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Morning Conference



Presented by Ext. Sorawit Boonyathee
         20 December 2012
Chief Complaint
•   ผู้ป่วยชาย อายุ 68 ปี
•   อ่อนแรงซีกซ้าย 2 ชั่วโมงก่อนมาโรงพยาบาล
•   Arrived at ER 14.30 น.
•   Vital Sign แรกรับ
    – Blood Pressure     127/77 mmHg
    – Pulse rate         84 /min
    – Respiratory rate   20 /min
    – Oxygen Sat         99 % (Room Air)
จาก CHIEF COMPLAINT และ VITAL SIGN แรกรับ
                TRIAGE ?
Triage
• Emergency

• เนื่องจากผู้ป่วยสงสัยภาวะ Stroke และ On set อยู่ในช่วงที่
  สามารถ Activated Fast track ได้
หลังจากนั้นจะต้องประเมินเบื้องต้นอย่างไร ?
Primary Survey
• Airway
   – Can talk, no stridor, dysarthria
• Breathing
   – Clear and equal breath sound both lungs, O2 sat 99%
• Circulation
   – BP 127/77 mmHg, PR 84 /min, no external bleeding
• Disability
   – E4V5M6, pupil 3 mm RTLBE
การวินิจฉัยแยกโรคและการส่งตรวจเบื้องต้น ?
Stroke ?
• Cincinnati Prehospital Stroke Scale (CPSS)
      “F A S T”
   – Facial Droop
   – Arm Drip
   – Speech Problems
   – Time

• Risk Assessment for Stroke
   – 1 problem = risk 72%     3 problems = 85%
Differential Diagnosis
• Stroke -> Ischemic or Hemorrhage
• Stroke mimic
   – Hypoglycemia or hyperglycemia -> DTX = 130 mg%
   – Syncope / Presyncope
   – Seizures and postictal state
   – Intracranial Mass (Space occupying lesion)
   – Functional hemiparesis (Psychiatric Disease/Syndrome)
   – Encephalopathy
   – Migraine
Laboratory Investigation for Stroke Fast Tract
• DTX
• CBC with platelet -> Decrease Platelet
• BUN, Cr, Electrolyte
    – High BUN (Uremic encephalopathy)
    – Hyponatremia
•   Coagulogram -> INR and PT Prolong ?
•   Electrocardiogram -> AF or Myocardial Infarction ?
•   Cardiac Enzyme
•   Chest x-ray
ข้อมูลประวัติผู้ป่วย
และการตรวจประเมินทางระบบประสาท ?
History Taking
• 2 hrPTA (12.30 น.) ขณะกาลังนั่งรับประทานอาหาร ผู้ป่วยมี
  อาการอ่อนแรงแขนขาซีกซ้าย ปากเบี้ยวด้านซ้าย มีอาการพูด
  ไม่ชัด
• ไม่มีอาการหน้ามืดหรือเป็นลม ไม่มีอาการชักเกร็งแขนขา
  รู้สึกตัวดีตลอดเวลา
• ไป รพช. (13.00 น.) ประเมิน Motor power Lt side = 0
• และ (13.30 น.) ประเมิน Motor power Lt side = III -> Refer
Physical Examination
• Vital Sign :
   – BP 127/77 mmHg, PR 84 /min, RR 20 /min, O2 Sat 99 % (RA)
• HEENT :
   – No pale conjunctivae, no icteric sclerae, no carotid bruit
• Heart :
   – Totally irregular, PMI at Lt 6th ICS MCL,
     PSM Grade III at LPSB + apex, DRM Grade II at Apex
• Lungs :
   – Clear and Equal Breath sound both lungs, no adventitious sound
Physical Examination (Cont.)
• Abdomen :
   – Soft, not tender
• Extremities :
   – No edema, no deformity, capillary refill < 2 sec
Physical Examination (Cont.)
