US-Guided PIV Placement + Ischemic Stroke + Meningitis (oops)

Question 1

When is PIV placement indicated?

Answer 1

Administration of IV fluids and medications

Question 2

What are 5 examples when IV access might be difficult?

Answer 2

Obesity
IV drug abuse
Multiple previous IV catheters
Children
Hx of difficult IVs

Question 3

When should US guidance be used?

Answer 3

After 2 failed attempts, or immediately if hx of difficult IV access

Question 4

What are the two approaches to positioning the US transducer and how do they vary?

Answer 4

Transverse - easier to learn, allows simultaneous visualization of veins, arteries, and other structures
Longitudinal - preferred by experienced providers because it allows better visualization of the needle

Question 5

List potential cannulation sites.

Answer 5

Antecubital
Basilic (medial)
Cephalic (lateral)
Brachial

Question 6

Common size range for standard IV catheters? Length of a standard catheter?

Answer 6

24-gauge (newborns) to 14-gauge (adult trauma); 3.2 cm

Question 7

When are long IV catheters needed?

Answer 7

For veins that lie >1 cm from the surface of the skin

Question 8

Where does the brachial artery lie?

Answer 8

Usually just medial to the median cubital vein

Question 9

87% of strokes are caused by what etiology?

Answer 9

Ischemic; others caused by intracerebral or subarachnoid hemorrhage

Question 10

DDx - stroke

Answer 10

Structural brain lesion (Tumor, AVM, aneurysm, hemorrhage)
Infection (encephalitis, meningitis, cerebral abscess, septic emboli)
Seizure disorder and post-seizure neuro deficit (Todd’s paralysis)
Peripheral neuropathy (Bell’s palsy)
Complicated migraine
Hypoglycemia
Hypertensive encephalopathy
Middle ear pathology (Meniere’s disease or labryinthitis)
Drug toxicity (eg, phenytoin, lithium)
Demyelinating disease
Bell’s Palsy
Conversion disorder

Question 11

Initial actions and primary survey in stroke?

Answer 11

ABCs
Hypoxemia and hypotension due to stroke may worsen symptoms and lead to death
Focused H&P to assess level of dysfunction, exclude alternate diagnoses, and determine eligibility for therapy

Question 12

Important features of the history in suspected stroke?

Answer 12

Exact time of onset (“last known well”)
Detailed history of onset, time course, pattern of symptoms
Stroke risk factors + stroke mimic risk factors

Question 13

Stroke risk factors?

Answer 13

HTN
DM
HLD
Tobacco abuse
Advanced age
AFib
Prosthetic heart valve
Prior stroke

Question 14

Components of NIH Stroke Scale?

Answer 14

Level of consciousness 
Level of consciousness questions - age? month?
Level of consciousness commands - "close your eyes" "make a fist" 
Best gaze
Visual fields
Facial paresis
Best motor - L arm
Best motor - R arm
Best motor - L leg
Best motor - R leg
Limb ataxia
Sensory (pinprick)
Best language
Dysarthria
Neglect/inattention

0: Normal
1-4: Minor
5-15: Moderate
15-20: Moderately Severe
>20: Severe

Question 15

Presentation of stroke in ACA territory?

Answer 15

Unilateral weakness and/or sensory loss of contralateral lower extremity > upper extremity

Question 16

Presentation of stroke in MCA territory?

Answer 16

Unilateral weakness and/or sensory loss of contralateral face and upper extremity > lower extremity with either aphasia (dominant hemisphere) or neglect (non-dominant hemisphere)

Question 17

Presentation of stroke in PCA territory?

Answer 17

Unilateral visual field deficit in both eyes (homonymous hemianopsia)

Question 18

Presentation of vertebrobasilar syndromes?

Answer 18

Multiple deficits which typically include contralateral weakness and/or sensory loss in combination with ipsilateral CN palsies; suspicion for posterior circulation stroke is heightened if there is one of the following - diplopia, dysarthria, dysphagia, droopy face, dysequilibrium, dysmetria, and decreased level of consciousness
N/V

Question 19

Presentation of lacunar infarcts?

Answer 19

Large variety of clinical deficits, characterized by >70 different clinical syndromes; 5 common syndromes - pure motor hemiparesis, sensorimotor stroke, ataxic hemiparesis, pure sensory stroke, dysarthria-clumsy hand syndrome

Question 20

Guidelines for initial evaluation and treatment of acute stroke in the ED?

Answer 20

Door to physician: 10 minutes
Door to stroke team: 15 minutes
Door to lab work completed: 45 minutes (CBC, BMP, PT/PTT, UA, EKG, CXR)
Door to non-contrast CT-head ordered: 25 minutes
Door to CT interpretation; 45 minutes
Door to decision to give tPA: 45 minutes
Door to drug administration: 60 minutes (and less than 3 hours from onset)
Door to admission: 180 minutes

Question 21

What is the earliest finding that may be present on CT in an acute ischemic stroke?

Answer 21

Hyperdensity representing acute thrombus or embolus in a major intracranial vessel (most frequently seen in MCA and basilar arteries)

Question 22

Subsequent findings on CT in acute ischemic stroke?

