Stroke Simulation Flashcards
Modifiable stroke risk factors?
HTN Smoking DM AFib Poor diet/sedentary lifestyle Obesity PAD Heart disease Drug and alcohol abuse
Interventions to address stroke risk factors?
Lifestyle modifications (diet exercise, smoking cessation, etc.)
BP management
Anti-thrombotic therapy
Statins
Possible stroke interventions by subtype?
Ischemic - IV tPA if candidate, endovascular therapy
Hemorrhagic - hemostasis
Steps in patients presenting with stroke-like symptoms:
- ABCs
- CC and HPI, time last known well (assess tPA treatment window),
- Monitor, vitals and glucose, PIV x2, labs (BMP, CBC, PT/INT, PTT (consider T&S, ETOh, tox screen, troponin I, lipid panel, A1C, LFTs, pregnancy test)), patient’s weight, EKG (do not delay CT for labs/EKG)
- Neurologic assessment (NIHSS, FAST), call code stroke/stroke kit
- Ensure patient is stable - STAT Non-contrast head CT
- Determine IV tPA eligibility
Stroke mimics?
Hypoglycemia Psychogenic Seizures (w/ post-ictal paralysis) CNS infections Brain tumors Drug toxicity Demyelinating disorders Complicated migraine HTNive encephalopathy (HA, delirium, seizure)
NINDS treatment windows?
Door to expertise <10 minutes
Door to CT initiation <25 minutes
Door to CT interpretation <45 minutes
Door to needle time <60 minutes
Indications to treat BP in patients presenting with extreme HTN and IV tPA candidates?
Extreme - SBP >220, DBP >120
IV tPA candidates - SBP >185, DBP>110
Rx BP in IV tPA candidates?
Labetalol 10-20 mg IV over 1-2 minutes, may repeat 1x
OR
Nicardipine 5 mg/hr IV, titrate up by 2.5 mg, give every 5-15 minutes to max dose of 15 mg/hr
Once IV tPA has been given, what should be done?
Monitor VS/neuro assessment: -Q15 minutes for first 2 hours -Q30 minutes for next 6 hours -Q1 hour for 6-24 hours Asseess signs and symptoms of bleeding Maintain SBP <180 and DBP<105
Time window for IV tPA?
Ischemic stroke from 0 to 3-4.5 hours of time last known well
Contraindications to tPA use?
CT with evidence of hemorrhage, hypodensity >1/3 hemisphere
BP >185/110
Glucose <50
History of ICH, stroke, or major head trauma within 3 months
Seizure at onset (unless thought to be due to stroke)
Noncompressible puncture of artery or organ <7 days
INR>1.7
Recent heparin with increased PTT
Platelet count <100,000
Contraindications to using tPA from 3-4.5 hours?
Age >80
Any warfarin use
NIHSS >25
Previous stroke AND diabetes
Relative contraindications to tPA use?
Recent surgery or major trauma <14 days Pregnancy GI or urinary tract hemorrhage <21 days MI <3 months Rapidly improving or minor neuro deficits likely to result in iminimal or no deficit
tPA dose?
0.9 mg/kg (max dose 90 mg)
Usually reconstituted 100 mg/100 mL
Dose must be independently verified by licensed provider
Administer 10% of total dose as bolus over 1 minute
Infuse remaining dose over 60 minutes
Call pharmacy for dosing support
Management of warfarin-associated ICH?
If on warfarin with elevated INR
Give Vitamin K (phytonadione) 5-10 mg IV (over 20-60 minutes not to exceed >1 mg/min)
KCentra (IV prothrombin complex concentrate)
Consider 2-4 units FFP