• Neuro Exam:
  – E4V5M6, Pupil 3 mm RTLBE, Good Orientation
  – Motor power     V    III+
                     V     II+
  – Reflex 2+ all
  – Sensory Intact
  – Cranial Nerve -> Full EOM, Facial Weakness Lt UMNL,
    Dysarthria
National Institute of Health Stroke Scale (NIHSS)

•   1a. level of consciousness                   0
•   1b. Question (Age and month)                 0
•   1c. Commands (Open/closed eyes, Grip hand)   0
•   2 Best Gaze (Horizontal EOM)                 0
•   3. Visual Field                              0
•   4. Facial Palsy                              Lt 1
•   5. Motor Arm                                 Lt 1
National Institute of Health Stroke Scale (NIHSS)

•   6. Motor Leg                                    Lt 2
•   7. Limb Ataxia (Finger to nose, Heel to knee)   0
•   8. Sensory                                      0
•   9. Best Language (name object, read, writing)   0
•   10. Dysarthria                                  1
•   11. Extinction/Neglect                          0
•   Summary NIHSS Score in this Patient             5
NIHSS and Patient Outcomes
• Total scores range from 0-42 with higher values representing
  more severe infarcts
   –   >25 Very severe neurological impairment
   –   15-24 Severe impairment
   –   5-14 Moderately severe impairment
   –   <5     Mild impairment
   –   Adams, HP, et al. (1999). Neurology: 53: 126-131.
• A 2-point (or greater) increase on the NIHSS administered
  serially indicates stroke progression. It is advisable to report
  this increase.
NIHSS and Patient Outcomes
• Initial score of 7 was found to be important cut-off point
     – NIHSS >7 demonstrated a worsening rate of 65.9%.
     – NIHSS <7 demonstrated a worsening rate of 14.8% and were almost twice (1.9x) as likely
       to be functionally normal at 48 hours (45%).
     – (DeGraba et al.,1999)
•   NIHSS <5 most strongly associated with D/C home
•   NIHSS 6-13 most strongly associated with D/C to rehab
•   NIHSS >13 most strongly associated with D/C to nursing facility
•   (Schlegel et al., 2003)
•   Likelihood of intracranial hemorrhage:
     – NIHSS > 20 = 17% likelihood
     – NIHSS < 20 = 3% likelihood
     – (Adams et al., 2003)
หลังจากได้ประวัติและตรวจร่างกายแล้ว
        จะต้องทาอะไรต่อ ?
CT Scan
• Hyperdense MCA
• Loss of Insular ribbon at Rt MCA territory,
จากผล CT SCAN ดังกล่าว สรุปการวินิจฉัยว่า
 อย่างไร และ จะให้การรักษาอย่างไรต่อไป ?
Diagnosis and Management
• Dx : Acute Ischemic Stroke (Right MCA)
• Management in Emergency Department :
   – Candidate for rtPA ?
   – Controlled Blood Pressure ?
Lab Result
EKG
Chest X-ray
Lab result
•   CBC -> no anemia, no leukocytosis, platelet adequate
•   BUN, Cr and Electrolyte -> within normal limited
•   Coagulogram -> no PT or PTT prolong
•   EKG -> Atrial Fibrillation rhythm, no ST – T change seen
•   CXK -> Cardiomegaly, no infiltration seen
Check Indication and Contraindication
                   for rtPA used
• Indication for IV rtPA
   – Clinical diagnosis of ischemic stroke causing a measurable
     neurological deficit
   – non-contrast CT showing no hemorrhage or well-established
     acute infarct
   – Time of onset well established to be less than 4.5 hours
Check Indication and Contraindication
                   for rtPA used
• Contraindication
   – Prior stroke or head trauma within 3 months
   – Recent myocardial infarction within 3 months
   – GI Hemorrhage or GU hemorrhage within 21 days
   – Major surgery within 14 days
   – Arterial puncture at a noncompressible site within 7 days
   – SBP > 185 or DBP > 110 mmHg, or aggressive treatment (IV
     medication) to achieve
Check Indication and Contraindication
                   for rtPA used
• Contraindication
   – CT finding suggesting ICH, SAH, or hypodensity > 1/3 of cerebral
     hemisphere
   – Suspicious of subarachnoid hemorrhage (Even if CT negative)
   – Seizure at onset
   – Hx. of intracranial hemorrhage or aneurysm or AVM or brain tumor
   – Platelet < 100,000
   – Heparin use within 48 hours with PTT > 40 (or exceeding upper limits)
   – Oral anticoagulant use with INR > 1.7
   – Known bleeding diathesis or other major disorder ass. with increased
     bleeding
   – Glucose < 50 or > 400 mg/dl
Check Indication and Contraindication
                   for rtPA used
• Additional Contraindication for patient treated
  between 3 - 4.5 hours
   – Age > 80 years
   – History of Prior Stroke and Diabetes mellitus
   – Any anticoagulant use prior to admission (Even if INR < 1.7)
   – NIHSS > 25 (Because suggestion to hemorrhage preferable)
   – CT findings involving more than 1/3 of the MCA territory
In this Patient
• Candidate for rtPA -> Yes (3 hours -> 15.08 น.)
