Successfully reported this slideshow.
We use your LinkedIn profile and activity data to personalize ads and to show you more relevant ads. You can change your ad preferences anytime.

Stroke emergency treatment

4,218 views

Published on

  • Be the first to comment

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

×