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Emergency Medicine > Stroke, HA, HTN > Flashcards

Stroke, HA, HTN Flashcards

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1
Q

Stokre sxs

A
  • Symptoms vary – location dependent
  • Weakness/numbness face/limbs, one side
  • Confusion, difficulty speaking/understanding
  • Agitation, seizure
  • Vision changes – one/both eyes, visual field cut
  • Difficulty walking, ataxia, loss of coordination
  • Dizziness, vertigo, loss of balance
  • Atraumatic loss of consciousness (did they have a seizure? Did they faint? Did they have a stroke?)
  • Sudden, severe headache
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2
Q

VA changes associated with stroke

A

visual periphery changes

difficulty seeing out of one eye

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3
Q

Sudden, severe headache would be associated with what type of stroke

A

hemorrhagic

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4
Q

RF for stroke (11) starting with number 1

A
  • TIA or previous CVA (#1)
  • HTN
  • DM
  • Atrial Fibrillation
  • EtOH, IVDU, stimulants
  • Atherosclerosis
  • High cholesterol
  • Sickle Cell
  • Obesity/inactivity
  • Tobacco
  • Increasing age
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5
Q

hx that would contribute to RF

A 
•	Heredity
	     Family Hx of CVA
•	Ethnicity
	        African Americans
	          Hispanic Americans
•	Gender
	            Men > Women
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6
Q

women are at greater risk for

A

Women > for SAH

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7
Q

critical timing hx for stroke pt

A
  1. When did symptoms begin?
    Treatment is time dependent
    When were you/they last normal?
  2. Sudden or gradual onset?
  3. What are the symptoms, exactly?
  4. Symptoms persistent or transient?

5 are you on anticoagulants?

  1. PMHx, meds, risk factors

7 . Trauma? Syncope? N/V?

8 . Headache??

what are out CI for TPA

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8
Q

what % of strokes are ischemic

A
  1. ~85% of all strokes
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9
Q

gradual vessel occlusion is known as a

A
  1. Thrombotic

Atherosclerosis, gradual vessel occlusion

b. Sx onset may be gradual, stuttering
c. May have hx TIA

no blood distal

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10
Q

Sudden occlusion; sudden, fixed deficit

A

embolic stoke

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11
Q

who has embolic strokes

A

A fib, atrial clot, endocarditis (

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12
Q

pts with a thrombotic strokes may have has

A

TIA

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13
Q

Types of hemorrhagic CVA

A
  1. Intracerebral Hemorrhage
  2. Subarachnoid Hemorrhage

THESE ARE 15% OF ALL STROKES

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14
Q

evens that made lead to hemorrhagic stroke

A

a. HTN –> really uncontrolled
b. Cocaine, Meth, stimulants
c. Aneurysm bursts open
d. Arteriovenous Malformation (AVM)

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15
Q

Tx for hemorrhagic stroke

A

a. ABCDE’s
b. Control BP carefully
c. Neurosurgical consult
d. Multi-detector CT angiography
e. NIHS will be greater than 20

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16
Q

Left is dominant hemisphere in what pts

A

a. All right-handed

b. 80% left-handed

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17
Q

what % of people are right hemisphere dominant

A
  1. Right is dominant in 20% lefties
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18
Q

how to tell where a stroke is- two major possibilities

A
  1. Anterior circulation CVA

3. Posterior circulation CVA

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19
Q

Anterior circulation CVA comes off of and includes

A

CC

i. Anterior Cerebral Artery
ii. Middle Cerebral Artery

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20
Q

Posterior circulation CVA is where in origin and includes what

A

a. Vertebral artery origin

i. Posterior Cerebral Artery
ii. Vertebrobasilar stroke
iii. Cerebellar stroke

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21
Q

motor differences seen with

anterior Circulation CVA

A

: Contralateral weakness (If R sided symptoms, then your bleed is on the left)
• Leg, foot symptoms> arm symptoms