• Blood Pressure -> 110/60 mmHg
  (No need to controlled before start rtPA)
• Start rtPA (Dose 0.9 mg/kg) BW 44 kg
   – Total dose of rtPA -> 39.6 mg
   – 10% of total dose -> 3.96 mg IV bolus in 1 minute
   – 90% of total dose -> 35.64 mg IV drip in 1 hour
PROGRESS CASE
Progress Case
• NIHSS Score (After treatment completed)
   – 1 hours -> 4 points
   – 6 hours -> 2 points
   – 12 hours -> 0 points
• Work up cause (Risk for embolism, atherosclerosis)
   – Echocardiogram -> RHD, Mild MS and MR, No clot, good LV
   – Lipid profile and FBS -> normal -> Start Simvastatin + diet
     control
   – รอนัด Doppler carotid ultrasound
Progress Case
• Start Enoxaparin SC bridging Warfarin
  due to CHA2DS2 Vasc Score = Stroke (2) Age (1) -> 3
                                         Condition                                     Points
  C Congestive heart failure (or Left ventricular systolic dysfunction)                  1
      Hypertension: blood pressure consistently above 140/90 mmHg (or treated
  H                                                                                      1
      hypertension on medication)
  A2 Age ≥75 years                                                                       2
  D Diabetes Mellitus                                                                    1
  S2 Prior Stroke or TIA or thromboembolism                                              2
     Vascular disease (e.g. peripheral artery disease, myocardial infarction, aortic
  V                                                                                      1
     plaque)
  A Age 65 – 74 years                                                                    1
  Sc Sex category (i.e. female gender)                                                   1
Progress Case
• Discharge with Warfarin (2) 1 tab PO OD
  Keep (INR 2-3)
Thank you

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Conference_acute ischemic stroke

  • 1. Morning Conference Presented by Ext. Sorawit Boonyathee 20 December 2012
  • 2. Chief Complaint • ผู้ป่วยชาย อายุ 68 ปี • อ่อนแรงซีกซ้าย 2 ชั่วโมงก่อนมาโรงพยาบาล • Arrived at ER 14.30 น. • Vital Sign แรกรับ – Blood Pressure 127/77 mmHg – Pulse rate 84 /min – Respiratory rate 20 /min – Oxygen Sat 99 % (Room Air)
  • 3. จาก CHIEF COMPLAINT และ VITAL SIGN แรกรับ TRIAGE ?
