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Pharm > Stroke > Flashcards

Stroke Flashcards

1
Q

Pathophysiology

Ischemic Stroke

Types: cardioembolic vs non-cardioembolic?

A

Blood clots (thrombus) block blood flow to brain
Thrombus usually formed by cerebral atherosclerotic infarction

Cardioembolic: clot forms in heart and travels to brain
* Common cause: atrial fibrillation

Non-cardioembolic: clot forms in brain, not the heart

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2
Q

Acute treatments for Ischemic Stroke?

A
  1. Fibrinolytics
  2. Blood pressure control (if tPA not given)
  3. Other treatments (antiplts, HTN management, hyperglycemia, DVT ppx)
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3
Q

Acute treatments for Ischemic Stroke

Fibrinolytics

Medications and dosing?

A
  1. Alteplase 0.9 mg/kg (max: 90 mg); 10% given IVP over 1 min, then 90% given IV infusion over 1 hour
  2. TNKase 0.25 mg/kg (max: 25mg) IVP over 5 seconds; flush with NS
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4
Q

Acute treatments for Ischemic Stroke

Fibrinolytics

tPA exclusions

A

Not hemorrhagic stroke
No active bleed – in non-compressible areas
No INR >1.7
No prior stroke/TIA (within 3 months)
No prior head trauma (within 3 months)
No BP >185/110
No LMWH within 24h OR DOAC within 48h

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5
Q

Acute treatments for Ischemic Stroke

Fibrinolytics

tPA exclusion; BP control for BP >185/110

A

BP control (maintain BP <180/105)

*Labetalol 10-20 mg IV push over 1-2 minutes
*Nicardipine 5 mg/hr IV infusion
Clevidipine 1-2 mg/hr IV infusion

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6
Q

Acute treatments for Ischemic Stroke

Fibrinolytics

tPA inclusion

A

Within 4.5 hours from symptom onset
Within 60 minutes (door-to-needle)

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7
Q

Acute treatments for Ischemic Stroke

Blood pressure control

A

Permissive HTN: 220/120
MD will allow BP < 220/120 and hold/decrease meds up to 48 hrs after stroke

Rationale: increase BP, increase blood flow/perfusion

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8
Q

Acute treatments for Ischemic Stroke

Other treatments: antiplatelets

A
  1. Aspirin 160-325 mg AFTER 24 hours of tPA, but within 48 hours of stoke onset
  2. Clopidrogel 300-600 mg
  3. Short-term DAPT (ASA + Plavix) – indicated for patients with TIA or acute ischemic stroke who can swallow and do not have a known cardioembolic source of presentation
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9
Q

Acute treatments for Ischemic Stroke

Other treatments: Hypertension management

A

Goal: <185/110
Maintain <180/105

Medications: labetalol, nicardipine, clevidipine

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10
Q

Acute treatments for Ischemic Stroke

Other treatments: Hyperglycemia management

A

Goal: 140-180 mg/dL

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11
Q

Acute treatments for Ischemic Stroke

Other treatments: Deep Vein Thrombosis (DVT) prevention

A

Intermittent Pneumatic Compression (IPC) devices – squeeze legs to increase blood flow
Medications: UFH, LMWH (only after 24h of receiving alteplase)

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12
Q

Secondary Prevention (outpatient) for Ischemic Stroke?

A
  1. Hypertension
  2. Dylipidemia
  3. Afib management – for cardioembolic
  4. Antiplts – for non-cardioembolic
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13
Q

Secondary Prevention for Ischemic Stroke

Hypertension management

A

Goal: BP <130/80
ACEi and thiazide-type diuretics

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14
Q

Secondary Prevention for Ischemic Stroke

Dyslipidemia

A

Goal: LDL >70
High-intensity statins – Lipitor 40-80 mg, Crestor 20-40 mg

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15
Q

Secondary Prevention for Ischemic Stroke

Atrial fibrillation

for cardioembolic

A

Anticoagulants

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16
Q

Secondary Prevention for Ischemic Stroke

Antiplatelets

for non-cardioembolic

A
  1. Aspirin
  2. DAPT – aspirin + clopidogrel
  3. Aspirin/dipyridamole (Aggrenox)
  4. Cilostazol (Pletal)
17
Q

