Tpa Flashcards
When something is still in a research phase you call it
In the pipe line
Not for prime time
Explain reperfusion injury concept
If you restore blood flow to an infarct brain you are exposing a very vulnerable area of the brain to cytokines and free radical and neurotoxins
Example of a method to reduce metabolic activity in acute stroke
Hypothermia
If you can’t follow up a tpa w MRI what can you do
Get in ct in 2 days
How many patients do you have to treat w tpa to see an effect.
13
What do you see in the original studies with tpa efficacy
30% better in 3 months
What is the time exclusion criteria for sx, stroke etc
7 days - art line
14 days - peed and poop
21 days gi and
3 mo mi heal stoke
If you have patient with mi and stroke
Cardio consult
If pt present with Todd’s paralysis or seizure
CTA, if you suspect seizure r o stroke
What on ct excludes stroke
Nothing subtle
When is consent required
When it is outside of std of care
If standard of care the excuse me bitched
Abbreviation for tpa
Rt pa
How do you mix tpa
1 to 1 with saline
Administer tpa ptotocol
10 percent over 2 min
90 over 1 hr
What is the dose of myocardial dose
1.1% mg kg
Want it lower bc an ischemic brain is more likely to bleed than a cardia dose with a normal brain
How often do you check vitals
During tpa - 15
After tpa 30 for lucky seven
Than ever 1 hr for sexy sixteen
After tpa what should bp be
160 to 180
80 to 100
What makes you stop tpa and get ct
HA
N/v
If you get a stat ct and it’s negative.
Restart drug
Treat headache
3 things to look for after tpa 6
Vitals Any pain head ache N v New weakness Angio edema
Why is sICH the most feared complication of tpa
45 percent death rate.
Treatment of ICH bleed
6 units of cryo
6 units of platelets
How often is angio edema associated with tpa
Up to 5 percent
Who gets angio edema w tpa
Ace
Frontal
Insular
Tell me about the study that supports 4.5 hr mark 5
Ecass 2008 hacke Small effect size N 400 Double blind
When did 4.5 get approved
2008
What were the three exclusion criterion for ecass
80
25
Hx of diabetes
What did they show as an effect size w tpa at 4.5
Absolute increase by 7 % 52 vs 45
What is number needed to treat w at 4.5
14 for 4.5
8 for disability
3 for any benefit
Hoe man get tpa nationally
2 to 8.5
Treatment for angio edema
Stop tpa
50 mg Benadryl
50 mg ranitidine
Refractory: resort solumedrol 100 mg
Last ditch epinephrine nebulizer
And stat ent cricotony
How big is the effect size of tpa at 4.5
Midwest 7 percent but significant
When do we give anti platelets with stroke
24 to 48
By 1percent in 2 weeks
How big was the effect size of Asa after tpa
1 percent in two weeks
Has Asa show efficacy with treating stroke
No. Only secondary prevention
What is the leading cause of disability in the us
Stroke cdc2005
Proven ways to help rehab post stroke
Inpt rehab Early rehab Long term language pathologist Improve attention Treat depression And emotion liability
What do you ask stroke pt durin follow up
Compliance Rehab Anxiety Snoring Sad
How long do you need to wait before you put foley into a tpa pt
1 hr
Define a Lazarus effect
14 point improvement
In 24 hr
How often does the Lazarus effect occur
20 in tpa 3 percent in control
The most important factor in treating stroke is
90 min (Marley 2000)
Why do thrombotics work.
They will recanalize the blood vessel
What type of clots are unlikely dissolved by tpa
Distal internal
Proximal mca
Saqqur 2007
What are three ways to protect stroke patients - neuroprotective
Hypothermia- (2002 Bernard et al)
Magnesium ( saver 2004)
High flow (singhal 2007)
Factor associated with tpa failure 5
Clot is too big- clo burden Clot is not blood - calcium dissection Clot is at a dead end Clot had a lot of platelets Clot is very organized and fibrotic)
What is the name of the thrombo lytic made from vampire bats
Des mot e plase
What thrombo lytic has long half life
Ret e plase
What are some ways to improve tpa performance
Ultrasound enhancement
How large was the effect size with tpa
12 percent more patient recovery
Coolest new approach to enhancing tpa
Nano bubbles/tpa/ultrasound
What is the problem with the intra arterial study
6 hr
Proactive Ii
Used prokinase
When is intraarterial thrombolitic
Large vessel ica or mca
What are the three types of Cather based devices
Endo vascular - suction
Mechanical disruption- stent or laser
Augmentum fibrolytics - ultrasound on catheter
First clot retriever FDA approved
Merci 2005
What is the tecanulization rate w stenting
80 perc
What is the hemorrhage rate with merci
5percent
SAH from puncturing wall
What is newest clot extractor
Penumbra system 100. Recanulized
Base 2008
How does the penumbra system work
Suction/aspiration
Ring if suction fail
Catheter
What kinD of clots do tpa dissolve
Love hanging fruit
What is the rational for doing both tpa and catheter system
Tpa dissolves the low hanging fruit clearing the way for extractor
How do you increase collateral blood flow
Increase bp
Best way to increase blood pressure
Phenyl ephrine alpha 1 ag
No effect on pulse
Side effects of phenyl ephephrine
Ischemic bowel
Digital necrosis in poorly hydrated
How long do you wait after spinal surgery?
90 days or three month
So for CNS sx who gets stroke how long do you wait until tpa
3 months
Dose of tpa for ais
0.9 mg kg x kg. —— total
Give ten percent over 2 min
Give other over 60 min
MI dose of tpa
Max is 100 mg
15 mg over 2 min
.75 x. Mg/kg max 50 over 30
0.5 mg/kg max 35 over 60
How many stroke survivors
7 million
What percentage of stroke survivors go to extended care center
26 percent
What percent of stroke or can walk after stroke
30 percent without walker
What percent of stroke are aphasia
19 perc
Cost of stroke in us 2010
74 billion
People with controlled bp have —- the risk of stroke 120/80
Half the life time risk
Smoker increases stroke risk by
2 to 4
Afib increases likely hood of stroke by
5 fold
How does pregnant affect stroke
Increases by 2.4 fold
What perc of stroke survivors get another stroke in future
23 percent
Who is more likely to have stroke men or women
Woman 45 to 54
Does estrogen increase stroke risk
Yes by 44 percent
Does family history of a stroke under 65 increase my risk of stroke
Yes by 300
What percent of strokes are hemorrhagic
13 hemorrhagic
3 SAH
10 intracerebral
What percent of stroke is ischemic
87 percent
Does a stroke age the brain
Yes by 4 each hour
1.9 million per min
Area of infarct caused
Infarct
What the name of tissue surrounding infarct
Penumbra
If you wait 3 hrs before you treat stoke how does the brain change?
360 million neurons die - brain does a 360
What does occipital detect
Color discrimination
And motion- blink to threat
Best distinguishing feature with mca stroke
Loc
Left gaze preference
Posterior stroke signs
Cross findings
Ipsilateral cn
Contralateral motor
Mortality rate of posterior stroke is
85 percent