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16 Cards in this Set
- Front
- Back
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Stroke and TIA: definitions |
Stroke- caused by an acute clot in a cerebral artery (ischemic stroke) or bleeding from cerebral artery (hemorrhagic stroke) -Ischemic stroke causes- embolized clot (a-fib), septic embolic from a heart valve, embolized DVT with patent foramen ovale -Hemorraghic stroke causes- ruptured aneurysm or bleeding from arteries stressed by years of hypertension
Stroke definition- an acute onset of a neurological deficit TIA definition- an acute neuro deficit that rapidly improves -Old definition of stroke- symptoms had to last 24 hours -Time period is irrelevant in age of thrombolytics since we only have 3 hours (or 4.5 hours in some patients) to give them -Most TIA symptoms resolve in 30-60 minutes
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Stroke and TIA: prehospital concerns |
Prehospital concerns -Get a good history- when exactly did the symptoms start? When was the last time the patient was seen normal?
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Stroke and TIA: thrombolytic window, mimicry of stroke |
PEARL- Thrombolytic window- 3 hours from onset of sxs (4.5 in some patients) Patients who “wake up” with symptoms generally aren’t eligible for thrombolytics
-Is this an old neuro deficit or a new deficit? -Bring family members/bystanders to the ER to help with history, if possible -Be aggressive with airway management
PEARL- GET A D-stick- hypoglycemia can mimic stroke (theory- area of brain damaged by a previous stroke is more susceptible to hypoglycemia and causes neuro deficits with low blood sugar)
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Stroke and TIA: Priorities |
Emergency Department priorities (if not done enroute by EMS)
1) Get a good history 2) Do a rapid neuro exam 3) Get a D-stick 4) IV access 5) Non-contrast head CT |
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Stroke and TIA: history and initial steps |
Activate stroke protocol (if applicable)- should alert labs and radiology to expedite labs and page the on-call call neurologist
History- find out exactly when the symptoms started, Slurred speech? Confusion? Motor weakness? Any headache or trauma? Any falls?
Medical History- Hx of HTN, DM, previous stroke? Surgical history (especially in any surgery in past 14 days, spinal or brain surgery in past 3 months), taking any anticoagulants (warfarin, dabigitran, clopidigrel)?
Rapid neuro exam prior to CT- use Cincinnati Stroke Scale as a basis -FAST- Facial droop, arm drift, slurred speech, time from onset -Add on to this- extremity strength in all extremities
D-stick- if low, treat and observe for effect, if over 400 may be contraindication to thrombolytics
IV access/EKG- DO NOT let IV access delay transport to CT scanner, if patient is a tough stick then take an IO device to the CT scanner just in case Labs- CBC, Chem 10, Coags, other testing as clinically indicated
PEARL- the only thing that should delay your transport to the CT scanner is to take the patient’s airway- watch their mental status! Should probably accompany these patients to the scanner with airway equipment
In CT scanner- do your own wet read looking for blood (bright white) and talk immediately to the radiologist. If you see blood on the CT, stay in the CT scanner and get a CT angiogram of the brain with contrast (helps determine where the patient is bleeding from). Defer until creatinine comes back if pt has a history of kidney disease. Acknowledge that you probably don’t have a creatnine back in your chart. Patients with intracranial bleeding aren’t candidates for thrombolytics
Back in ED- repeat your neuro exam and do a complete NIH stroke scale (use an app or look on google)- helps us speak the same language as the neurologists- stroke scale too low or too high may be contraindication to thrombolytics
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Stroke and TIA: deciding whether or not to use thrombolytics |
A word on thrombolytics- lots of controversy in EM regarding their safety and efficacy. Test answer = give them
Patient with acute ischemic stroke, in the treatment window, persistent neuro deficit, normal blood sugar, and normal non-contrast head CT- Thrombolytic contraindications
4 categories- increased bleeding risk, severe hypertension, history that suggests seizure/SAH, miscellanrous
Increased bleeding risk: -Surgery or trauma in past 14 days -Intracranial or spinal surgery in past 3 months -Any history of intracranial bleeding -History of brain tumor or aneurysm -Active internal bleeding -Recent puncture at a non-compressible site -Platelets less than 100,000 -INR above 1.7 (controversial- some say warfarin use is an absolute contraindication no matter what the INR is)
Severe hypertension- BP above 185/110 despite aggressive treatment -Use a titratable IV med like nicardipine, labatelol, or esmolol to lower patient’s BP to above but no more than 20% in first hour
History suggesting seizure or subarachnoid hemorrhage
-Patients can have neuro deficits after a seizure (Todd’s paralysis) -Any history of seizure? Intra-oral trauma? Incontinence?
