Stroke Flashcards
1
Q
Anticoagulants Cause?
A
Bleeding
2
Q
Hemostats (Coagulants) Cause?
A
Clot:
- Facilitate the clotting cascade
- Prevent fibrinolysis
3
Q
When do you use Hemostats (Coagulants)?
A
Trauma patients with uncontrolled bleeding
Severe oral anticoagulant overdose
Coronary artery bypass graft
Orthopedic (& spinal) procedures
4
Q
Types of Hemophilia
A
- ) Hemophilia A
- Factor VIII
- Classic - ) Hemophilia B
- Factor IX
- Christmas Disease
5
Q
What is used in COAGULOPATHIES?
A
- ) clotting factors
2. ) Cryoprecipitate (pure blood product)
6
Q
What are the clotting factors for coagulopathies?
A
- Factor Eight Inhibitor Bypassing Activity:
- Anti-Inhibitor Coagulant Complex
- FEIBA™ - Recombinant Factor VIIa
- NovoSeven™
* Coagulopathies associated with liver disease
* Major bleeds secondary to trauma, surgery - Prothrombin complex concentrate (Kcentra™)
7
Q
What is the Anti-Inhibitor Coagulant Complex?
A
- FEIBA, Injectable (bolus or infusion)
Precursor and activated forms of Factors II, VII, IX and X
8
Q
Indication for Anti-Inhibitor Coagulant Complex
A
Hemophilia A and B patients with inhibitors who are to undergo surgery or those who are bleeding
9
Q
Unlabeled indications for Anti-Inhibitor Coagulant Complex
A
treatment of life-threatening bleeding associated with dabigatran (Pradaxa™)
- Patient on Pradaxa to prevent clots, but we’re giving them a drug to cause clotting!!! Possible problems, b/c we’re counteracting Pradaxa’s effects
10
Q
ADR of Anti-Inhibitor Coagulant Complex
A
Thrombotic events
Allergy
11
Q
Prothrombin complex concentrate (Kcentra™) Contains what?
A
- Contains Factors II, VII, IX, X and Protein C and Protein S
- Protein S is cofactor for Protein C which then turns into activated protein C
- Balance clotting with a natural anticoagulant (Protein C)
- Is an injectable
12
Q
Indication for Prothrombin complex concentrate (Kcentra™)
A
- Vitamin K antagonist (warfarin) reversal in patients with acute major bleeding
- Dosing based on INR value
13
Q
Balancing act with Prothrombin complex concentrate (Kcentra™)
A
Reversal yes, but patient obviously has a clot “problem” which you might have just aggravated
14
Q
What INR value normally causes panic?
A
~ 6 - 8
with signs of bleeding (decreased Hematocrit, bruising, overt bleeding)
15
Q
What INR value with Prothrombin complex concentrate (Kcentra™) causes panic?
A
4
16
Q
Recombinant Factor VIIa is what?
A
Activates factor IX and factor X in association with tissue factor
Injectable agent given until bleeding stops
17
Q
Indication for Recombinant Factor VIIa?
A
Hemophilia A and B
18
Q
Unapproved Indication for Recombinant Factor VIIa?
