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Stroke Case Scenarios

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Stroke Case Scenarios

  1. 1. Stroke Workshop Case Scenario
  2. 2. Stroke Workshop Case Scenario 65 year old female with a history of DM and HTN develops acute onset left face droop, left arm and leg weakness. 118 is called and arrives within 15 minutes. Patient has a BP 200/110. • What interventions should be provided in the field? • Antihypertensive? • Aspirin? • Where should the patient be transported? • Closest hospital?
  3. 3. Stroke Workshop Field Management in Stroke • Cardiac monitor, O2 • Blood sugar • Reassurance / no pharmacologic intervention for BP • Time of onset documented; medications; physical exam focusing on speech, facial droop, drift • Rapid transport with notification of receiving hospital
  4. 4. Stroke Workshop Case Scenario Patient arrives in the ED with unchanged blood pressure, unchanged neurologic exam. • What are the key components of history? • What are the key components of the physical exam? • What laboratory tests should be ordered? • Pharmacologic interventions?
  5. 5. Stroke Workshop Key Components of the History
  6. 6. Stroke Workshop Key Components of the History • Time of onset • Head trauma, previous stroke • Known AVM or aneurysm • Major surgery within 14 days • Seizure • Medications: use of anticoagulants • Symptoms suggestive of MI / pericarditis • Symptoms suggestive of hemorrhage • Severe headache • Neck stiffness / Pain • Nausea / vomiting
  7. 7. Stroke Workshop Key Components of the Physical
  8. 8. Stroke Workshop Key Components to the Physical • ABC’S • Vital signs (BP both arms; presence of fever) • LOC (when depressed, consider other diagnoses) • Trauma exam • Neck exam • Cardiopulmonary exam
  9. 9. Stroke Workshop Key Components of the Neuro Exam
  10. 10. Stroke Workshop Neurologic exam • Glasgow coma scaleGlasgow coma scale • NIHSS: 15 Item measure: 42 PointsNIHSS: 15 Item measure: 42 Points • < 4 Not a candidate for thrombolytics • > 22 Increased risk for hemorrhage
  11. 11. Stroke Workshop NIH Stroke Scale • Level of consciousness • Orientation (month and age) • Follow commands • Best gaze • Visual fields • Facial palsy • Motor arm • Motor leg • Limb ataxia • Sensory • Best language • Dysarthria • Extinction and inattention (neglect)
  12. 12. Stroke Workshop What Laboratory Tests Should be Ordered?
  13. 13. Stroke Workshop What Laboratory Tests Should be Ordered? • Glucose • CBC and platelets • Electrolytes • PT, PTT • ECG • CXR • Noncontrast head CT
  14. 14. Stroke Workshop Interventions?
  15. 15. Stroke Workshop Blood Pressure Management in Ischemic Stroke • Systolic 185 - 220, Diastolic 105 - 120; Do not treat for the first hour (consider benzodiazepines); if persists, IV Labetolol, 10 mg. • Systolic > 220 mm Hg or diastolic 121 - 140; 2 readings 20 min apart: Start Labatolol 10 MG IV. Patients requiring more than 2 doses are not candidates for t-PA • Diastolic > 140 mm Hg; 2 readings 5 minutes apart: Start Nitroprusside. Patient is not a candidate for t- PA
  16. 16. Stroke Workshop Case Scenario • Patient has a NIHSS score of 8 • ECG is normal sinus • Glucose 140; Platelets 200 K • PT / PTT are normal • Head CT is read as “normal” • What are the indications for t-PA?
  17. 17. Stroke Workshop Indications for t-PA • Symptoms less than 3 hours from onset • Symptoms not improving • No evidence of hemorrhage on CT • No recent head trauma, surgery, GI bleeding • No use of anti-coagulants • No known aneurysm, neoplasm • Blood pressure controlled
  18. 18. Stroke Workshop Case Scenario A decision is made to give t-PA. • How is t-PA administered • How is suspected intracranial hemorrhage managed?
  19. 19. Stroke Workshop Administering t-PA • .9 mg/kg in a 1:1 dilution • Maximum dose 90 mg • 10% initial bolus over 1-2 minutes; the rest infused over 60 minutes • Monitor blood pressure • Do not give heparin or aspirin!
  20. 20. Stroke Workshop Management of Suspected Intracranial Hemorrhage • Discontinue t-PA • Obtain immediate CT • Check PT, PTT, platelet count, fibrinogen level • Prepare cryoprecipitate and fibrinogen (6-8 units) • Prepare platelets (6-8 units) • Obtain neurosurgical consultation
  21. 21. Stroke Workshop Case Scenario The patient received t-PA and within one hour her strength was markedly improved. She was admitted to the stroke unit where she was monitored and began early rehabilitation She was discharged home one week later with minimal left sided weakness.

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