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General Emergent Management of Patients with Stroke, Including Blood Pressure Management.

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Presentation on theme: "General Emergent Management of Patients with Stroke, Including Blood Pressure Management."— Presentation transcript:

1 General Emergent Management of Patients with Stroke, Including Blood Pressure Management

2 Objectives Review initial evaluation of the patient with an AIS –history, physical exam, diagnostics, imaging Discuss acute supportive care –stroke vital signs: ABCC’s, hypertension, glucose, temperature, seizure management Understand that emergent management requires simultaneous evaluation and intervention

3 Goals of Acute Supportive Care Assure optimal perfusion and oxygenation Protect the C-spine Secure the airway Support oxygenation and ventilation Assure appropriate circulation

4 The History Age - approximately 65 yr Sudden onset focal neurologic deficit Specific vascular territory Seizure at onset of Sx: 5% Headache at onset: 10-30% Fall or trauma at onset

5 Time of Symptom Onset Most difficult portion of the history Start when patient “was last seen normal” Work forward in time (TV guide) Patients that awake with symptoms - onset = time of sleep Confirm with family, friends, care taker EMS - bring family along in ambulance

6 Past Medical History Medications: –diuretic, antihypertensive, antithrombotic Risk Factors: hypertension TIA smoking previous stroke diabetes atrial fibrillation African-American carotid artery disease

7 Physical Exam Vital signs are vital, –but occasionally inaccurate C-Spine tenderness, pain BP in both arms, symmetry of pulses Signs of trauma, associated injuries Neurologic deficit - characteristic vascular distribution

8 Stroke Scales Severity –NIH stroke scale 0-42, 0 = normal valid, reproducible, assists in patient selection, facilitates communication Functional Scales –m-Rankin0-5, 0 = normal –Barthel index100, 100 = normal –Glasgow outcome0-5, 5= normal in NINDS t-PA stroke trial, 0 = normal

9 Stroke Scales NIH stroke scale 0-42 0-5 mild/minor in most patients 5-15 moderate 15-20moderately severe > 20 very severe underestimates volume of infarct in non- dominant (R) hemispheric strokes

10 Diagnostic Testing Laboratory studies –CBC, differential, platelets –electrolyte profile, glucose (finger stick) –INR, aPTT –Troponin EKG CXR

11 Non-contrast CT of the Head Initial imaging study of choice Readily available Very sensitive for blood in the acute phase –blood - 50-85 Hounsfield Units –bone- 120 (70-200) Hounsfield Units Not sensitive for acute ischemic stroke –nearly 100% sensitive by 7 days Posterior fossa structures - bone artifact

12 Non-contrast CT of the Head May shows early signs of ischemia in the 1st 3 hours –loss of gray/white matter distinction –hypodensity –mass effect, edema –hyperdense middle cerebral artery sign Re-evaluate the time of symptom onset, if early signs of ischemia are present

13 ECT 2 hours 24 hours

14 Other Imaging Modalities MRI –standard –DWI/PWI Xenon CT Perfusion CT CT Angiography

15 Differential Diagnosis Deciphered by history, PE, diagnostics DDx: TIAvascular disorders seizureinfections (endocarditis) traumacomplex migraine mass lesionsmetabolic abnormalities

16 Stroke Vital Signs Airway Breathing Circulation C-spine Glucose Temperature

17 Airway Management Upper airway patency Maintain C-Spine precautions Asses level of consciousness Inspect for loose dentures, foreign bodies Suction secretions Assess gag reflex, tongue control

18 Oxygenation and Ventilation Respiratory rate and depth Signs of fatigue - Paradoxical respirations Breath sounds - (CHF, pneumonia, COPD) Supplemental O 2 with O 2 sat > 95% Support with Basic airway techniques Ventilatory support as required

19 Basic airway techniques Foreign body removal Suction with rigid suction device Positioning –jaw thrust –chin lift Nasal airway Bag valve mask

20 Advanced Airway Management Rapid sequence intubation, orotracheal –sedation and paralysis prevent increase in ICP Most common indications –inability to maintain airway –depressed level of consciousness –need for hyperventilation to manage ICP Treat the underlying cause of respiratory distress: CHF, MI, etc.