  • 4. Triage • Emergency • เนื่องจากผู้ป่วยสงสัยภาวะ Stroke และ On set อยู่ในช่วงที่ สามารถ Activated Fast track ได้
  • 6. Primary Survey • Airway – Can talk, no stridor, dysarthria • Breathing – Clear and equal breath sound both lungs, O2 sat 99% • Circulation – BP 127/77 mmHg, PR 84 /min, no external bleeding • Disability – E4V5M6, pupil 3 mm RTLBE
  • 8. Stroke ? • Cincinnati Prehospital Stroke Scale (CPSS) “F A S T” – Facial Droop – Arm Drip – Speech Problems – Time • Risk Assessment for Stroke – 1 problem = risk 72% 3 problems = 85%
  • 9. Differential Diagnosis • Stroke -> Ischemic or Hemorrhage • Stroke mimic – Hypoglycemia or hyperglycemia -> DTX = 130 mg% – Syncope / Presyncope – Seizures and postictal state – Intracranial Mass (Space occupying lesion) – Functional hemiparesis (Psychiatric Disease/Syndrome) – Encephalopathy – Migraine
  • 10. Laboratory Investigation for Stroke Fast Tract • DTX • CBC with platelet -> Decrease Platelet • BUN, Cr, Electrolyte – High BUN (Uremic encephalopathy) – Hyponatremia • Coagulogram -> INR and PT Prolong ? • Electrocardiogram -> AF or Myocardial Infarction ? • Cardiac Enzyme • Chest x-ray
  • 12. History Taking • 2 hrPTA (12.30 น.) ขณะกาลังนั่งรับประทานอาหาร ผู้ป่วยมี อาการอ่อนแรงแขนขาซีกซ้าย ปากเบี้ยวด้านซ้าย มีอาการพูด ไม่ชัด • ไม่มีอาการหน้ามืดหรือเป็นลม ไม่มีอาการชักเกร็งแขนขา รู้สึกตัวดีตลอดเวลา • ไป รพช. (13.00 น.) ประเมิน Motor power Lt side = 0 • และ (13.30 น.) ประเมิน Motor power Lt side = III -> Refer
  • 13. Physical Examination • Vital Sign : – BP 127/77 mmHg, PR 84 /min, RR 20 /min, O2 Sat 99 % (RA) • HEENT : – No pale conjunctivae, no icteric sclerae, no carotid bruit • Heart : – Totally irregular, PMI at Lt 6th ICS MCL, PSM Grade III at LPSB + apex, DRM Grade II at Apex • Lungs : – Clear and Equal Breath sound both lungs, no adventitious sound
  • 14. Physical Examination (Cont.) • Abdomen : – Soft, not tender • Extremities : – No edema, no deformity, capillary refill < 2 sec
  • 15. Physical Examination (Cont.) • Neuro Exam: – E4V5M6, Pupil 3 mm RTLBE, Good Orientation – Motor power V III+ V II+ – Reflex 2+ all – Sensory Intact – Cranial Nerve -> Full EOM, Facial Weakness Lt UMNL, Dysarthria
  • 16. National Institute of Health Stroke Scale (NIHSS) • 1a. level of consciousness 0 • 1b. Question (Age and month) 0 • 1c. Commands (Open/closed eyes, Grip hand) 0 • 2 Best Gaze (Horizontal EOM) 0 • 3. Visual Field 0 • 4. Facial Palsy Lt 1 • 5. Motor Arm Lt 1
  • 17. National Institute of Health Stroke Scale (NIHSS) • 6. Motor Leg Lt 2 • 7. Limb Ataxia (Finger to nose, Heel to knee) 0 • 8. Sensory 0 • 9. Best Language (name object, read, writing) 0 • 10. Dysarthria 1 • 11. Extinction/Neglect 0 • Summary NIHSS Score in this Patient 5
  • 18. NIHSS and Patient Outcomes • Total scores range from 0-42 with higher values representing more severe infarcts – >25 Very severe neurological impairment – 15-24 Severe impairment – 5-14 Moderately severe impairment – <5 Mild impairment – Adams, HP, et al. (1999). Neurology: 53: 126-131. • A 2-point (or greater) increase on the NIHSS administered serially indicates stroke progression. It is advisable to report this increase.
  • 19. NIHSS and Patient Outcomes • Initial score of 7 was found to be important cut-off point – NIHSS >7 demonstrated a worsening rate of 65.9%. – NIHSS <7 demonstrated a worsening rate of 14.8% and were almost twice (1.9x) as likely to be functionally normal at 48 hours (45%). – (DeGraba et al.,1999) • NIHSS <5 most strongly associated with D/C home • NIHSS 6-13 most strongly associated with D/C to rehab • NIHSS >13 most strongly associated with D/C to nursing facility • (Schlegel et al., 2003) • Likelihood of intracranial hemorrhage: – NIHSS > 20 = 17% likelihood – NIHSS < 20 = 3% likelihood – (Adams et al., 2003)
  • 21. CT Scan • Hyperdense MCA • Loss of Insular ribbon at Rt MCA territory,
  • 22. จากผล CT SCAN ดังกล่าว สรุปการวินิจฉัยว่า อย่างไร และ จะให้การรักษาอย่างไรต่อไป ?