-A sudden onset of headace could be a SAH- three questions: -Was it sudden in onset? -Is this the worst headache of your life? -Was the headache maximal at its onset? -If one is positive, strongly consider SAH -Remember that head CT may be negative in the first few hours after a SAH and SAH is an absolute contraindication to TPA
Miscellaneous contraindications -Pregnancy or lactating -Blood sugar over 400 Extended window criteria (4.5 hours from symptom onset vs. 3) Contraindications for extended window (generally accepted) -Age over 80 -A history of a previous stroke and diabetes -More than 1/3 of MCA involved on head CT -Any history of anticoagulation regardless of INR |
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Stroke and TIA: use of thrombolytics |
Use of thrombolytics- TPA most common -Get two IV lines if possible (one for TPA, one for other meds) -Dosing -0.9 mg/kg (max dose 90mg- maxes out at 100kg) -10% given as a bolus -90% given over the next hour -Double and triple check this dose with the entire team -Routine foley? -Most medical literature says to avoid Foleys with TPA -Most stroke protocols have it on there -Theory- in case patient gets hemorrhagic cystitis? -If the patient can’t void on their own put foley in prior to TPA -Otherwise not sure about this given risk of catheter related UTI -Admit to ICU
No bleed but not eligible for TPA- consult neurology, interventional radiology if available (may be able to do a clot retrieval, intra-arterial TPA) Hemorrhagic stroke- Consult neurosurgery for possible interventions, reverse any anticoagulation, control hypertension below 180/110 but not more than 20% in first hour, transfer if needed for neurosurgical care TIA- Symptoms resolve and do not come back, negative head CT- give aspiring 325 mg PO if not allergic and admit for further workup
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Stroke and TIA: bell's palsy |
Bell’s palsy- stroke mimic, unilateral facial droop and can’t close eye w/o any other neuro symptoms, may have viral symptoms, MUST involve the forehead or could represent a central stroke (forehead sparing = BAD), CT not required for dx- usually caused by viruses, steroids effective, antivirals with less evidence, prednisone 60mg PO daily for 6 days, taper by 10mg per day over next 4 days. Antivirals- acyclovir- 400mg PO five times a day for 10 days- valcyclovir (Valtrex)- 500 mg PO BID for 5 days, tape eye shut at night, lubricating eye drops during the day and lacrilube at night
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Dizziness: definition according to patient? |
What does the patient mean by dizzy? -Dizzy= sensation of the room or person spinning -Lightheaded= almost passing out = near syncope -Different workup for syncope -Disequilibrium= loss of balance -Dizziness workup with low threshold for extensive testing -Generalized weakness- ACS? Electrolyes? Low hemoglobin? -Different workup if it is weakness without dizziness
PEARL- Say to the patient “What do you mean by dizzy?” “Does it feel like the room is spinning or like you are going to pass out?” “Does it feel like you have lost your balance?”
History of dizziness -Sudden or gradual onset? -Recent onset or weeks to months? -Dizzy all the time or just episodes? -Have you had this dizziness before? -What makes it better or worse? -Head or body position changes? -Other neuro symptoms? -Limb weakness, ataxia, slurred speech -Hearing loss or ringing in the ears (tinnitus)? |
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Dizziness: definition of peripheral vs central vertigo |
Most important question- is this peripheral or central vertigo?