Pathophysiology

Hemorrhagic Stroke

A

Brain bleed due to ruptured blood vessel

Two types: (1) intracranial, (2) acute subarachnoid

Intracranial etiology: ↑ intracranial pressure (ICP)

18
Q

Management of Hemorrhagic Stroke

Reversal of Anticoagulants

UFH, LMWH, warfarin, anti-Xa , Pradaxa, argatroban (just antidote)

A

Heparin –> protamine
LMWH –> Andexxa, protamine
Warfarin –> vit K, Kcentra (w/ vit K), fresh frozen plasma (FFP), Novoseven RT
Apixaban, rivaroxaban –> Andexxa
Pradaxa –> Praxbind

19
Q

Management of Hemorrhagic Stroke

A
  1. reversal of anticoagulants
  2. IV fluids (+ elevate head 30 deg)
  3. anticonvulsants – only for seizure tx, NOT ppx
  4. Non-invasive cerebral angiogram
21
Q

Management of Hemorrhagic Stroke

Reversal of Anticoagulants

Protamine dose for UFH

A

1 mg of protamine for each ~100 units of heparin
* Since UFH has a very short half-life (1-2 hours), reverse the amount of heparin given in the last 2-2.5 hours

21
Q

Management of Hemorrhagic Stroke

Reversal of Anticoagulants

Protamine dose for LMWH (enoxaparin, dalteparin)

A

Enoxaparin
Within 8 hours: 1 mg protamine per 1 mg
> 8 hours ago: 0.5 mg protamine per 1 mg

Dalteparin
1 mg protamine for each 100 anti-Xa units

22
Q

Management of Hemorrhagic Stroke

Reversal of Anticoagulants

Andexxa doses (high and low) for LMWH

A

High dose: 800 mg IV bolus at 30 mg/minute over 30 minutes, followed by 960 mg IV infusion at 8 mg/minute for up to 120 minutes

Low dose:

23
Q

Management of Hemorrhagic Stroke

Reversal of Anticoagulants

Vitamin K indication and dose for warfarin

A

1-10 mg PO/IV

Avoid SQ and IM
IV must be SLOW IV infusion and diluted
* BBW: hypersensitivty, anaphylaxis, SE: hypotension

If no significant/major bleeding → PO
* INR >10 WITHOUT bleeding –> 2.5-5mg PO
If serious bleeding → IV infusion (NEVER PUSH) AND Kcentra
* Major, life-threatening bleed –> 5-10 mg SLOW IV injection

24
Q

Management of Hemorrhagic Stroke

Reversal of Anticoagulants

KCentra indication and dose for warfarin

A

Indication: severe bleeding
Factors 2, 7, 9, 10
ALWAYS administer with vitamin K

Dosing based on body weight and INR
Do not repeat dose

25
Q

Management of Hemorrhagic Stroke

Reversal of Anticoagulants

Andexxa for factor Xa inhibitors

A

IV bolus, followed by infusion

Dosing is specific to the Xa inhibitor, the dose and when the last Xa inhibitor dose was taken

26
Q

Management of Hemorrhagic Stroke

Reversal of Anticoagulants

Praxbind for Pradaxax

A

5 g IV
give (2) 2.5 g doses no more than 15 min apart

27
Q

Management of Hemorrhagic Stroke

IV Fluids

(and elevate head 30 degrees)

A

Rationale: ↓ ICP
Mannitol
Hypertonic saline (3% NS)

28
Q

Management of Hemorrhagic Stroke

Non-invasive cerebral angiography

A

computed tomography angiography (CTA)/magnetic resonance angiography (MRA) within 48 hours of onset should be considered for all patients

29
Q

Pathophysiology

Subarachnoid Hemorrhage (SAH)

A

cerebral aneurysm rupture → sx include severe headache

30
Q

Management of Subarachnoid Hemorrhage (SAH)?

A

Nimodipine 60 mg PO q4hr
* Rationale: prevent vasospasm (usually occurs 3-21 days after the bleed)
* DHP CCB that is more selective for cerebralk arteries due to increasewd lipophilicity –> only indicated for SAD
* BBW: NO IV, causes life-threatening adverse events (e.g. hypotension)
* If it cannot be swallowed, puncture and withdraw contents of the capsule with a parenteral/needle syringe –> transfer to oral syringe to be administed through a nasogastric tube

Pharm (7 decks)

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