Stroke Workshop

Case Scenario

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?

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

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?

Stroke Workshop

Key Components of the History

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

Stroke Workshop

Key Components of the Physical

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

Stroke Workshop

Key Components of the Neuro Exam

Stroke Workshop

Neurologic exam

• Glasgow coma scaleGlasgow coma scale• NIHSS: 15 Item measure: 42 Points NIHSS: 15 Item measure: 42 Points

• < 4 Not a candidate for thrombolytics• > 22 Increased risk for hemorrhage

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)

Stroke Workshop

What Laboratory Tests Should be Ordered?

Stroke Workshop

What Laboratory Tests Should be Ordered?

• Glucose• CBC and platelets• Electrolytes• PT, PTT• ECG• CXR• Noncontrast head CT

Stroke Workshop

Interventions?

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

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?

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

Stroke Workshop

Case Scenario

A decision is made to give t-PA.

• How is t-PA administered• How is suspected intracranial

hemorrhage managed?

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!

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

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.