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Stroke emergency treatment


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Stroke emergency treatment

  1. 1. Emergency Treatment of Stroke
  2. 2. Normal Brain Physiology 2-3% of body weight 15% of cardiac output 20% of all O2 25% of all glucose
  3. 3. Cerebral Ischaemia - Threshold Normal flow, normal function Synaptic transmission failure Membrane pump failure 20 50 10 0 Time in hours CBF (ml/100g brain) Low flow, raised O2 extraction, normal function 1 2 3 4 5
  4. 4. Cerebral infarct <3hrs Onset Infarct Ischaemic penumbra
  5. 5. Cerebral infarct 6hrs Infarct Ischaemic penumbra
  6. 6. Cerebral infarct 24hrs Infarct Ischaemic penumbra
  7. 7. NA, Dopamine Ca2+ i  Ischaemic Brain Injury Ischaemia - 02  glucose  Anoxic depolarisation  lactate Glutamate Hi  Free Fe2+ Free radicals Lipolysis NO synthase Proteolysis
  8. 8. Cerebral Arterial territory Anterior cerebral Middle cerebral Posterior cerebral Anterior choroidal
  9. 9. <ul><li>ANY ONE OF THESE:- </li></ul><ul><li>Two out of three as TACI </li></ul><ul><ul><li>Higher Dysfunction </li></ul></ul><ul><ul><li>Dysphasia </li></ul></ul><ul><ul><li>Visuospatial </li></ul></ul><ul><ul><li>Homonymous Hemianopia </li></ul></ul><ul><ul><li>Motor / Sensory Deficit </li></ul></ul><ul><ul><li>>2/3 Face / Arm / Leg </li></ul></ul><ul><li>Higher Dysfunction Alone </li></ul><ul><li>Limited Motor / Sensory Deficit </li></ul>Partial Ant. Cir. Syndrome (PACS)
  10. 10. <ul><li>ALL OF THESE:- </li></ul><ul><li>Higher Dysfunction </li></ul><ul><ul><li>Dysphasia </li></ul></ul><ul><ul><li>Visuospatial </li></ul></ul><ul><li>Homonymous Hemianopia </li></ul><ul><li>Motor / Sensory Deficit </li></ul><ul><ul><li>>2/3 Face / Arm / Leg </li></ul></ul>Total Ant. Cir. Syndrome
  11. 11. Lacunar syndromes (LACS) <ul><li>ANY ONE OF THESE:- </li></ul><ul><li>Pure Motor Stroke (>2/3 Face/Arm/Leg) </li></ul><ul><li>Pure Sensory Stroke (>2/3 Face/Arm/Leg) </li></ul><ul><li>Sensorimotor Stroke (>2/3 Face/Arm/Leg) </li></ul><ul><li>Ataxic Hemiparesis </li></ul>
  12. 12. Lacunar Infarct Types <ul><li>MUST HAVE NONE OF THESE:- </li></ul><ul><li>New Dysphasia </li></ul><ul><li>New Visuospatial Problem </li></ul><ul><li>Proprioceptive Sensory Loss only </li></ul><ul><li>No Vertebrobasilar features </li></ul>
  13. 13. Posterior Cir. syndrome (POC) <ul><li>ANY OF THESE FEATURES </li></ul><ul><li>Cranial Nerve Palsy AND Contralateral Motor/Sensory Deficit </li></ul><ul><li>Bilateral Motor OR Sensory Deficit </li></ul><ul><li>Conjugate Eye Movement problems </li></ul><ul><li>Cerebellar Dysfunction WITHOUT Ipsilateral Long Tract Signs </li></ul><ul><li>Isolated Homonymous Hemianopia </li></ul>
  14. 14. Stroke types Al 35-44 yr Infarct 80% 42% Athero-thrombo-embolism 50% Intracranial small vessel 25% Cardioembolic 20% Rare 5% PICH 10% 10% SAH 5% 38% Unknown 5% 10% 75%
  15. 15. Pre Hospital Care <ul><li>1. Early recognition of Stroke warning signal by patient </li></ul><ul><li>2. Call ED if a person has symptoms of acute stroke. </li></ul><ul><li>3. Emergency transport and care </li></ul>
  16. 16. ED immediate care of Stroke <ul><li>1. Check Vitals, general assessment </li></ul><ul><li>2. Stabilize: Respiration, circulation </li></ul><ul><li>3. Control Seizure </li></ul><ul><li>4. Reduce intracranial tension </li></ul><ul><li>5. Maintain blood sugar </li></ul><ul><li>6. Maintain temperature </li></ul>
  17. 17. Emergency tests <ul><li>Complete blood count, PCV, TRBC, platelet, smear for MP, </li></ul><ul><li>Blood sugar, blood urea, serum creatinine, serum electrolyte, </li></ul><ul><li>Blood gas, </li></ul><ul><li>SGOT, SGPT, </li></ul><ul><li>PT, PTT </li></ul><ul><li>HIV, Hepatitis profile </li></ul><ul><li>ECG / X-ray / CBC / </li></ul>