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22
Q

Sensory differences seen with

anterior Circulation CVA

A

Contralateral deficit

• Leg sx’s > arm sx’s

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23
Q

Loss of frontal lobe control seen with anterior cerebral artery

A
  • Personality change
  • Perseveration
  • Incontinence
  • Gait disturbances
  • Apraxia (you know you want to move the muscle but you cannot)

this is seen in anterior cerebral artery strokes

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24
Q

apraxia is

A

can’t perform tasks or follow commands even though they know the task and wish to follow the command. Several specific types

seen with loss of anterior cerebral artery

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25
Q

Most common area to get a stroke – bad if big/central

A

Middle Cerebral Artery

often in the corners of the middle cerebral artery

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26
Q

Motor deficits with middle cerebral CVA

A

Contralateral weakness
• Face/arms > legs
• Facial droop

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27
Q

sensory deficits with middle cerebral CVA

A

Contralateral deficit

• Arms > legs

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28
Q

if a pt has a CVA in the middle cerebral of dominant hemisphere

A

If affecting the dominant hemisphere: aphasia (either receptive or expressive

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29
Q

if a pt has a CVA in the middle cerebral of non dominant

A

Non-dominant: neglect (neglect that part of the body that is affected completely)

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30
Q

Middle Cerebral Artery see the eyes doing this

A

Eyes turned toward side of stroke –> common in MCA strokes that are large

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31
Q

Homonymous hemianopsia

A

seen with posterior circulation CVA AND middle cerebral

s hemianopic visual field loss on the same side of both eyes.

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32
Q

Posterior Circulation CVA is seen with

A

Visual disturbances

  1. Posterior Cerebral Artery
  2. Occipital cortex affected

(cortical blindness)
• Homonymous hemianopsia

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33
Q

cortical blindness

A

** (normally functioning pupils and normal eye reflexes but they can’t see. Visual loss can be profound)

seen with posterior circulation

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34
Q

what type of motor findings do we see with posterior circulation CVA

A
  1. Ipsilateral CN 3 palsy

5. Minimal motor findings

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35
Q

Vertebrobasilar CVA seen with

A
  • IPSIlateral eye, cranial nerve defects
  • CONTRAalateral motor defects
  • Vertigo/ataxia, nausea/vomiting
  • Tinnitus/deafness, nystagmus
  • LOC or ALOC, coma
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36
Q

central vertigo think

A

vertebral basilar issue

diplopia with CNIII palsy is experienced with both horizontal and vertical eye movement

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37
Q

“Locked-in” syndrome associated with CVA in what artery

A

Basilar artery/Pontine

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38
Q

Basilar artery/Pontine sxs

A
  • “Locked-in” syndrome
  • Extensive motor deficit (you do not move, you are awake)
  • Consciousness, eye movements spared
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39
Q

Cerebellar strokes classically seen with these sxs

A
  • Central vertigo, vertical nystagmus
  • Cranial nerve deficits
  • Abnormal finger->nose, RRAM, etc
  • Ataxia
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40
Q

Small vessels that perforate the deep, subcortical areas

A

Lacunar Infarcts

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41
Q

Lacunar Infarcts RF

A

HTN, DM = 2 big risks

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42
Q

sxs of lacunar infarct

A

Pure” motor or sensory sx’s

4. “Clumsy hand” syndrome

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43
Q

tx of lacunar strokes

A

Usually don’t require treatment unless there are persistent symptoms

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44
Q

difference between a TIA and lacunar stroke

A

location

lacunar is deep

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45
Q

NIHSS when is a initial score good

A

a. Initial score <15 better

46
Q

NIHH when is a score not so good

A

b. Initial score >20 not so good

location
prognosis
severeity

47
Q

ED work up of a stroke need a

A

Recognition first, ABCDE’s, D-stick (glucose)

48
Q

D-stick

A

dextrose stick

or

POC glucose

49
Q

what tests do you need to order for a suspected stroke

A

FIRST- D-stick

IV
EKG
monitor
O2
basic labs (CBC -need to know platelets)ƒ
PT/INR
troponin (high risk of stroke also puts you at a high risk of CV event as well), 
utox
upreg

THEN CT of the brain NON-contrast

50
Q

if you have a negative CT for blood and the sxs are significant

A

CTA of brain and neck

51
Q

if you have an ischemic event on CT it will look like ….

what do you do

A

a. Ischemic? No gross blood, +/- edema?

i. Call Neurology/Stroke Team

52
Q

if you have a hemorrhagic stroke on CT it will look like

A

b. Hemorrhagic? Gross blood on CT?

i. Call Neurosurgery

53
Q

the Penumbra is…

A

the area that is affected past the blockage)!

