if its useful.....comment please.... its helps us have a short quick review about the medical managements of CVA..... its describe about the types and how as a nurse how to care the patients on the bases of nursing care

1. Medical management
of
By
S.A.KEERTHI VASAN 3rd year B.Sc.Nursing
DEPARTMENT OF MEDICAL SURGICAL NURSING
SHNC.

2. TYPES OF STROKE
85% Ischemic 15 % hemorrhagic

3. Ischemic Stroke
Embolic - cardiogenic sources such as atrial fibrillation
Thrombotic - associated with atherosclerotic plaque

6. Thrombolytic therapy
• It is used to treat ischemic stroke by
dissolving the already formed blood clot
that is blocking blood flow to the brain.

7. 1. Fibrinolytic therapy
Non – fibrin specific fibrin specific
•Streptokinase
•Anistreplase.
•urokinase
Tissue plasminogen
Activators (t-PA).
 Alteplase
 Reteolase
 Tenecteplase

8. DIFFERENCE BETWEEN FIBRIN SPECIFIC AND NON SPECIFIC
AGENTS
FIBRIN SPECIFIC AGENTS
• Binds equally to circulating
and non circulating
plasminogen .
• Produces breakdown of clot
(local fibrinolysis )and
circulating plasminogen and
other plasma proteins thus
cause an unwanted leading
to bleeding .
• Half life of fibrin specific
agents is 18 mins
FIBRIN NON SPECIFIC AGENTS
• Binds preferentially to
plasminogen at the fibrin
surface (non circulating )
rather than circulating
plasminogen in blood .
• Risk of bleeding is less than
non specific agents .
• Activity is enhanced upon
binding to fibrin .
• The half life of tPA in the
bloodstream is rather than
5-10 minutes in humans

9. Mechanism of action
• The fibrinolytic action of tPA occurs at
the plasminogen is converted into
plasmin, whose enzymatic action then
digests fibrin and fibrinolytic , thus
breaking down the clot.
• Tissue plasminogen activators(tPA) is
used to produce localized fibrinolysis by
binding to the fibrin in the thrombi.

10. CLOT DISSOLUTION
PLASMINOGEN
PLASMINOGEN ACTIVATOR
PLASMIN
FIBRIN DEGRADATION PRODUCTS

11. t-PA IV administeration
• To reestablish blood flow through a
blocked artery to prevent cell death in
patients with the acute onset of ischemic
stroke.
• It must be administered within 3 to 41/2
hours of the onset.
• Patients are screened (noncontrast CT
scan, MRI, Blood test) carefully before
tPA can be given.

12. Intraarterial infusion
• Patients with an ischemic stroke when the
mechaincal thrombectomy is not an
option.
• It must be administered within 6 hours of
sudden onset .
• The tPA is administered through the
catheter and immediately targets the
clots.

13. Dosage and administration
• The dosage for t-PA is 0.9 mg/kg , with a
maximum dose of 90mg.
• 10% of the calculated dose is given IV bolus
over 1 minute.
• The remaining dose (90%) is given IV over 1
hour via an infusion pump.
• No other antithrombotic treatment for 24 h.
• Avoid urethral catheterization.

14. rtPA Alteplase
• Must be given within 4.5 hours of stroke
• Do not mix rt-PA with any other medications
• Do not use IV tubing with infusion filters.
• Must be on a cardiac monitor
 Must be given with an INFUSION PUMP
• When infusion is complete, saline flush with Normal
saline
• rt-PA must be used within 8 hours of mixing when
stored at room temperature or within 24 hours if
refrigerated

15. THROMBOLYSIS
Alteplase rTPA 0.9mg /Kg
10 % of total dose –Bolus 2-3 mins
90 % of total dose –Infuse over 60 mins

16. • Intracranial hemorrhage
• Active internal bleeding
• Endocarditis or acute pericarditis
ABSOLUTE CONTRAINDICATIONS

