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
K-Centra dosing?
If INR 2 to <4: 25 IU/kg (max 2500)
If INR 4-6: 35 IU/kg (max 3500)
If INR >6: 50 IU/kg (max 5000)
Contraindications to KCentra?
Patient on/given recombinant activated factor seven (rFVIIa)
Patient Hx of HIT or DIC
ICH management
Reverse coagulopathy if present (obtain weight for dosing)
Admit to neuro ICU
Early BP lowering limits hematoma expansion but hasn’t been established to improve outcomes, optimal targets remain uncertain
Consider neurosurgery consult
Elevated BP, temperature, glucose, intracranial pressure, and seizure activity have been associated with poor outcomes