  18. 18. Stroke Emergency Imaging <ul><li>CT / CTA </li></ul><ul><li>MRI / MRA/ / PI/ DI </li></ul><ul><li>Echocardiography </li></ul><ul><li>Carotid doppler, </li></ul><ul><li>Transcranial doppler </li></ul><ul><li>Cerebral Angiography </li></ul><ul><li>SPECT </li></ul>
  19. 19. MRA & MRI in Stroke
  20. 20. When TIA is an emergency? <ul><li>High risk TIA,S </li></ul><ul><ul><li>1. A high grade vascular stenosis </li></ul></ul><ul><ul><li>2. An antiplatelet failure </li></ul></ul><ul><ul><li>3. A cardioembolic </li></ul></ul><ul><ul><li>4. Crescendo TIA. </li></ul></ul><ul><ul><li>Heparin-> warfarin if a long term anticoagulation is required </li></ul></ul><ul><ul><li>Aspirin if anticoagulant contraindicated </li></ul></ul>
  21. 21. Carotid endarterectomy in TIA’s <ul><li>High grade ipsilateral carotid stenosis with TIA has high risk (30%) of stroke within first week </li></ul><ul><li>CE reduces mortality in such cases </li></ul>
  22. 22. “ Patients who have improved neurologically but have a persistent neurologic deficit when seen, should be managed as a recent stroke ”
  23. 23. Aspirin in Acute Stroke <ul><li>“ In acute stroke aspirin is the only proven antiplatelet agent. It should be commenced as soon as the diagnosis of cerebral infarction has been made, using a starting dose of 150-300mg a day and continuing until decisions have been made about secondary prevention” </li></ul>
  24. 24. Anticoagulant in Acute Stroke <ul><li>Not shown to prevent progression </li></ul><ul><li>LMH long term improved </li></ul><ul><li>Hemorrhagic transformation is high </li></ul><ul><li>Cardioembolic infarct </li></ul><ul><ul><li>Immediate for small infarct </li></ul></ul><ul><ul><li>Delayed for large infarct </li></ul></ul><ul><li>Heparin - 1000 units/hr. PTT 1.5 </li></ul><ul><li>Heparinoid - 2500 to 3200 units SC BD </li></ul>
  25. 25. rTPA Inclusion criteria <ul><li>Clinical evidence for an ischemic stroke </li></ul><ul><li>Age >18 years </li></ul><ul><li>Signed consent, if possible </li></ul><ul><li>Onset of stroke within 3 hours of initiation of therapy* </li></ul><ul><li>Normal PT and PTT </li></ul><ul><ul><li>If a patient has stroke on awakening from sleep or if the onset of symptoms is not known, then stroke onset is determined from time patient was last seen as &quot;normal&quot; (eg, when he or she went to bed). </li></ul></ul>
  26. 26. rTPA exclusion criteria <ul><li>Historical </li></ul><ul><ul><li>Stroke or serious head trauma in past 3 months </li></ul></ul><ul><ul><li>Major surgery or invasive procedure within past 14 days </li></ul></ul><ul><ul><li>GI or urinary bleeding within past 21 days </li></ul></ul><ul><ul><li>Puncture of noncompressible artery or biopsy of internal organ within past 7 days </li></ul></ul><ul><ul><li>Ongoing alcohol or drug abuse </li></ul></ul><ul><ul><li>Seizure preceding or during stroke </li></ul></ul>
  27. 27. rTPA exclusion criteria <ul><ul><li>History of intracranial hemorrhage (including subarachnoid bleeds) or known history of cerebral vascular malformations </li></ul></ul><ul><ul><li>(including aneurysms or arteriovenous malformations) </li></ul></ul><ul><ul><li>Pericarditis, endocarditis, septic emboli, recent pregnancy, or active inflammatory bowel disease </li></ul></ul>