  • 23. Diagnosis and Management • Dx : Acute Ischemic Stroke (Right MCA) • Management in Emergency Department : – Candidate for rtPA ? – Controlled Blood Pressure ?
  • 25. EKG
  • 27. Lab result • CBC -> no anemia, no leukocytosis, platelet adequate • BUN, Cr and Electrolyte -> within normal limited • Coagulogram -> no PT or PTT prolong • EKG -> Atrial Fibrillation rhythm, no ST – T change seen • CXK -> Cardiomegaly, no infiltration seen
  • 28. Check Indication and Contraindication for rtPA used • Indication for IV rtPA – Clinical diagnosis of ischemic stroke causing a measurable neurological deficit – non-contrast CT showing no hemorrhage or well-established acute infarct – Time of onset well established to be less than 4.5 hours
  • 29. Check Indication and Contraindication for rtPA used • Contraindication – Prior stroke or head trauma within 3 months – Recent myocardial infarction within 3 months – GI Hemorrhage or GU hemorrhage within 21 days – Major surgery within 14 days – Arterial puncture at a noncompressible site within 7 days – SBP > 185 or DBP > 110 mmHg, or aggressive treatment (IV medication) to achieve
  • 30. Check Indication and Contraindication for rtPA used • Contraindication – CT finding suggesting ICH, SAH, or hypodensity > 1/3 of cerebral hemisphere – Suspicious of subarachnoid hemorrhage (Even if CT negative) – Seizure at onset – Hx. of intracranial hemorrhage or aneurysm or AVM or brain tumor – Platelet < 100,000 – Heparin use within 48 hours with PTT > 40 (or exceeding upper limits) – Oral anticoagulant use with INR > 1.7 – Known bleeding diathesis or other major disorder ass. with increased bleeding – Glucose < 50 or > 400 mg/dl
  • 31. Check Indication and Contraindication for rtPA used • Additional Contraindication for patient treated between 3 - 4.5 hours – Age > 80 years – History of Prior Stroke and Diabetes mellitus – Any anticoagulant use prior to admission (Even if INR < 1.7) – NIHSS > 25 (Because suggestion to hemorrhage preferable) – CT findings involving more than 1/3 of the MCA territory
  • 32. In this Patient • Candidate for rtPA -> Yes (3 hours -> 15.08 น.) • Blood Pressure -> 110/60 mmHg (No need to controlled before start rtPA) • Start rtPA (Dose 0.9 mg/kg) BW 44 kg – Total dose of rtPA -> 39.6 mg – 10% of total dose -> 3.96 mg IV bolus in 1 minute – 90% of total dose -> 35.64 mg IV drip in 1 hour
  • 34. Progress Case • NIHSS Score (After treatment completed) – 1 hours -> 4 points – 6 hours -> 2 points – 12 hours -> 0 points • Work up cause (Risk for embolism, atherosclerosis) – Echocardiogram -> RHD, Mild MS and MR, No clot, good LV – Lipid profile and FBS -> normal -> Start Simvastatin + diet control – รอนัด Doppler carotid ultrasound
  • 35. Progress Case • Start Enoxaparin SC bridging Warfarin due to CHA2DS2 Vasc Score = Stroke (2) Age (1) -> 3 Condition Points C Congestive heart failure (or Left ventricular systolic dysfunction) 1 Hypertension: blood pressure consistently above 140/90 mmHg (or treated H 1 hypertension on medication) A2 Age ≥75 years 2 D Diabetes Mellitus 1 S2 Prior Stroke or TIA or thromboembolism 2 Vascular disease (e.g. peripheral artery disease, myocardial infarction, aortic V 1 plaque) A Age 65 – 74 years 1 Sc Sex category (i.e. female gender) 1
  • 36. Progress Case • Discharge with Warfarin (2) 1 tab PO OD Keep (INR 2-3)