolic phenomenon (e.g., atrial fibrillation)

57
Q

HTN drug choices for monotherapy treatment

A

Angiotensin inhibitor (ACEI or ARB) or long-acting dihydropyridine CCB (like amlodipine) or diuretic (HZTZ, Chlorthalidone)

AVOID beta-blockers due to evidence showing no reduction in stroke risk

58
Q

HTN drug choices for combination therapy treatment

A

• ACE inhibitor plus a diuretic

or

• Angiotensin inhibitor (ACEI or ARB) PLUS long-acting dihydropyridine CCB

59
Q

For patients with atherosclerotic origin of stroke, they are recommend have high-intensity statin therapy with _____.

A

atorvastatin 80 mg/d

60
Q

Restrict sodium if BP an issue in patients to a max of _____

A

2400 mg/d

*Neuro Block Pharm (8 decks)

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