  28. 28. rTPA exclusion criteria <ul><li>Clinical, radiologic, or laboratory </li></ul><ul><ul><li>SBP >185 mm Hg or DBP >110 mm Hg after repeated measurements </li></ul></ul><ul><ul><li>Rapidly improving or minor symptoms </li></ul></ul><ul><ul><li>Coma or stupor </li></ul></ul><ul><ul><li>CT of brain indicative of tumor, blood, or early signs of cerebral edema </li></ul></ul><ul><ul><li>Elevated PT and/or PTT </li></ul></ul><ul><ul><li>Serum glucose <50 mg/dl or >400 mg/dL </li></ul></ul><ul><ul><li>Platelet count <100,000/mm 3 </li></ul></ul>
  29. 29. rTPA Protocol <ul><li>Obtain and review stat CT scan of the brain. </li></ul><ul><li>Establish peripheral IV access (two separate sites). </li></ul><ul><li>Obtain CBC, chemistry panel, PT & PTT, type and screen, and urinalysis. </li></ul><ul><li>Review inclusion and exclusion criteria </li></ul><ul><li>Determine patient's weight. </li></ul>
  30. 30. IV rTPA for Acute Ischaemic Stroke <ul><li>Administer TPA, 0.9 mg/kg (maximum, 90 mg) as a 10% bolus over 1 to 2 minutes, followed by the remaining 90% as a 1-hour infusion </li></ul><ul><li>Monitor for bleeding and neurologic deterioration. </li></ul><ul><li>Admit to ICU for 24 hours. </li></ul><ul><li>Monitor BP </li></ul><ul><li>Do not give antiplatelet or anticoagulant therapies for 24 hours. </li></ul><ul><li>Do not perform arterial punctures, invasive procedures, or IM injections for 24 hours. </li></ul><ul><li>Obtain CT scan of brain 24 hours postinfusion or sooner if neurologic deterioration occurs . </li></ul>
  31. 31. BP Control during thrombolysis <ul><li>Monitor BP every 15 minutes for 2 hours after start of infusion </li></ul><ul><li>Then every 30 minutes for 6 hours </li></ul><ul><li>Then every hour, from the 8th hour until 24 hours after the start of TPA </li></ul><ul><li>Then per routine </li></ul><ul><li>If after two readings 5-10 minutes apart: </li></ul><ul><li>SBP = 180-230 mm Hg or DBP = 105-120 mm Hg </li></ul><ul><li>Give labetalol 10 mg IV over 1-2 minutes. May repeat or double the dose every 10 minutes, up to maximum of 150 mg or iv infusion. </li></ul>
  32. 32. BP Control during thrombolysis <ul><li>SBP >230 mm Hg or DBP = 121-140 mm Hg </li></ul><ul><li>Give labetalol 10-20 mg IV over 1-2 minutes. May repeat or double the dose every 10 minutes, up to maximum of 150 mg or infusion. . </li></ul><ul><li>If response is inadequate, start sodium nitroprusside </li></ul><ul><li>DBP >140 mm Hg </li></ul><ul><li>Give sodium nitroprusside 0.5-10 µg/kg/minute </li></ul>
  33. 33. Emergency CE in acute Stroke <ul><li>1. Stroke in evolution with a minimal fixed neurologic deficit, </li></ul><ul><li>2. A moderately severe neurologic deficit of abrupt onset when the surgery can be completed within the first 3 hours after the onset of deficit, and </li></ul><ul><li>3. CT scan without evidence of hemorrhagic transformation of an infarct or edema. </li></ul>
  34. 34. “ Role of Neuro-protection in Stroke is not clear and not recommended routinely”
  35. 35. Subarachnoid hemorrhage <ul><li>Bed rest Analgesic </li></ul><ul><li>Blood pressure control </li></ul><ul><li>Oral nimodipine 60mg q6hx21 days </li></ul><ul><li>Angiography for localization of bleeding </li></ul><ul><li>If aneurysm </li></ul><ul><li>Immediate surgical clipping for </li></ul><ul><ul><li>Grade 1-3 patient without contraindication </li></ul></ul><ul><ul><li>Grade 4-5 with intracerebral clot and deterioration </li></ul></ul>
  36. 36. Primary Intracerebral hemorrhage <ul><li>Small (<3cm) hematoma has good prognosis </li></ul><ul><li>Large hematoma (>6cm) in comatose patient have poor prognosis. </li></ul><ul><li>Surgical evacuation for 3-6cm superficial lobar hematoma in a conscious patient </li></ul><ul><li>Cerebellar hematoma with deteriorating level of consciousness </li></ul><ul><li>Control of BP </li></ul>
  37. 37. Thank You