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 or 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 o 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 oke T PA • Mo re pa tie nts e ve ntua lly ha ve a • He mo rrha g e g o o d o utc o me (~40% vs ~27% • Inc re a se d ICP/ ma ss e ffe c t/ shift func tio n a t 3 mo nths). • 90 minute s: NNT 3 • De c re a se d L OC (intub a tio n) • 3 ho urs: NNT 8 • HT N c o mplic a tio ns • 4.5 ho urs: NNT 12 • Afib (ra pid) • De a th • 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?
HYPE RACUT E ACUT E • IV • BP mo nito ring • VS & Pe x • Admissio n (Mo nito re d unit) • Gluc o se • Ma inte na nc e fluids • L a b s • Dyspha g ia sc re e n • Hx • 24h Re pe a t CT he a d • NIHSS • ASA/ Pla vix • CT / CT A • W/ up: E CHO, Ho lte r, CAT • Che c k la b re sults do pple rs, A1C, L ipids • Co nse nt • Se c o nda ry pre ve ntio n me ds • F luids • F o le y • T PA
CASE 1 • 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 2 • 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 3 • 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 4 • 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 5 • 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.
L AT E RAL ME DUL L ARY SYNDROME
CASE 6 • 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 7 • 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
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
THANK YOU!
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