Stroke Workshop Case Scenario

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?

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

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?

Key Components of the History

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 18

Key Components of the Physical

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 19

Key Components of the Neuro Exam

Neurologic exam Glasgow coma scale NIHSS: 15 Item measure: 42 Points < 4 Not a candidate for thrombolytics > 22 Increased risk for hemorrhage

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)

What Laboratory Tests Should be Ordered?

What Laboratory Tests Should be Ordered? Glucose CBC and platelets Electrolytes PT, PTT ECG CXR Noncontrast head CT

Interventions?

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 22

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?

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

Case Scenario A decision is made to give t-PA. How is t-PA administered How is suspected intracranial hemorrhage managed?

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!

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

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.