Peripheral vertigo- caused by dysfunction in the ear/inner ear- mostly benign causes- (BPPV being most common) Central vertigo- caused by something that is obstructing bloodflow- tumor, mass, intracranial bleeding, carotid dissection- serious pathology
PEARL- In general, the worse the patient feels, the more sudden the onset, and it is episodes of dizziness instead of continous = peripheral vertigo
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Dizziness: peripheral vs central vertigo differences |
peripheral: sudden onset, severe intensity, duration of seconds-minutes, horizontal nystagmus, worsened by certain positions, no neuro position, may have decreased hearing or tinnitus
central: usually gradual onset, mild intensity, usually weeks to months, horizontal/vertical/rotatory nystagmus, no relation to position, usually neuro findings, no auditory findings |
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Dizziness: exam |
Exam- do a complete exam including examining the ear and ear canal (foreign body, bulging TM, etc?) Neuro exam- really focus on cerebellar testing (finger to nose, rapid alternating movements, pronator drift, and gait) Extra-ocular movements- if extra-ocular movements induce patient’s dizziness and resolves with visual fixation- it suggests BPPV PEARL- patients with BPPV may have difficulty walking and positive Romberg as long as no neuro deficits and no red flags
Dix Hallpike Maneuver- drop head of bed, tell patient to fall backwards and turn head to one side, observe for symptoms or nystagmus- if positive, suggests BPPV
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Dizziness: differential dx of dizziness for central vertigo |
Central Vertigo
Tumor/Mass/intracranial bleeding- history suspicious for a central cause of vertigo plus or minus an objective neuro deficit
Carotid or vertebral artery dissection- challenging diagnosis to make history of even minor head and neck trauma, plus or minus neck pain and neurological symptoms- non-contrast head CT followed by CT neck angiogram (with contrast)
Vertebero-basilar insufficiency- elderly patients with a sudden onset of vertigo and a history of atherosclerosis. Symptoms are more related to movement of their head rather than movement of their entire body. Usually a headache and a neruo deficit or syncope.
Cerebellar stroke- Dizziness and a neuro deficit or any patient who has what sounds like a central cause of vertigo. Should have a deficit in their cerebellar neuro, may have an abnormal gait. MRI is imaging of choice after a non-contrast head CT (see section on HiNTS exam)
Infection- meningitis, encephalitis, or brain abscess. Patient is febrile and toxic appearing with dizziness, plus/minus neck stiffness or meningismus. Non-contrast head CT followed by a lumbar puncture and aggressive antibiotic/antiviral treatment as indicated.
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Dizziness: differential dx of dizziness for peripheral vertigo |
Peripheral vertigo
Benign Paroxysmysal Postional Vertigo (BPPV)- this is what we are usually talking about when we say “vertigo”. BPPV tells you what it is- BPPV is benign, it has paroxysms or episodes, the vertigo is related to position, and its vertigo.
Acute otitis media- a patient with a lot of ear pain with a bulging tympanic membrane and viral symptoms. Rare in adults
Labrynithitis- a patient with dizziness plus hearing loss. Mild cases- outpatient with antibiotics, toxic patients- admit for IV antibiotics. Usually have preceding URI symptoms or the patient is taking ototoxic medications (example- aminoglycosides). Consider ENT consult Perilymphatic fistula- sudden onset of dizziness and hearing loss that is worse with valsalva. Causes- congenital, barotrauma, severe coughing, retching, or direct ear trauma. Consider ENT consult
Meniere’s disease- triad of dizziness, fluctuating hearing loss, and tinnitus that waxes and wanes over a period of years.
Ear canal foreign body- anything that irritates the tympanic membrane can cause dizziness
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Dizziness: workup |
Lab Workup- usually low yield in dizziness, in older patients- consider CBC, Chem 10, UA, coags (if anticoagulated) to look for electrolyte abnormalities, UTI, etc.
Imaging- not needed in peripheral vertigo, if suspecting central causes of vertigo, start with non-contrast head CT.
PEARL- a head CT is not sensitive for cerebellar or posterior strokes (cranial bones cause scatter)- MRI is imaging of choice
HiNTS exam (Head impulse testing, Nystagmus, Test of Skew)- shown in one study to be superior to MRI in diagnosing posterior strokes- see EmCrit podcast 33 at http://emcrit.org/podcasts/posterior-stroke/ |
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Dizziness: meds/tx |
Medications
Meclizine (Antivert)-antihistamine with anti-emetic properties Dose- 25mg PO twice a day, mildly sedating
Diazepam (Valium)- benzodiazepine Dose- 5mg PO three times a day, very sedating- give sedation warnings (no alcohol, driving, etc.)
Ondansetron (Zofran)- anti-emetic- can be used in between doses of meclizine for vomiting if needed Dose- 4 or 8mg PO/ODT every 6 hours as needed
Epley maneuver- can be helpful in patients who are having recurrent vertigo or they failed outpatient medications. Give patient a handout or have them search youtube for videos |
