ST ROKE SCHOOL F OR INT E RNIST S PART 2 Dr. Gurpre e t Ja - - PowerPoint PPT Presentation

ST ROKE SCHOOL F OR INT E RNIST S PART 2

• Dr. Gurpre e t Ja swa l & Dr. Alb e rt Jin

OBJE CT I VE S

1) Suc c e ssfully c o nduc t b a sic re susc ita tio n a c tio ns a nd pro c e dure s in hype ra c ute stro ke . 2) De sc rib e inc lusio n a nd e xc lusio n c rite ria fo r thro mb o lytic the ra py. 3) Re c o g nize a nd ma na g e c o mplic a tio ns o f isc he mic a nd he mo rrha g ic stro ke a nd stro ke mimic s. 4) Re c o g nize a nd ma na g e c o mplic a tio ns o f T PA, inc luding a ng io e de ma

I NCL USI ON CRI T E RI A

• Isc he mic stroke a g e ≥ 18 years old
• L

a st known we ll < 4.5 hours

ABSOL UT E CONT RAINDICAT IONS

Ac tive He mor r hage

• r

Intr ac r anial He mor r hage

RE L AT I VE CONT RAI NDI CAT I ONS

• Stro ke / se rio us he a d tra uma (within 3 mo nths)
• Stro ke Mimic
• Pre vio us ICH/ SAH
• Ong o ing he mo rrha g e / ma jo r surg e ry (within 14 da ys)
• Arte ria l no n-c o mpre ssib le site (within 7 da ys)

BE F ORE T PA

• Re fra c to ry HT

N (180/ 105)

• Blo o d g luc o se < 2.7 mmo l/ L
• r > 22.2 mmo l/ L
• E

le va te d PT T

• INR > 1.7
• Pla te le ts < 100,000 pe r c ub ic millime te r

COMPL I CAT I ONS

Str

• ke
• He mo rrha g e
• Inc re a se d ICP/ ma ss e ffe c t/ shift
• De c re a se d L

OC (intub a tio n)

• HT

N c o mplic a tio ns

• Afib (ra pid)
• De a th

T PA

• Mo re pa tie nts e ve ntua lly ha ve a

g o o d o utc o me (~40% vs ~27% func tio n a t 3 mo nths).

• 90 minute s: NNT

3

• 3 ho urs: NNT

8

• 4.5 ho urs: NNT

12

• 6% ma y ha ve ma jo r b le e ding a nd

3% fro m this ma y b e fa ta l

0.9 mg/ kg

Ma x dose 90 mg . 10% bolus ove r 1 min 90% dose ove r a n hour

ANGI OE DE MA

• 1. Be na d ryl 50mg IV
• 2. Ra nitid ine 50mg IV
• 3. Hyd ro c o rtiso ne 100mg IV

GROUPWORK

• 62M with pe rsiste nt le ft a rm & le g

we a kne ss

• Sudde n o nse t 45 minute s a g o
• Hx o f die t-c o ntro lle d DM2, HT

N

• No me ds.
• NI

HSS: 4

• VS/ L

a b s no rma l

• CT

sc a n hype rde nse R MCA sig n

• No T

PA c o ntra indic a tio ns.

WHAT DO YOU DO?

• IV
• VS & Pe x
• Gluc o se
• L

a b s

• Hx
• NIHSS
• CT

/ CT A

• Che c k la b re sults
• Co nse nt
• F

luids

• F
• le y
• T

PA

• BP mo nito ring
• Admissio n (Mo nito re d unit)
• Ma inte na nc e fluids
• Dyspha g ia sc re e n
• 24h Re pe a t CT