54
Q

how do you preserve the Penumbra

A

don’t let the BP drop!

ASA (not in hemorrhagic!)

thrombolytics

thrombectomy

55
Q

BP control for ischemic ot

A

Avoid acute drop in BP. Raise BP if very low to perfuse

b. -Tx BP if >220/120, MAP goal
c. -Labetolol, Nicardipine - easy to titrate IV
d. -Goal: situation/tPA or not/end-organ issues

56
Q

ASA use in ischemic stroke

A

a. -To prevent recurrent event

b. –OK to give before thrombolytics

57
Q
  1. Thrombolytics help with this in ischemic stroke
A

Maximize flow to penumbra

b. -Save brain tissue
c. -BP must be <185/110 for tPA

58
Q

TPA needs to be given

A

3-4.5 hours

  • May improve outcome
  • Hemorrhage risk
  • FUNCTION not life-saving
59
Q

goal for ischemic pt

A

door to TPA <60

stroke center <30 min

60
Q

who benefits from tPA

A
  • Any adult over 18
  • ANTERIOR circulation stroke does better
  • Moderate neuro deficit
  • Known time of onset
  • CT: no hemorrhage
61
Q

CI for tPA (8)

A
  • ANY blood on CT, SAH
  • Seizure at onset
  • Hx hemorrhagic CVA
  • Known tumor, AVN
  • Very minor strokes

• Recent trauma, LP, arterial puncture*,
surgery, GI bleed

• Can’t control BP

• On coumadin*, recent heparin, <1k
platelets

62
Q

Sudden onset ischemic stroke after trauma, neck manipulation, minor trauma

A

Carotid Dissection

Spontaneous: family hx, genetic, CAD

63
Q

Carotid Dissection presentation

A

HA, neck/face pain, partial Horner’s Syndrome (ptosis, miosis, anhydrosis), Cranial Nerve abnormalities

64
Q

dx tests for carotid dissection

A

Diagnosis: CT angio of neck, MRI

65
Q

we typically see carotid dissection in

A

Young w/ CVA or CN issues

66
Q

Sickle cell risk

A

> 20% of patients with sickle cell disease have ischemic CVA’s by the age of 45

Most common cause of stroke in children

c. Think about ICB/SAH too

67
Q

tx of hemorrhagic CVA

A

ABCDE
control BP

nerusurgical consult
multi-detector CT angiography/MRI

after initial ED dx

68
Q

Stroke mimics

A

i. Hypoglycemia – get a d-stick right away
ii. Seizure

iii. Complicated migraine (visual symptoms present)
iv. Sepsis

v. Toxic/metabolic/neurologic conditions
demyelinating conditions, Lyme’s, etc

vi. Brain tumor or spinal cord tumor/met
vii. Isolated cranial nerve abnormalities
viii. Functional (psych) disturbance

69
Q

how does seizure mimic a stroke

A

Prolonged post-ictal state, Todd’s paralysis

70
Q

Toxic/metabolic/neurologic conditions that would mmiic stroke

A
  1. OD, Wernicke’s, peripheral neuropathy,
71
Q

Isolated cranial nerve abnormalities that might mimic stroke

A

Bell’s Palsy, 6th nerve palsy

72
Q

TIA presentation

A

weakness and tingling in her left arm and leg that completely resolves

Stroke-like symptoms lasting < 24 hours and usually 1-2hrs which completely resolve

73
Q

TIA definition

A

Ischemia causing neuro deficit without infarct (official definition)

74
Q

TIA

A

Risk of CVA measured in 2, 7, 30, 90 days

Big risks, large vessel Dz, significant sx’s - all increase CVA risk

75
Q

ABCD2

A

helps predict risk of future stroke

  1. Age, BP, clinical features of TIA, duration, diabetes
  2. > or = 4: higher risk stroke in 2 days; higher score = greater risk
76
Q

anticoagulation for TIA

A

could be ASA

could be plavix

77
Q

work up of TIA

A
  • CT brain non-con first
  • Should be normal if TIA
  • O2, IV, monitor + d-stick
  • Labs, EKG, PT/INR, troponin
  • Aspirin (if no blood on CT)

Workup also includes:
ADMIT for
Duplex US of carotids to look for large
vessel dz

