Couple of Clots 70 year old female Smoker Mopping the floor and started feeling dizzy and tired Witnessed sudden onset of aphasia, right sided weakness
12: 15 - last seen normal 12:40 - stroke code activated – pre hospital EMS states right side weakness 12:45 - Handsome paramedic arrives with patient who only has a right facial droop
Time to relax? A.Don’t cancel stroke code. Let’s give tPA. B.Cancel stroke code, but still get imaging. C.Scold EMS for not knowing facial droop from complete weakness. D.Get EMS call back number, the charge nurse also thinks he is hot.
Secondary Hemorrhage Coagulopathies Tumor AVM / aneurysm Illicit drug use Excess EtOH
Getting sleepy… Frequent neuro checksPatient becoming more sleepy Head of bed > 30 degreesDone Blood pressureTitrating nicardipine gtt to keep SBP < 160 Fever controlNo fever SedationPatient calm Surgical or medical?Deep territory, medical management
CT scan Bleed is stable More swelling Ventricles – no change
Hyperosmolar Therapy Isotonic hypertonic hypotonic 300 to 320 mOsm/kg 280-300 mOsm/kg 0.45% Na D5W Mannitol 3% NaCl
DO IT FOR THE BRAIN ! Neuro exam Blood pressure control Head of bed Hyperosmolar therapy Sedation Fever control Prepare for EVD placement
Stroke Code on ortho 72 yo male Hip fx POD 2 Sudden onset left facial droop & slurred speech
Increased risk of MI/ PE 1 week after surgery and stroke 1-2 weeks after surgery. Patient is at increased risk of stroke after surgery if: They have had a stroke. They have atrial fibrillation.
Risky Business? Hypertension Diabetes – type 2 Overweight There was something else, but….
Exacerbation of Old Symptoms Metabolic – Electrolytes – Medications – Hypercarbia Infectious – WBC – Fever Exacerbation of stroke symptoms by infection and metabolic perturbations – A diffusion-weighted MRI study S. Iyadurai, K. Knievel, M. Flaster (St. Louis, Phoenix, Las Vegas, US)
If a Tree Falls in the Forest… 87 year old female EMS: Trauma! AMS following a non-witnessed fall at about 7 pm Family: Patient got up to get ready for bed. There was a loud thud in the bedroom, and she was found "down" by her vanity table gripping tightly unto her walker and chair and "shaking." Trauma Team: She sustained multiple lacerations, the worst of which is on her R forearm.
CHADS2 Score in Atrial Fibrillation CHAD2 itemPoints Congestive heart failure1 Hypertension (systolic >140 mmHg)1 Age greater than 75 years1 Diabetes1 Prior cerebral ischemia / TIA2
Annual Stroke Risk CHADS2 ScoreYearly risk of stroke 01.9% 12.8% 24.0% 35.9% 48.5% 512.5% 618.2% BF Gage et al. Validation of clinical classification schemes for predicting stroke. Results from the national registry of atrial fibrillation. JAMA 2001 285: 2864-2870.
Balancing Act CHADS Score is 5, 12.5% chance per year will have a stroke Two GI Bleeds requiring hospitalization in past 3 months
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