he a d

• ASA/ Pla vix
• W/ up: E

CHO, Ho lte r, CAT do pple rs, A1C, L ipids

• Se c o nda ry pre ve ntio n me ds

HYPE RACUT E ACUT E

• 65M with Rig ht fa c e , a rm a nd le g we a kne ss &

numb ne ss + a pha sia + dysa rthria + Rig ht HH

• PMHx: HT

N, DL P, DM2, Atria l fib , smo ke r

• Me ds: Ca nde sa rta n, Ato rva sta tin, Me tfo rmin,

Wa rfa rin

• Histo ry
• L

a st se e n we ll: 2 ho urs a g o

• Onse t: sudde n
• Physic a l E

xa m

• 195/ 110 BP, NSR 85, c a p g luc o se 4.6
• NI

HSS: 15

• L

a b wo rk

• Pts 106, I

NR 1.6

CASE 1

• 75M with re so lving L

a rm numb ne ss

• PMHx: HT

N, DL P

• Me ds: Ra mipril, Ro suva sta tin
• Histo ry
• L

a st se e n we ll: 30 min a g o

• Onse t: sudde n
• Co urse : T

ra nsie nt

• Physic a l E

xa m

• 153/ 68 BP, NSR 72, c a p g luc o se 5.6
• NI

HSS: 0

• L

a b wo rk no rma l

CASE 2

• 53F

with H/ A, dysa rthria , rig ht a rm & le g we a k

• PMHx: HT

N

• Me ds: Amlo dipine
• Histo ry
• L

a st se e n we ll: 30 min a g o

• Onse t: sudde n
• Co urse : Wo rse ning L

OC

• Physic a l E

xa m

• 220/ 90 BP, NSR 90, c a p g luc o se 7.8
• NI

HSS: 0

• L

a b wo rk no rma l

• Plts 260, I

NR 0.9, a PT T34s

CASE 3

• 69F

with L a rm & le g we a kne ss, de c L OC

• PMHx: HT

N

• Me ds: HCT

Z

• Histo ry
• L

a st se e n we ll: 20 min a g o

• Onse t: sudde n
• Co urse : Wo rse ning L

OC

• Physic a l E

xa m

• 178/ 76 R a rm, 85/ 50 L

a rm, 120 HR, 95% 2L NP

• AR murmur, De c b re a th so unds
• NI

HSS: 16

• L

a b wo rk:

• L

a c ta te 4.6, Hb 84, tro p 0.6, Cr 140

CASE 4

• 46M with L

side d H/ A, dyspha g ia , dysa rthria , R fa c e / a rm/ le g numb ne ss, L fa c e we a kne ss, g a it a ta xia

• PMHx: Ob e sity, GE

RD, smo ke r

• Me ds: Anta c ids
• Histo ry
• L

a st se e n we ll: 1 da y a g o

• Onse t: sudde n
• Co urse : Pe rsiste nt
• Physic a l E

xa m

• 135/ 68 a rm, 78 HR
• As a b o ve + L

e ft pa la te e le va tio n a b no rma l

• L

a b wo rk no rma l. CT re po rte d no rma l.

CASE 5

L AT E RAL ME DUL L ARY SYNDROME

• 32F

with R a rm & le g numb ne ss

• PMHx: Sz a fte r MVA, mig ra ine
• Me ds: K

e ppra

• Histo ry
• L

a st se e n we ll: 40 min a g o

• Onse t: o ve r 5-10 min. H/ A
• Co urse : Re so lving
• Physic a l E

xa m

• 110/ 80, 89 HR
• NI

HSS: 1

• L

a b wo rk no rma l. K e ppra le ve l o k.

CASE 6

• 78F

with R fa c e / a rm/ le g numb ne ss + we a kne ss + g lo b a l a pha sia

• PMHx: Afib , HT

N, DL P, DM2, re c e nt la rg e le g he ma to ma

• Me ds: Apixa b a n he ld, Me to pro lo l, Amlo dipine , Ro suva sta tin, Insulin
• Histo ry
• L

a st se e n we ll: 2.5 ho urs a g o

• Onse t: sudde n
• Physic a l E

xa m

• 182/ 100, 98 HR (Afib )
• NI

HSS: 12

• L

a b wo rk:

• Plts 280, I

NR 0.7, a PT T32 se c o nds, Gluc o se 25

CASE 7

OBJE CT I VE S

1) Suc c e ssfully c o nduc t b a sic re susc ita tio n a c tio ns a nd pro c e dure s in hype ra c ute stro ke . 2) De sc rib e inc lusio n a nd e xc lusio n c rite ria fo r thro mb o lytic the ra py. 3) Re c o g nize a nd ma na g e c o mplic a tio ns o f isc he mic a nd he mo rrha g ic stro ke a nd stro ke mimic s. 4) Re c o g nize a nd ma na g e c o mplic a tio ns o f T PA, inc luding a ng io e de ma

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