A
Bleeding with trauma
Bleeding with surgery
Intracranial bleeding
Warfarin toxicity
19
Q
MOA of Aminocaproic acid
A
- Binds competitively to plasminogen
- Plasminogen can’t convert to plasmin
- Plasmin can’t activate the breakdown of fibrin
- Helps clotting
20
Q
MOA of Tranexamic acid
A
- Displaces plasminogen from fibrin
- Inhibits fibrinolysis
- Inhibits proteolytic activity of plasmin
Stops natural process
21
Q
Aminocaproic acid unapproved uses
A
- Prevention of dental procedure bleeding in patients on warfarin,
- prevention of perioperative bleeding associated with cardiac surgery (CABG)
- ACCF/AHA Guidelines for CABG find it safe
- control of bleeding with severe thrombocytopenia
22
Q
ADR of Aminocaproic acid
A
Multiple but noted:
- Intrarenal obstruction –> maintain clots, so get clots in urine
- Skeletal muscle weakness
23
Q
Aminocaproic acid approved indication
A
acute bleeding
24
Q
Tranexamic acid approved indications
A
- Short-term use in hemophilia patients to reduce or prevent hemorrhage following tooth extraction
- Treatment of cyclic heavy menstrual bleeding
- oral med, worry about side effects (prone to thrombotic events)
25
Tranexamic acid unapproved indications
Perioperative bleeding in cardiac surgery and orthopedic surgery (spinal surgery)
26
MOA of Tranexamic acid
Hypersensitivity reactions
| Seizures
27
Topical thrombin
- Activates platelets and catalyzes the conversion of fibrinogen to fibrin
- Restricted to one route! --> Powder, liquid, liquid spray
28
Cellulose (oxidized)
- Referred to as Surgicel™
- Aids in clot formation
- Gellatinous plug
- Lay over a weeping/oozing area --> allow RBC's to lay on naturally and clot up
29
Gelatin absorbable
- Referred to as Gelfoam™
and gel film
- Lay over a weeping/oozing area --> allow RBC's to lay on naturally and clot up
30
Ferric subsulfate
- Referred to as Monsel’s Solution
- for cervical biopsies
- dark orange and topical
31
Fibrin sealant
- Referred to as Tisseal™
| - Combination of fibrinogen, fibrin and aprotinin
32
Desmopressin
- Classified as an antihemophilic agent and hemostatic agent --> Injection
- It increases von willebrand factor
- Intravenous infusion or nasal spray for indications
* Diabetes Insipidus
* Nocturnal enuresis (bed wetting)
* Uremic bleeding
33
What to remember with Stroke? (Symptom wise)
```
FAST
F = face (droop, uneven smile)
A = arm (numbness, weakness
S = Speech (slurred speech, difficulty speaking)
T = Time (call 911 and get to hospital)
```
34
Risk factors for Stroke
- HTN
- High Cholesterol
- Diabetes
- Tobacco
- Unhealthy diet
- Physical Inactivity
- Obesity
35
What is High risk factors on the stroke risk score card?
```
BP > 140/90
A-Fib
Smoker
Cholesterol > 240
Diabetic
Couch Potato
Overweight
Stroke in family
```
36
What is Caution factors on the stroke risk score card?
BP 120-139/80-89
```
Trying to quit Smoking
Cholesterol 200-239
Borderline Diabetic
Some Exercise
Slightly Overweight
```
37
What is Low risk factors on the stroke risk score card?
```
BP < 120/80
Regular Heartbeat
NonSmoker
Cholesterol < 200
Regular Exercise
Healthy weight
none in family
```
38
What is High risk on the stroke risk score card?
Greater than or equal to 3
| - in that column
39
What is Caution on the stroke risk score card?
4-6
| - in that column
40
What is Low risk on the stroke risk score card?
6-8
| - in that column
41
2 types of strokes
1. Hemorrhagic stroke
2. Ischemic Stroke
- symptoms generally the same, hard to differentiate
42
What if Hemorrhagic stroke
| - do first after established it is
Consider BP lowering
| - But be careful with lowering too much, don't drop down to normal BP, can't profuse the brain well.
43
Types of Hemorrhagic stroke
- Intracerebral hemorrhage
- Subarachnoid hemorrhage
- Intracerebral aneurysm
- Arteriovenous malformation (AVM)
High mortality
44
Intracerebral hemorrhage
Spontaneous rupture of small vessels damaged by chronic hypertension
45
Subarachnoid hemorrhage
Underlying cerebrovascular malformation in an otherwise normal patient
46
Intracerebral aneurysm
Vessel rupture
47
Arteriovenous malformation (AVMs)
Congenital vascular anomaly
| - good to detect as a child
48
What do you do for Intracerebral hemorrhage?
1."ABC”
Airway, breathing, circulation
2. Blood pressure control
- Lower blood pressure and you reduce ongoing bleeding from rupture small arterioles
- Lower blood pressure and you may decrease cerebral perfusion and worsen brain injury
3.*** Analgesia and sedation
49
What do you do for Subarachnoid hemorrhage?
1. Prophylactic anti-seizure drugs
- Tendency for them to have seizure which could worsen the hemorrhage
2. Probably a “no” on lowering blood pressure
50
What drug is used in Subarachnoid hemorrhage?