Echocardiography to look for clots in the atria

MRI brain

CTA or MRA of neck vessels

78
Q

when would you admit a TIA pt past the workup

A
  • TIA w/ mod/high ABCD2, high risk pt
  • “Stuttering” or “crescendo” TIA (symptoms throughout the day but it got better but then it came back again but worse this time)
79
Q

RF for headaches

A
  • “Worst”, “different”
  • Sudden onset- thunder!
  • New
  • Exertional (HA during sex is classic for SAH)
  • Fever-
  • Stiff neck
  • Vision loss/eye sx’s
  • ALOC
  • Focal deficit on exam
  • Trauma/fall
  • Coumadin
  • Etoh w/ HA fall down
  • Syncope
  • HIV, cancer
  • Sickle cell disease
  • Multiple patients from same location
80
Q

HA with fever

A

meningitides

81
Q

Multiple patients from same location with HA

A

carbon monoxide !

82
Q

what is the ddx of a HA

READ THIS

A
  • Subarachnoid Hemorrhage
  • Hemorrhagic CVA
  • Subdural/Epidural Hematoma
  • Meningitis
  • Idiopathic (Benign) Intracranial Hypertension (young women, obese, on OCP)
  • Hydrocephalus
  • Glaucoma –>increased IOP
  • Giant Cell (Temporal) Arteritis –>can lose your vision **
  • Cavernous Sinus Thrombosis –> facial or dental infxn that causes a thrombosis in the sinus which is right next to 3 CN’s (deadly)
  • Carbon Monoxide
  • Tumor, mets
  • Abscess, encephalitis
  • Etc…
83
Q

who gets a CT for a HA

A

i. Sudden, “worst HA”, especially if onset during exertion (SAH)
ii. HA plus fever, stiff neck (meningitis)
iii. HA plus vomiting and no hx same sx’s in past (SAH)
iv. HA plus neuro findings (CN, focal findings)
v. New HA after/with facial, sinus, dental infection (Cavernous sinus thrombosis)
vi. HA in young, obese female, +/-papilledema (Benign intracranial HTN)
vii. HA plus seizure or syncope
viii. HA plus trauma, fall or EtOH
ix. >50, new HA (likely not new migraine Dx after age 50)
x. New HA plus cancer, HIV (toxic causes), pregnancy, coumadin

84
Q

who needs a LP for a HA

A

i. Sudden, worst HA
ii. HA plus fever, stiff neck
iii. ALOC plus HA
iv. HA in young, obese female
v. New HA in HIV pt
vi. Looking for infection, blood, increased ICP

vii. CT generally precedes LP b/c looking for a shift. If there is a shift and you extract CSF, you can affect the pressure dynamics and the brain can herniate
viii. No LP if midline shift, blood or mass on CT

85
Q

important points on PE for HA

A

Mental status, temperature and blood pressure

Eye exam, including fundoscopy

Neuro exam: CN, strength, sensory, gait, cerebellar

Neck: Meningeal Signs

HEENT: periorbital/dental/facial infection? Older pt’s palpate the temporal artery!
Rash

After the Hx and PE cross the unlikely Dx’s off the list. Tx/test for most likely – be able to “tell the story” of each and why it is off or on your list

86
Q

labs for HA if no red flags

A

Upreg. Special: ESR, PT/INR

87
Q

TX for – migraine or non-specific HA

A
  • IV hydration – esp w/ vomiting
  • NSAID, anti-emetic, antihistamine IM/IV
  • NSAIDS: oral; IM/IV Ketorolac
  • Anti-emetics – Metoclopramide, Compazine or Phenergan IM/IV
  • Antihistamines – Benadryl IM/IV
88
Q

if the standard tx does not help for HA treat with

A
  • Steroids – Dexamethasone 8-10mg IM/IV
  • Serotonin blockers: DHE, triptans – migraine specific
  • Avoid narcotics!
  • Home if:
  • Pain less/gone
  • Can take po’s/walk
  • No new neuro deficit or change in VS
  • Give return precautions, should not drive self home
  • Rx oral NSAID, anti-emetic and/or triptan for your dx
89
Q

first steps in managing high BP

A

High? Check it yourself, both arms, correct sized cuff

BP readings change during visit

Tx pain, anxiety before tx high BP

90
Q

most important questions for pt with high BP

A
  1. Is this an accurate reading?
  2. How rapidly did it get this high?
  3. Does the patient have symptoms?**
  4. Is there evidence of end-organ damage?
91
Q