17. Indication contraindication
• Clinical diagnosis of
stroke.
• Onset of symptoms to
time of drug
administration ≤4.5 Hb.
• CT scan showing no
hemorrhage or edema
of >1/3 of the MCA
territory
• Age 18 ≥years.
• Consent by patient or
surrogate.
• Sustained bp
>185/110mmHg despite
treatment.
• Platelets <100,000 ;
Hct<25%; glucose <50
or >400 mg/dl.
• Use of heparin within
48 hrs and prolonged
PTT or elevated INR.
• Rapidly improving
symptoms
• Prior stroke or head
injury within 3 mon;
prior intracranial

18. • Avoid
taking BP in arm with IV’s or venipunctures
invasive procedures
unnecessary handling of the patient
unnecessary venous or arterial punctures
• Blood is drawn from IV saline lock if possible
• Apply pressure dressing to potential sources of bleeding
• Assess all secretions and excretions for blood
• Bed rest for 12 – 24 hours
Assessment during and after t-PA

19. • NPO for 6 hours post t-PA
• Complete swallow screen prior to any oral
intake
• If fails, keep NPO then reassess
DIET

20. Eligibility criteria for Tissue plasminogen Activators
Administration
• Age ≥ 18 years
• Clinical diagnosis of ischemic stroke.
• Time of onset of stroke known and is less than 3 hours
before treatment.
• Systolic blood pressure ≤185mm Hg:diastolic ≤110mm
Hg .
• No seizure at onset of stroke.
• Prothrombin time ≤15seconds or international
normalized ratio ≤1.7(if taking an anticoagulants,the
same guidance is used )
• Platelet count ≥100,000/mm3.

21. • Not received heparin during the past 48 hours with
elevated partial thromboplastin time.
• Glucose >50mg/dl.
• No prior intracranial hemorrhage , neoplasm,
arteriovenous malformation or aneurysm.
• No major surgical procedures or serious trauma within
14 days .
• No stroke , serious head injury, or intracranial surgery
within 3 months.
• No gastrointestinal or urinary bleeding within 21 days.
• No pregnancy.
• { There are more stringent criteria if t-PA is considered
for those patients in the 3.0 to 4.5 hours time
window.}

22. Anticoagulants &
platelet inhibitors
• After the patients has stabilized and to prevent
further clot formation.
• Patients with stroke caused by thrombi and
emboli may be treated with anticoagulants
&platelet inhibitors.
• For patients who have atrial fibrillation , oral
anticoagulants includes – WARFARIN,.
• platelet inhibitors includes –
ASPIRIN,CLOPIDOGREL,TICLOPIDINE.
• To reduce ICP, such as administering osmotic
diuretic (eg, mannitol)

26. Review & Questioner
• Time limitations for Intraarterial
infushion is -------
• tPA & drug should be administered
within -------
• List out the fibrinolytic drugs .
• Compare & contrast half life period of
fibrin specific and non-fibrin specific?

27. HemorRhagic stroke
weakened regions of blood vessels rupture as a
result of increased pressure

28. Anticoagulants
&
platelets inhibitors
Anticoagulants &platelets inhibitors are
contraindicated in hemorrhagic stroke

29. • The main drug therapy is to
management of hypertension.
• It may be of oral/IV agents are used to
maintain normal BP.(systolic BP less
than 160mmHg).
• Seizure prophylaxis in the acute
period after intracerebral &
subarachoid hemorrhage .(diazepam,
lorazepam)

30. BP relationship
• BP increase due to an arterial
occlusion,( ie.,an effort to
perfuse penumbra).
• Failure to recanalize ( with or
without thrombolytic therapy)
result in high BP and poor neuro
outcomes.
• Lowering BP starves penumbra,
worsens outcomes.

31. Why questions ?
• why Anticoagulants &platelets inhibitors are
contraindicated in hemorrhagic stroke ?
• Why fibrin specific agent is superior to non
fibrin specific thrombolytic agent?
• What are the screening protocol to be checked
before tPA treatment?
• List down any few absolute contraindication
for tPA.
• What is the dosage of tPA.

32. S.A.KEERTHI VASAN B.SC,NURSING