Nimodipine (Nimotop™, Nymalize™)
| - Sole indication is treatment of subarachnoid hemorrhage
51
What is Nimodipine
Calcium channel blocker (dihydropyridine)
- Greater effect on cerebral arterials than other arterials
- Increased lipophilicity and cerebral distribution when compared to nifedipine
- Works best as a liquid
- take for ~ 4 weeks 5 times a day
52
Nimotop™ route
Capsule
- take syringe and withdraw liquid to give orally
- but some nurses accidentally injected it IV
53
Nymalize™ route
Oral Liquid
| $$$$$
54
Nimodipine (Nimotop™, Nymalize™) ADR
Hypotension
| Headache
55
What causes Ischemic stroke?
End result?
- From cerebral artery occlusion
| - Cell death in 4-10 mins is end result
56
What can interrupt the arachidonic acid production pathway
aspirin
57
Primary goal for treating ischemic stroke
Prevent or reverse brain injury
- ABCs (Airway, breathing, circulation)
- Treat hyper- or hypoglycemia if identified
- STAT emergency noncontrast head CT
58
Treatment for Ischemic stroke
```
Medical support
****IV thrombolysis
Endovascular techniques
****Antithrombotic treatments
Neuroprotection
Rehabilitation
```
59
How fast should treatment be done in Ischemic stroke for success?
Everything must be done in 1 hour from presentation (Assessment, CT, treatments)
60
IV THROMBOLYTIC in Treatment for Ischemic stroke?
Alteplase (Activase™)
- clear benefit for alteplase in select patients with acute stroke
- Central component of primary stroke center treatment
61
Time frame Alteplase (Activase™) can be used?
- Original: 3 hours from first sign
| * ** now: 4.5 hours from 1st sign, if > 4.5 hours, then can't do this treatment
62
What needs to be proven in order for Alteplase to be used?
1. Has an Indication
2. Not Contraindicated
3. Meets NIH stroke Severity scale
63
Indications for Alteplase
- Clinical diagnosis of stroke
- Onset of symptoms to time of drug administration 3 hours
- CT scan showing no hemorrhage or edema of greater than 1/3 of the MCA territory
- Age 18 years
- Consent by patient or surrogate
64
Contraindications for Alteplase
- Sustained BP > 185/110 despite treatment
- Platelets < 100,000; HCT < 25%; glucose < 50 or > 400 mg/dL
- Use of heparin within 48 h and prolonged PTT, or elevated INR
- Rapidly improving symptoms
- Prior stroke or head injury within 3 months; prior intracranial hemorrhage
- Major surgery in preceding 14 days
- Minor stroke symptoms
- Gastrointestinal bleeding in preceding 21 days
- Recent myocardial infarction
- Coma or stupor
65
NIH stroke Severity scale, score 0
No stroke symptoms
66
NIH stroke Severity scale, score 1-4
Minor stroke
67
NIH stroke Severity scale, score 5-15
Moderate stroke
68
NIH stroke Severity scale, score 16-20
Moderate to severe stroke
69
NIH stroke Severity scale, score 21-42
Severe stroke
70
Administration of Alteplase
Administer 0.9 mg/kg IV (maximum 90 mg) IV as 10% of total dose by bolus, followed by remainder of total dose over 1 hour
71
After Administration of Alteplase, what do?
- Frequent cuff blood pressure monitoring
- No other antithrombotic treatment for 24 hours
- For decline in neurologic status or uncontrolled blood pressure, stop infusion, give cryoprecipitate, and reimage brain emergently
- Avoid urethral catheterization for 2 hours
72
What antiplatelet for ischemic stroke
aspirin!
73
Aspirin
1. Only antiplatelet proven effective for the acute treatment of ischemic stroke
- Other agents may be used for secondary prevention
2. Trials consistently prove aspirin to be safe and effective in acute ischemic stroke
- Modest improvements:
* In first few weeks out of 1000 patients, 9 deaths or nonfatal reoccurrence will be prevented
* At 6 months 13 out of 1000 saved
74
how much aspirin to prevent stroke
81 mg once a day
75
Antilipemics and stroke
The larger the reduction in LDL-C, the greater the reduction in stroke risk
- Get lipid panel
- If LDL > 120 --> start therapy
- **Statins
76
Antiplatelets (Plavix/Clopidogrel) and stroke
Along with aspirin; no advantage to combination
But…
For minor strokes or transient ischemic attacks, combination is safe and effective
77
Anticoagulants and stroke
Inconsistent results; aspirin continues to “win”