Answer 22

Subtle hypoattenuation causing obscuration of the nuclei in the basal ganglia and loss of gray/white differentiation in the cortex

Frank hypodensity is indicative of completed stroke

Question 23

Inclusion criteria for IV rTPA in acute ischemic stroke?

Answer 23

Dx of ischemic stroke causing measurable neurologic deficits
Onset of symptoms <3 hours before beginning treatment
Age 18+

Question 24

Exclusion criteria for IV rTPA in acute ischemic stroke?

Answer 24

Significant head trauma or prior stroke in past 3 months
Symptoms suggesting SAH
Arterial puncture at non-compressible site in previous 7 days
History fo previous ICH
Intracranial neoplasm, AV malformation, or aneurysm
Recent intracranial or intraspinal surgery
Elevated BP (systolic >185 or diastolic >110)
Active internal bleeding
Acute bleeding diathesis including but not limited to:
-Platelets <100,000
-Heparin received within 48 hours resulting in aPTT > upper limit of normal
-Current use of anticoagulant with INR >1.7 or PT>1.5
-Current use of direct thrombin inhibitors or director factor 10a inhibitors
Blood glucose <50
CT demonstrates multilobar infarction (hypodensity >1/3 hemisphere)

Question 25

Relative exclusion criteria for IV rTPA in acute ischemic stroke?

Answer 25

Only minor or rapidly improving stroke symptoms
Pregnancy
Seizure at onset with post-ictal residual neuro impairments
Major surgery or serious trauma within previous 14 days
Recent GI or urinary tract hemorrhage in previous 21 days
Recent acute MI in past 3 months

Question 26

Important aspects of care during and after administration of tPA?

Answer 26

Admission to ICU or stroke unit
Frequent reassessment of the patient’s neuro status
Careful BP monitoring
Emergent non-contrast head CT if development of acute severe headache, acute severe hyeprtension, intractable N/V, AMS, or other evidence of neuro deterioration

Question 27

Alternative therapies in stroke?

Answer 27

Select patients presenting to specialized stroke centers >4.5 hours after onset of symptoms may be eligible for intra-arterial thrombolytic therapy, mechanical thrombectomy, or intracranial angioplasty and stenting in the setting of a clinical trial

Question 28

Supportive care in stroke patients not receiving rTPA or other therapy?

Answer 28

Prevent or treat acute complications by providing supportive care, including ventilatory support and O2, prevention of hyperthermia, cardiac monitoring and treatment, and control of BP and blood glucose

Question 29

Goal BP in patients receiving rtPA?

Answer 29

<180/105

Question 30

For patients not receiving rTPA and who do not have other medical conditions requiring aggressive BP control, do not initiate anti-hypertensives unless BP exceeds ___.

Answer 30

220/120

Question 31

Antiplatelet therapy in acute ischemic stroke?

Answer 31

Administration of aspirin within 48 hours has been shown to improve outcomes by reducing the rate of early recurrent stroke

In those not receiving rtPA, oral administration within 24-48 hours of onset is recommended Do not administer for at least 24 hours in those receiving rTPA.

Question 32

When is meningitis classified as aseptic?

Answer 32

When the inflammation is due to drugs or non-bacterial causes

Question 33

Most common causes of aseptic meningitis? Other causes?

Answer 33

Enterovirus
Echovirus

Drugs, rheumatologic conditions, viruses, parasitic infections, fungal infections, malignancy, HIV, HSV, syphilis, Lyme disease, RMSF, Ehrlichiosis, autoimmune diseases

Question 34

Initial actions and primary survey in suspected meningitis?

Answer 34

ABC
If bacterial meningitis is likely, antibiotics should be given immediately after a prompt LP or soon after BCx are drawn if there is an anticipated delay in obtaining the LP
Antivirals if HSV encephalitis is suspected

Question 35

When should a CT scan be considered prior to an LP?

Answer 35

Altered mental status
New onset seizures
Immunocompromise
Focal neurologic signs
Papilledema

Question 36

CSF findings suggestive of bacterial meningitis?

Answer 36

Positive Gram stain with identified organism
Glucose <40 or ratio fo CSF/blood glucose <0.40
Protein >200/dL
WBC >1000/mL
>80% PMNs
Elevated opening pressure of CSF (obtained with patient in lateral decubitus position)

Question 37

CSF findings suggestive of encephalitis?

Answer 37

Increased WBCs with a lymphocytic predominance

May reveal increased RBCs due to neuronal cell death leading to edema, hemorrhage, and necrosis

Question 38

Empiric therapy in suspected meningitis (neonate <1 month)

Answer 38

Ampicillin and cefotaxime

Alternative - ampicillin and gentamicin

Question 39

Empiric therapy in suspected meningitis (infants 1-3 months)

Answer 39

Ampicillin and cefotaxime

Question 40

Empiric therapy in suspected meningitis (children >3 months + adults <50 years)

Answer 40

Dexamethasone Q6hrs for 4 days
(consider before 1st dose ABX)
and cefotaxime (or ceftriaxone) and vancomycin

Question 41

Empiric therapy in suspected meningitis (adults >50 years)

Answer 41

Dexamethasone Q6hrs for 4 days
(consider before 1st dose ABX)
and cefotaxime (or ceftriaxone) and vancomycin and ampicillin