21 Monitoring of oxygenation Pulse oximetry –indicator of oxygenation not ventilation –falsely high in CO poisoning –falsely low in PVOD, hypotension, peripheral vasoconstriction ABG –pCO 2 allows eval of ventilation –obtain from compressible site Supernormal oxygenation –not of proven benefit

22 Circulation Goal: maintain cerebral perfusion Optimize cardiovascular status Monitor and reevaluate

23 Circulation Evaluate cardiac history and status Cardiac output –preload –afterload –contractility –stroke volume

24 Circulation Monitor vital signs Q 15 min in acute phase –pulse (palpate in all 4 extremities) –heart rate –rhythm –blood pressure (both arms) –central venous pressure

25 ECG Cardiac Arrhythmia: 5% -30% Acute MI: 1%-2% ECG abnormalities –more common with hemorrhagic infarct –T-Wave inversions –nonspecific ST and T-wave changes

26 Vascular Access Two peripheral IVs Use.9NS or.45 NS unless hypotensive Use.9NS if hypotensive Replace blood products as indicated

27 Autoregulation The ability of the vasculature in the brain to maintain a constant blood flow across a wide range of blood pressures Autoregulation - impaired or lost in the area of the infarction Ischemic tissues are perfusion dependant Autoregulation is shifted to higher pressure patients with a history of HTN

28 Autoregulation of Cerebral Blood Flow

29 Hypertension Ischemic Stroke Loss of autoregulation Treat judiciously if at all Treatment guidelines - not receiving rt- PA –AHA: MAP > 130 or Sys BP > 220 MAP= [(2x DP)+SP]B3 –NSA: 220/115

30 Hypertension - Ischemic Stroke Drugs - short acting, titrate Labetalol IV: 10-20 mg increments, double dose Q 20 min, max cumulative dose 300mg Enalapril Oral: 2.5 - 5.0 mg/day, max 40mg/day IV : 0.625-1.25 mg IV Q 6hrs, max 5.0 Q 6 hrs

31 Hypertension -Ischemic Stroke Nitroglycerine Paste: 1-2 inches to skin IV Drip: 5mcg/min, increase in increments of 5-10mcg every 3-5 min Nitroprusside IV Drip: 0.3 - 10 mcg/min/kg Continuos BP monitoring check thiocyanate levels AVOID NIFEDIPINE

32 Hypertension Intracerebral Hemorrhage Treat aggressively Elevate head of bed Use labetalol, nitroglycerine, nitroprusside or lasix AVOID NIFEDIPINE Keep systolic < 160 mm Hg diastolic < 100 mm Hg

33 Hypotension More detrimental than hypertension Seek cause and treat aggressively CVP monitoring may be necessary Use.9 NS first to ensure adequate preload Then add vasopressors if needed

34 Hypertension: rt-PA Candidate Exclude for persistent BP > 185/110 Check BP q 15 min May not aggressively lower BP to meet entry criteria Use Labetolol or Nitropaste Avoid Nifedipine

35 Glucose Worse outcome after stroke: –diabetics –acute hyperglycemia at time of infarct Mechanism uncertain –increase in lactate in area of ischemia –gene induction, –increased number of spreading depolarizations Insulin is a neuroprotective

36 Glucose Avoid any IV fluids with D5 –instruct prehospital personnel not to give D50 as part of the “coma cocktail” to acute stroke patients Check a finger stick ASAP –treat only if low (< 50) Use insulin to establish euglycemia

37 Temperature Fever worsens outcome: –for every 1°C rise in temp, risk of poor outcome doubles (Reith, Lancet 1996) Greatest effect in the first 24 hours Brain temp is generally higher than core Treat aggressively with acetaminophen, ibuprofen, or both Search for underlying cause Hypothermia currently under investigation

38 Seizures Occur in 5% of acute strokes Usually generalized tonic-clonic Possible causes: severe strokes cortical involvement unstable tissue at risk spreading depolarizations hx of seizure disorder

39 Seizures Protect patient from injury during ictus Maintain airway Benzodiazepines: –lorazepam (1-2 mg IV) –diazepam (5-10 mg IV) Phenytoin: –18 mg/kg loading dose, at 25-50 mg/min infusion with cardiac monitor No need for prophylaxis

40 Primary treatment of AIS Supportive care Aspirin IV thrombolysis No role for antithrombotics

41 Summary Evaluation History with time of symptom onset Physical exam –trauma, NIHSS score Laboratory evaluation Non-contrast CT head

42 Summary Supportive Care Secure airway; basic and advanced methods Protect C-spine Assure oxygenation and ventilation Maximize perfusion, IV fluids Blood pressures (both arms), treat carefully Normalize the temperature and glucose Treat seizure if occurs Reevaluate

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