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Pharm Quiz 3 > Stroke > Flashcards

Stroke Flashcards

1
Q

Anticoagulants Cause?

A

Bleeding

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2
Q

Hemostats (Coagulants) Cause?

A

Clot:

  • Facilitate the clotting cascade
  • Prevent fibrinolysis
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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

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4
Q

Types of Hemophilia

A
  1. ) Hemophilia A
    - Factor VIII
    - Classic
  2. ) Hemophilia B
    - Factor IX
    - Christmas Disease
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5
Q

What is used in COAGULOPATHIES?

A
  1. ) clotting factors

2. ) Cryoprecipitate (pure blood product)

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6
Q

What are the clotting factors for coagulopathies?

A
  1. Factor Eight Inhibitor Bypassing Activity:
    - Anti-Inhibitor Coagulant Complex
    - FEIBA™
  2. Recombinant Factor VIIa
    - NovoSeven™
    * Coagulopathies associated with liver disease
    * Major bleeds secondary to trauma, surgery
  3. Prothrombin complex concentrate (Kcentra™)
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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

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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

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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
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10
Q

ADR of Anti-Inhibitor Coagulant Complex

A

Thrombotic events

Allergy

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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
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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
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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

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14
Q

What INR value normally causes panic?

A

~ 6 - 8

with signs of bleeding (decreased Hematocrit, bruising, overt bleeding)

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15
Q

What INR value with Prothrombin complex concentrate (Kcentra™) causes panic?

A

4

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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

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17
Q

Indication for Recombinant Factor VIIa?

A

Hemophilia A and B

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18
Q

Unapproved Indication for Recombinant Factor VIIa?

A

Bleeding with trauma
Bleeding with surgery
Intracranial bleeding
Warfarin toxicity

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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
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20
Q

MOA of Tranexamic acid

A
  • Displaces plasminogen from fibrin
  • Inhibits fibrinolysis
  • Inhibits proteolytic activity of plasmin

Stops natural process

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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
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22
Q

ADR of Aminocaproic acid

A

Multiple but noted:

  • Intrarenal obstruction –> maintain clots, so get clots in urine
  • Skeletal muscle weakness
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23
Q

Aminocaproic acid approved indication

A

acute bleeding

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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)
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25
Q

Tranexamic acid unapproved indications

A

Perioperative bleeding in cardiac surgery and orthopedic surgery (spinal surgery)

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26
Q

MOA of Tranexamic acid

A

Hypersensitivity reactions

Seizures

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27
Q

Topical thrombin

A
  • Activates platelets and catalyzes the conversion of fibrinogen to fibrin
  • Restricted to one route! –> Powder, liquid, liquid spray
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28
Q

Cellulose (oxidized)

A
  • 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
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29
Q

Gelatin absorbable

A
  • Referred to as Gelfoam™
    and gel film
  • Lay over a weeping/oozing area –> allow RBC’s to lay on naturally and clot up
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30
Q

Ferric subsulfate

A
  • Referred to as Monsel’s Solution
  • for cervical biopsies
  • dark orange and topical
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31
Q

Fibrin sealant

A
  • Referred to as Tisseal™

- Combination of fibrinogen, fibrin and aprotinin

32
Q

Desmopressin

A
  • 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
Q

What to remember with Stroke? (Symptom wise)

A 
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
Q

Risk factors for Stroke

A
  • HTN
  • High Cholesterol
  • Diabetes
  • Tobacco
  • Unhealthy diet
  • Physical Inactivity
  • Obesity
35
Q

What is High risk factors on the stroke risk score card?

A 
BP > 140/90
A-Fib
Smoker
Cholesterol > 240
Diabetic
Couch Potato
Overweight
Stroke in family
36
Q

What is Caution factors on the stroke risk score card?

A

BP 120-139/80-89

Trying to quit Smoking
Cholesterol 200-239
Borderline Diabetic
Some Exercise
Slightly Overweight
37
Q

What is Low risk factors on the stroke risk score card?

A 
BP < 120/80
Regular Heartbeat
NonSmoker
Cholesterol < 200
Regular Exercise
Healthy weight
none in family
38
Q

What is High risk on the stroke risk score card?

A

Greater than or equal to 3

- in that column

39
Q

What is Caution on the stroke risk score card?

A

4-6

- in that column

40
Q

What is Low risk on the stroke risk score card?

A

6-8

- in that column

41
Q

2 types of strokes

A
  1. Hemorrhagic stroke
  2. Ischemic Stroke
  • symptoms generally the same, hard to differentiate
42
Q

What if Hemorrhagic stroke

- do first after established it is

A

Consider BP lowering

- But be careful with lowering too much, don’t drop down to normal BP, can’t profuse the brain well.

