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21 Cards in this Set
- Front
- Back
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Name 2 prehospital stroke scales and differentiate them.
Hint: Midwest city, west coast city |
(1) Cincinnati Prehospital Stroke Scale - face, arm, speech - anterior ischemic stroke
(2) Los Angeles Prehospital Stroke Scale - screening: age, baseline, hx sz, BG, onset time - asymmetry of smile or grimace, hand grip, arm strength |
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What is the golden hour? |
Hospital door to IV tPA administration =< 60 minutes |
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What are goal times in the ER? There are 5 of them. |
Hospital door... to MD, 10 minutes to stroke team, 15 minutes to CT start, 25 minutes to CT interpretation, 45 minutes to drug administration, 60 minutes |
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What is purpose of ABCD2 Score? |
Predict 2-day stroke risk following TIA. Determines if patient should be inpatient or can be followed as an outpatient. |
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What are the elements of the ABCD2? |
Age >= 60 (1) BP >= 140/90 (1) Clinical features: unilateral weakness (2), speech disturbance without weakness (1) Duration of symptoms: >= 60 min (2), 10-59 min (1), < 10 min (0) DM? Yes (1) |
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What is the significance of the ABCD2 score? |
Score = 0-3 means pt has a 1% chance of having a stroke in the next 2 days and 0-3.5% in 90 days. ==> DC'ed and f/u as outpatient Score = 4-5, 4.1% 2-day and 8-12% 90-day ==> inpatient Score = 6-7, 8.1% 2-day, 17-22% 90-day ==> inpatient |
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What stroke scale predicts outcome from a SAH? What are the grades (5)? |
Hunt and Hess Stroke Scale. Think: SAH and HAHS. Higher score = poor outcome. I - asymptomatic or minimal HA or nuchal rigidity II - mod-severe HA, nuchal rigidity, no neuro deficit except CN palsy III - drowsiness, confusion, or mild focal deficit IV - stupor, mod-severe hemiparesis, possible early decerebrate rigidity, vegetative disturbances V - deep coma, decerebrate rigidity, moribund appearance |
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What does the Glascow Coma Scale measures and what are indications of the score? |
GCS measure LOC: eye opening (1-4), best verbal response (1-6), best motor response (1-5). Max = 15, min = 3 |
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Which stroke scale predicts a vasospasm after SAH? What are the levels (4)? |
Fisher Grade, based on blood volume on CT scan. (1) no hemorrhage (2) SAH < 1 mm thick (3) SAH > 1 mm thick (4) SAH of any thickness with IVH or parenchymal extension |
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What is the ICH Score? |
Predicts 30-day mortality of a pt with ICH. Scores 0-6. Higher score = higher mortality. |
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What is grading system predicts surgical risk of AVM? |
Spetzler-Martin grading system calculates surgical risk of AVM, f(size AVM, eloquence of brain tissue, pattern of venous drainage) Size: small < 3 cm: 1, med (3-6 cm): 2, large (>6 cm): 3 Location: noneloquent (0), eloquent (1) Venous drainage: superficial (0), deep (1) |
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What are time limits for IV tPA? What are other inclusion criteria? |
FDA - 3 hours from symptom onset
American Stroke Association - 4.5 hours, but with exclusions: > 80 yoa, NIHSS > 25, on oral anticoagulant, Hx DM, Hx ischemic stroke
Dx of ischemic stroke causing measurable neuro deficity and >= 18 yoa |
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Is tPA administered interossesously? |
Nope, not recommended. |
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Do you wait for lab results before administering tPA? |
No, unless the pt is on an anticoagulent. |
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Is pregnancy a CI for tPA? |
It's a relative exclusion criteria. |
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List absolute exclusion criteria of tPA (15) |
1. head trauma or stroke w/i 3 mos 2. symptoms of SAH 3. arterial puncture at noncompressible site in last 7 days 4. hx ICH 5. intracranial neoplasm, AVM, aneurysm 6. recent intracranial or intraspinal surgery 7. SBP > 185 or DBP > 110 8. active internal bleeding 9. acute bleeding diathesis (susceptibility to bleeding) 10. platelet count < 100K/mm3 11. heparin w/in 48h, resulting in aPTT > normal 12. on anticoagulant with INR > 1.7 or PT > 15s 13. on direct thrombin inhibitors or direct factor Xa inhibitors with elevated labs (ie aPTT, INR, platelet count, ECT, etc.) 14. BG < 50 mg/dL 15. CT shows multilobar infarct |
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List relative (benefit > risk) exclusion criteria of tPA (6) |
1. minor or rapidly improving stroke symptoms 2. pregnancy 3. seizure at onset with postictal residual neuro deficits 4. major surgery or serious trauma w/i 14 days 5. recent GI or urinary tract hemorrhage (w/i 21 days) 6. recent acute MI (w/i 3 months) |
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What are complications during and soon after tPA administration, and what do you do whey they occur? |
1) symptomatic ICH: stop tPA, CT, labs (coag, fibrinogen, type and crossmatch, CBC), administer 6-8 U of cryoprecipitate containing factor VIII and 6-8 U of platelets 2) bleeding from another site: monitor 3) angioedema (higher risk if on ACE inhibitor): histamine antagonists (ie benadryl, corticosteroids, airway management if necessary) |
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Describe monitoring during and 24 hours post tPA. |
Vital signs and neuro status q15" during tPA infusion, then q15" x2h, then q30" x6h, then q1h x16h |
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What are acute interventions for hemorrhagic stroke (4)? |
1. Correct coagulopathy a. thrombocytopenia - platelet tx, goal > 100K ppm b. if on anticoagulation - reverse warfarin with Vit K, FFPlasma (need ABO blood type first) to replace clotting factors, prothrombin complex concentrates (contains 3-4 of factors II, VII, IX, X) - new anticoagulants - no reversal agents 2. Ventriculostomy - reduces ICP - for intracerebral stroke, if GCS <=8, or for IVH, hydrocephalus or signs of herniation - for SAH, it pt has acute hydrocephalus 3. Manage ICP 4. Surgery - cerebellar hemorrhage with neuro deterioration, brain stem compression, or hydrocephalus causing compressing obstruction - supratentorial clots > 30 ml and w/in 1 cm of surface ==> craniectomy |
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What are interventional radiology treatments for ischemic stroke (3)? |
1. IA tPA - not approved by FDA, 90-120" door to IA tPA 2. Mechanical thrombectomy devices (coil retrievers, aspiration / debulking systems, stent retriever devices) 3. Hemicraniectomy - to decompress brain. Surgery within 48 hr has better outcomes than medical management.
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