RF for HTN

A
  • Headache: sudden or severe or new
  • Neuro complaints: weakness, confusion, ataxia: CVA, encephalopathy
  • Visual changes: CVA, optic ischemia, papilledema
  • Chest pain: ACS; TAD – thoracic aortic dissection (pulses equal?)
  • SOB, DOE, edema: L/R pump failure: new CHF
  • Abdominal/Back pain: AAA
  • Urine changes – foamy (protein), blood? Think new renal failure
  • Syncope: CVA, SAH
  • Seizure: CVA, hemorrhage, Tox
  • On meds – still HTN – consider secondary causes
  • Pregnancy – preeclampsia, eclampsia
  • Hyperthyroid, Tox
  • End-organ damage usually involves kidney, heart, brain
92
Q

Neuro complaints w/ HTN

A

weakness, confusion, ataxia: CVA, encephalopathy

93
Q

EOD with HTN

A

kidney
heart
brain

94
Q

• Visual changes with hTN

A

CVA, optic ischemia, papilledema

95
Q

CP with HTN

A

ACS; TAD – thoracic aortic dissection (pulses equal?)

96
Q

• SOB, DOE, edema with HTN

A

L/R pump failure: new CHF

97
Q

• Abdominal/Back pain with HTN

A

AAA

98
Q

• Urine changes with HTN

A

– foamy (protein), blood? Think new renal failure

99
Q

• Syncope with HTN

A

CVA, SAH

100
Q

seizures with HTN

A

CVA, hemorrhage, Tox

• On meds – still HTN – consider secondary causes

101
Q

pregnancy with HTN

A

– preeclampsia, eclampsia

102
Q

iii. New HTN Testing

A 
\: CBC, 
CMP, 
UA,
 Upreg, 
Tox screen, 
EKG,
 CXR; 
Urine microalbumin
 TSH
 Lipids (as outpt?)
103
Q

poorly controlled HTN in ED

A
  1. Long-standing dx, no sx’s, appears well
  2. Out of meds common, no secure follow-up
  3. Testing as outpt if secure f/u
  4. Give meds in ED, refill meds
  5. BP must respond to tx
  6. Discharge home, educate
104
Q

New Dx of HTN – persistent readings >160/100 in ED

A
  1. No prior dx/tx but no sx’s, appears well
  2. Repeat BP after pain control
  3. Initiate work up, secure f/u
  4. Begin meds: if SBP >180, high risk for cardiac event w/in 1yr (usually amlodapine)
  5. Discharge home, educate
105
Q

DPB range fro HTN urgency

A

DPB 120-140mmHg or persistent systolic BP >180

  1. Usually “poorly controlled” HTN – not sudden
106
Q

HTN urgency with NO sxs of EOD

A

Order labs, UA, EKG, CXR (look for cardiomegaly, CHF, pleural effusions, widened mediastinum)

Oral tx in ED while waiting for labs/diagnostics (amlodipine)

  1. Home with Rx if BP responds and still NO signs/sx’s

Secure f/u

Educate

107
Q

HTN emergency (malignant)

A
  1. DBP >130 or persistent sys BP >180 w/ signs/sx’sHx HTN; rapid, acute elevation
108
Q

HTN emergency often seen with

A

flash pulmonary edema

109
Q

sxs with malignant HTN

A
  1. End-organ dysfunction is evident
    a. Symptoms: chest pain, SOB, ALOC, hematuria, proteinuria, abdominal pain,etc
    b. Lab/Diagnostics
110
Q

Tx of HTN emergency

A
  1. Reduce BP in the ED – goal is 25% reduction of MAP over 30-60min. (IV: Labetolol, Nicardipine, Nitrates)
  2. Tx end-organ damage
  3. Admit all
111
Q

first cardinal sx of a hemorrhagic stroke

A

headache and then LOC

112
Q

Todd’s paralysis

A

prolonged partial or complete paralysis, usually unilateral, after a generalized seizure. Can last up to 36-48hrs

Emergency Medicine (28 decks)

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