2Case Scenario65 year old female with a history of DM and HTN develops acute onset left face droop, left arm and leg weakness 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?
3Field Management in Stroke Cardiac monitor, O2Blood sugarReassurance / no pharmacologic intervention for BPTime of onset documented; medications; physical exam focusing on speech, facial droop, driftRapid transport with notification of receiving hospital
4Case ScenarioPatient 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?
6Key Components of the History Time of onsetHead trauma, previous strokeKnown AVM or aneurysmMajor surgery within 14 daysSeizureMedications: use of anticoagulantsSymptoms suggestive of MI / pericarditisSymptoms suggestive of hemorrhageSevere headacheNeck stiffness / PainNausea / vomiting18
15Blood Pressure Management in Ischemic Stroke Systolic , Diastolic ; Do not treat for the first hour (consider benzodiazepines); if persists, IV Labetolol, 10 mg.Systolic > 220 mm Hg or diastolic ; 2 readings 20 min apart: Start Labatolol 10 MG IV. Patients requiring more than 2 doses are not candidates for t-PADiastolic > 140 mm Hg; 2 readings 5 minutes apart: Start Nitroprusside. Patient is not a candidate for t-PA22
16Case Scenario Patient has a NIHSS score of 8 ECG is normal sinus Glucose 140; Platelets 200 KPT / PTT are normalHead CT is read as “normal”What are the indications for t-PA?
17Indications for t-PA Symptoms less than 3 hours from onset Symptoms not improvingNo evidence of hemorrhage on CTNo recent head trauma, surgery, GI bleedingNo use of anti-coagulantsNo known aneurysm, neoplasmBlood pressure controlled
18Case Scenario A decision is made to give t-PA. How is t-PA administeredHow is suspected intracranial hemorrhage managed?
19Administering 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 minutesMonitor blood pressureDo not give heparin or aspirin!
21Case ScenarioThe 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 rehabilitationShe was discharged home one week later with minimal left sided weakness.