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Acute Stroke Care 2008 A Clinical Update 2008 Mary Becker, MD

Acute Stroke Care 2008 A Clinical Update 2008 Mary Becker, MD. Acute Stroke Initial Assessment in the ED. Physical Exam Assess patient’s ability to swallow (or make patient NPO) NIH Stroke Scale. Acute Stroke Initial Assessment in the ED. Diagnostic Studies Non contrast CT of the head

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Acute Stroke Care 2008 A Clinical Update 2008 Mary Becker, MD

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  1. Acute Stroke Care 2008A Clinical Update 2008 Mary Becker, MD

  2. Acute Stroke Initial Assessment in the ED • Physical Exam • Assess patient’s ability to swallow (or make patient NPO) • NIH Stroke Scale

  3. Acute Stroke Initial Assessment in the ED • Diagnostic Studies • Non contrast CT of the head • Lab work: CBC with diff., BS, PT/INR, PTT (if on coumadin), lytes, BUN/Cr, cardiac enzymes • EKG • For select patients consider: toxicology screen, pregnancy test

  4. Acute Stroke Initial Assessment in the ED • Diagnosis • Consider Stroke Mimics: • Metabolic- hyper/hypoglycemia • Trauma • CNS lesions/tumors • Complicated migraines • Post ictal state (Todd’s paralysis) • Pyschogenic

  5. Acute Stroke in the ED Consults • Consider a neurology consult on any patient who may be a tPA candidate or any patient with an unclear presentation • Call One Call: 1 866-662-6632

  6. Acute Stroke in the ED • Treatment • For tPA refer to the MaineGeneral tPA Guideline • ASA (unless contraindicated)

  7. Acute Stroke in the ED • BLOOD PRESSURE Treatment • For patients NOT receiving lytic therapy: Treat SBP> 220 or DBP> 120 or MAP > 120 • Recommended drugs: LABETALOL 10 MG IV, may repeat dose every 10 minutes to a max of 150 mg if needed • OR • NICARDIPINE (1mg/ml) start at 5mg/hr and titrate (max dose of 15mg/hr) • AVOID LARGE OR RAPID DECREASES IN BP( no more than a 15-25% decrease over 24 hrs)

  8. Acute Stroke in the ED • For patients receiving lytic therapy treat for SBP>185 or DBP >110 • Recommended drugs: • LABETOLOL 10-20 mg iv over 1-2 min, may repeat x1 • Or • NITRO PASTE 1-2 inches • Or • NICARDIPINE drip 5mg/hr, titrate up by 0.25 mg/h at 5-15 min intervals, max dose 15 mg/h; when desired BP achieved reduce to 3mg/h

  9. Acute Stroke in the ED • Treatment, cont. • O2 as needed • Treat hypo/hyperglycemia (>160) as needed

  10. Acute Stroke Day 1 • Additional Diagnostic Studies • If necessary: TEE, MRI/MRA, carotid dopplers, CXR (if not done in ED) • If ECG abnormal, consider cardiac enzymes • Telemetry for first 24 hours of stay • Lipid panel

  11. Acute Stroke Day 1 • For all patients: lipid panel • If no evidence of Htn, increased lipids or older age consider hypercoaguable work-up: • Leiden factor V, Protein C and S, homocysteine, ANA, anticardiolipin antibodies, lupus anticoagulant, ESR, RPR, TSH, RF,

  12. Acute Stroke Day 1 • Treatment • Evaluate for continuation of patient’s prior medications, (especially antihypertensives & antihyperglycemics) • If necessary: IV hydration, treatment of pain • If necessary: lipid lowering therapy • VTE PROPHYLAXIS: (heparin 5000units sc BID (do not combine with iv heparin therapy) • Lovenox 40mg sc qd • if patient’s creatinine clearance less than 30 or patient body weight less than 45 kg use: Lovenox 30mg sc qd

  13. Acute Stroke Day 1 • Treatment, con’t. • Antiplatelet drugs • ASA is gold standard and lowers stroke risk by aprx 15% • Plavix and/or aggrenox may be considered in select cases

  14. Acute Stroke Day 1 • Treatment: Heparin • Possible uses: • Suspected hypercoaguable state • Low blood flow from significant large vessel stenosis • Arterial dissection • Cardiac embolic source with high risk of occurrence

  15. Acute Stroke Day 1 • Treatment: Coumadin • Proven treatment for cardiac embolic source of stroke in a fib patients • Commonly used for c embolic source in patients with LV thrombus, recent MI or cardiomyopathy • Unproven efficacy if no embolic source found

  16. Acute Stroke Day 1 • Contraindications for Heparin/Coumadin • Recent GI bleed • Recent ICH • Vitamin K deficiency • Abnormal platelet level • Frequent falls

  17. Acute Stroke Day 1 • Contraindications for Antiplatelet drugs • Active bleeding • GI lesions (ulcers) • Recent ICH • Allergy • Use caution with liver or kidney impairment

  18. Acute Stroke: • Begin patient and family education early • Begin developing a plan for rehab early • Consider rehab for every patient • Physiatrists are available by phone through New England Rehab Hospital to assist in determining patient appropriateness for rehab.

  19. References: 1. AHA, Guideline for the Diagnosis and Treatment of Acute Ischemic Stroke, 4/07 2. MaineHealth Ischemic Stroke Pathway (this tool was developed in the fall of 2007 by neurologists from across the MH system based on a review of the acute stroke literature)

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