43
Q

Types of Hemorrhagic stroke

A
  • Intracerebral hemorrhage
  • Subarachnoid hemorrhage
  • Intracerebral aneurysm
  • Arteriovenous malformation (AVM)

High mortality

44
Q

Intracerebral hemorrhage

A

Spontaneous rupture of small vessels damaged by chronic hypertension

45
Q

Subarachnoid hemorrhage

A

Underlying cerebrovascular malformation in an otherwise normal patient

46
Q

Intracerebral aneurysm

A

Vessel rupture

47
Q

Arteriovenous malformation (AVMs)

A

Congenital vascular anomaly

- good to detect as a child

48
Q

What do you do for Intracerebral hemorrhage?

A

1.”ABC”
Airway, breathing, circulation

  1. 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
Q

What do you do for Subarachnoid hemorrhage?

A
  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
Q

What drug is used in Subarachnoid hemorrhage?

A

Nimodipine (Nimotop™, Nymalize™)

- Sole indication is treatment of subarachnoid hemorrhage

51
Q

What is Nimodipine

A

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
Q

Nimotop™ route

A

Capsule

  • take syringe and withdraw liquid to give orally
  • but some nurses accidentally injected it IV
53
Q

Nymalize™ route

A

Oral Liquid

$$$$$

54
Q

Nimodipine (Nimotop™, Nymalize™) ADR

A

Hypotension

Headache

55
Q

What causes Ischemic stroke?

End result?

A
  • From cerebral artery occlusion

- Cell death in 4-10 mins is end result

56
Q

What can interrupt the arachidonic acid production pathway

A

aspirin

57
Q

Primary goal for treating ischemic stroke

A

Prevent or reverse brain injury

  • ABCs (Airway, breathing, circulation)
  • Treat hyper- or hypoglycemia if identified
  • STAT emergency noncontrast head CT
58
Q

Treatment for Ischemic stroke

A 
Medical support
****IV thrombolysis
Endovascular techniques
****Antithrombotic treatments
Neuroprotection
Rehabilitation
59
Q

How fast should treatment be done in Ischemic stroke for success?

A

Everything must be done in 1 hour from presentation (Assessment, CT, treatments)

60
Q

IV THROMBOLYTIC in Treatment for Ischemic stroke?

A

Alteplase (Activase™)

  • clear benefit for alteplase in select patients with acute stroke
  • Central component of primary stroke center treatment
61
Q

Time frame Alteplase (Activase™) can be used?

A
  • Original: 3 hours from first sign

* ** now: 4.5 hours from 1st sign, if > 4.5 hours, then can’t do this treatment

62
Q

What needs to be proven in order for Alteplase to be used?

A
  1. Has an Indication
  2. Not Contraindicated
  3. Meets NIH stroke Severity scale
63
Q

Indications for Alteplase

A
  • Clinical diagnosis of stroke
  • Onset of symptoms to time of drug administration3 hours
  • CT scan showing no hemorrhage or edema of greater than 1/3 of the MCA territory
  • Age18 years
  • Consent by patient or surrogate
64
Q

Contraindications for Alteplase

A
  • Sustained BP > 185/110 despite treatment
  • Platelets < 100,000; HCT < 25%;glucose< 50 or > 400 mg/dL
  • Use ofheparinwithin 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
Q

NIH stroke Severity scale, score 0

A

No stroke symptoms

66
Q

NIH stroke Severity scale, score 1-4

A

Minor stroke

67
Q

NIH stroke Severity scale, score 5-15

A

Moderate stroke

68
Q

NIH stroke Severity scale, score 16-20

A

Moderate to severe stroke

69
Q

NIH stroke Severity scale, score 21-42

A

Severe stroke

70
Q

Administration of Alteplase

A

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
Q

After Administration of Alteplase, what do?

A
  • 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 for2 hours
72
Q

What antiplatelet for ischemic stroke

A

aspirin!

73
Q

Aspirin

A
  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
Q

how much aspirin to prevent stroke

A

81 mg once a day

75
Q

Antilipemics and stroke

A

The larger the reduction in LDL-C, the greater the reduction in stroke risk

  • Get lipid panel
  • If LDL > 120 –> start therapy
  • **Statins
76
Q

Antiplatelets (Plavix/Clopidogrel) and stroke

A

Along with aspirin; no advantage to combination

But…
For minor strokes or transient ischemic attacks, combination is safe and effective

77
Q

Anticoagulants and stroke

A

Inconsistent results; aspirin continues to “win”

Pharm Quiz 3 (4 decks)

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