MDSO - NEURO

Question 1

Clinical Guidelines: Stroke:

BP goals in ischemic stroke ?

Answer 1

If eligible for thrombolytic - aim for < 180/105

If not getting thrombolytic - - - no treatment of Hypertension unless SBP > 220 or DBP > 120.
- if treating, goal is 15-25% reduction in BP over 1st 24 hrs

Question 2

Clinical Guidelines ; Stroke:

Temperature considerations ?

Answer 2

Keep below 37.5 C (treat if above, ie Tylenol)

Question 3

Clinical Guidelines: Stroke

Ischemic Stroke Treatments and Time Goals

Answer 3

..tPA within 4.5 hrs and Endovascular Therapy (EVT) within 6 hrs

Question 4

Clinical Guidelines : Stroke

Ischemic Stroke: What is the medication? Time LIne ? And Dosage?

Answer 4

…tPA
- witching 4.5 hrs

Dose: 0.9 mg/kg to max 90mg - - - - 10% (0.09mg bolus > 1 min) and 90% (0.81mg/kg ) as infusion over an hour

• note: no evidence for use of FFP, PCC, PLT for tPA assoc bleeding

Question 5

Clinical Guidelines: Stroke

Which ischemic stroke patients get EVT (Endovascular Therapy) ? And time line for EVT ?

Answer 5

Both those that qualified to get tPA, and those that did not !

Within 6-12 hrs for EVT

Question 6

Clinical Guidelines: Stroke:

What role does ASA play ?

Answer 6

Acute stroke, not receiving tPA, after brain imaging rules out ICH and dysphasia screening has been performed and passed (able to swallow) — give ASAP 160 mg ASA - loading dose

Question 7

Clinical Guidelines: Stroke

Acute ICH: BP goals ? 1st line med to use ?

Answer 7

Target SBP 140. Labetalol.

Question 8

Clinical Guidelines : Stroke:

Acute ICH: Anticoag Reversal:

A) What would you use for patients on Warfarin ?
………………………………….B) on Antiplatelts (ASA, clopidogrel, TICAGRELOR,)
………………………………….C) NOAC - Dabigatran (Pradaxa)
………………………………….D) NOAC - Rovaroxaban / Apixaban

Answer 8

A) PCC preferred (fast onset) but FFP + Vit K also good option
B) nothing, d/c med ASAP
C) Idarucizumab (Praxabind) - 5 g/100 mL > 10 min, risk anaphylaxis
D) PCC 2000 IU

Question 9

MDSO: Stroke

What do you have to rule out in Stroke for the MDSO ?

Answer 9

BS <4
TBI

Question 10

MDSO : Stroke:

Tx, Dose, Conditions, Patch

Answer 10

1) Labetalol : if HR > 60; 10-20 mg IVP q 20 min prn to target MAP ; Infuse 0.5 - 2 mg/min - - - MP

2) Hypertonic Saline (3%) - 3 mL/kg, max rate 20 ml/hr - MP ….or

3) Can also consider Mannitol ; if MAP > 80 (diuresis, will want foley) - at 1g/kg bolus.

3% or Mannitol - only if herniation , the flowchart outlines everything the best.

Question 11

MDSO: Stroke : Flowchart:

5 “AVOIDS” for Brain Protection:

Answer 11

AVOID: Hypo/Hyperoxemia, Hypotension, Hypercapnea, Hyperthermia, Hypo/Hyperglycemia
94-98%. MAP > 80. ETCO2 30-35 w herniation ; 37.5 ; > 4

Question 12

MDSO : Stroke : Flowchart:

SIGNS OF HERNIATION:

Answer 12

Any combination of GCS < 9 and
- Abnormal Pupils (fixed, dilated, non-reactive)
-Abnormal Motor Exam (flaccid or posturing)
- Cushing’s : wide Pulse Pressure, Bradycardia, Irregular Resp)

Question 13

MDSO: Stroke : Flowchart

BP Targets: ICH, SAH, Ishchemis

Answer 13

ICH: SBP 140 (MAP > 80)

SAH: 140 - 160

Have gotten or will be getting thrombolytic (tPA) - - - attempt to maintain < 180/105 but > 160/95

Ischemic - not getting tPA/thrombolytic - - - -generally do not treat , unless BP > 220/120

Question 14

What should be considered in Hemorrhagic Stroke but not Thrombotic Stroke ?

Answer 14

REVERSAL of Coagulopathy……PCC ? FFP ? Vit K ? PLT ? PROTAMINE ? DDVAP ? Factor VIII, NOAC Reversal.

Question 15

MDSO: Stroke : FLOWCHART:

CO2 Goals in Herniation:

PaCO2
PvCO2
ETCO2

Answer 15

PaCO2 - 32-35
PvCO2 - 35-40
ETCO2 - 30-35

Question 16

MDSO: Adult : Seizure:

Rule out

Answer 16

BS < 4

Question 17

MDSO: Seizures:

Tx: Medications, Doses, Conditions, Patch Status.

Answer 17

1) MIDAZ - 5 mg IV q 5 min , max 0.2 mg/kg (so 70 kg = 14 mg - - almost 2 doses, so adult weight, 2 doses no problem, by that time you are moving onto the next drug). - - - - if no IV 10 mg IM - - - - IP

2) Phenytoin (Dilantin) - 20 mg/kg to 250 NS ONLY < less than 25 mg/min - - - MP.
- 70 kg = 20 x 70 = 1400 mg / 250 = 5.6mg/mL = 25/5.6 = 4.46 mL/min x 60 = 267 mL/hr
- remember to use 0.2 micron filter
do not use in Na+ channel overdose
** some risk of hypotension if given to fast although MIDAZ infusion not in MDSO, it’s in the FLOW CHART 0.05 - 0.15 mg/kg/hr or Propofol on the chart*
3) Propofol - 50 mg q 5 min PRN - IF MAP > 70, and prepare to intubate. ; then infuse at 0-5 mg/kg/hr.

Question 18

MDSO: Seizure : Flowchart