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Exam 4
Lecture 12- managment of stroke
62
Anatomy
2nd Grade
12/12/2013

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Cards

Term
Tx of acute stroker depedns on category, what are the 3
Definition
TIA
hemorrhagic
embolic
Term
look at algorythm on slide 2 to see quick overview before exam
Definition
Term
if TIA occurs in front of you how do you tx?
Definition
as emergency since cant tell if full stroke at that point
Term
action to take if acute TIA occurs : 4
Definition
treat as emergency
basic life support
keep pt safe
transfer to ER
Term
2nd prevention of TIA stroke gold stanadrd
Definition
aspirin
Term
when prescribing apsirin, 81 mg or 325?
Definition
doesnt matter, want tog ive lowest dose possible but normally the dosage form drives the one used
Term
the two issues with aspriin for 2nd prevention are-
Definition
81 or 325 mg
underuse
Term
why isnt ticlopidine used anymore-2
Definition
BEER's List
neutropeia
Term
if a pt fails apsirin, like intolerant or allergy what is the nex med to use
Definition
clopiogrel 75 mg
Term
* in 2nd prevention study show that if apsirin isnt usable, just switch to clop instead of combo, as combo increase risk fo bleeding and no decrease in stroke
Definition
Term
dipyridamole ER and aspriin combo shown to more effective than monotherapy, but what are the 2 rpoblems-
Definition
1- high % of dypyridmole pts d/c due to side effects
2. daily dose of aspirin with this is only 50 mg (if have risk of Mi would need additionla apsinrin)
Term
when are anticaogs used as 2nd prevention in TIA-2
Definition
if pt has a fib or mechanical heart valves
Term
INr for mechanical valves is
Definition
2.5-3.5
Term
the dose for warfarin 2nd prevention TIA is
Definition
5 mg qdaily
Term
what is not a loading for warfarin
Definition
10 mg x 3 day ->7.5->5 mg
Term
INr monitoring for warfarin
when can you go to monthly?
Definition
2x weekly for first 2 weeks, then q 2 weeks
2 good INRs 2 wks apart
Term
when is dabigitran superior to warfarin
Definition
in a fib
Term
what are the problems with dabigitran-3
Definition
no antidote
renal adjustment
elderly have hgiher GI bleeds and worse renal
Term
rixaroxiban and apixiban are non inferior to warfarin when?
when would you use these?
Definition
non valve a fib
if hard to stabilize on warfarin
Term
when is surgery indicated for TIA
Definition
>75% stenosis and symtpomatic
Term
intitial work up for stroke pt needs to done in how long
Definition
10 min
Term
what needs to be addressed in initial work up of stroke pt at ER-3
Definition
consciousness, ataxia, vital
Term
what 4 labs need to be drwan when stroke pt shows up
Definition
CMP
CBC
cardiac enzymes
EKG
Term
what is the most important test to run when stroke pt comes in
Definition
NON CONTRAST CT scan w/i 180 min onset of symtpoms
Term
pros to using MRI over CT-2
cons-2
Definition
better when know thromoblytics cant be used, can better Id deep infarcts
labs dont alwyas offer MRI and contraindt in pacemakers or metal implants
Term
general supoprtive measures (give to everyone)-6
Definition
airway managment
Oxygen
hydration
BP control
fever control
hyperglycemia
Term
when do you give O2?
Definition
if hypoxic
Term
for hydraiton what is reccomedned and what is not
Definition
ringers/saline reccomedn
not= dextrose jic hyperglycemic
Term
BP control for pt not candidate for t PA,when do you treat
Definition
if BP > 220-240/120-140
Term
for pt who is candidate for t pa, what is BP control tx
Definition
use labetolol before an d during t pa admin
Term
what is most common time to intiate BP regimen after stroke
Definition
48 hrs (no real evidence tho)
Term
indicaitons for thrombolytic therapy
Definition
over 18
embolic confirmed thru CT scan
pt presents w/i 3 hrs
Term
some contraindications for T pa-7
Definition
heparine w/i 48 hrs AND elevated aPPT
recent warfarin AND elevated INR
trauma last 3 months
recent MI
any bleeding
seizure
BP>185 or Dys>110
Term
is 75 yo a cut off for T PA?
Definition
no
Term
** if have premorbid neuro deficits prior to onset of symtpoms of stroke dont do T PA
Definition
Term
dose of alteplase
Definition
.9 mg/kg, 10% bolus over 1 min then rest over 1 hr
Term
risk of hemorrhage for acute embolic stroke is what hrs
Definition
first 36
Term
when can T Pa window be extended to 4.5 hrs:
Definition
pt qualifies for T PA AND
<80
no anticoags
NIHSS< 25
NO prev x stroke and diabetes
Term
for BP control in supportive care what do you use if BP >220 or diastolic >121
what is diastolic > 140
Definition
labetolol 10 mg over 1 min
nitroprusside for BP decrease 20%
Term
can use low dose SQ heparin after stroke, if you wanted to how long do you have to wait?
Definition
24 hrs post T pa
Term
*2nd prevention for full stroke is same as TIA
Definition
Term
if intracerebral hemorrg assoc with factro def or thombocytopenia what do you do
Definition
factor replace/platelets
Term
if hemorrhage stroke assoc with high INR from warfarin what do you do
Definition
hold warfarin
IV Vit K + PCC/FFP
Term
pros and cons of PCC
smae but for FFPrxn, large vol needed
Definition
all vit k factors, use small vol; not FDA approved
FDA approved; can cause allergic
Term
when do you give seizure meds for stroke pt?
Definition
hemorrhagic and had to have had one or EEG shows evidence
Term
seconadry prevention of hemorrhagic stroke
Definition
BP control <140/90, if diabetic 130/80
Term
if subarachnoid hemorrhage tx for
how long after can this ocurr
Definition
vasopsam prevention/DCI
-3 wks
Term
what drug is started at subarachnoid hemorg? how long do you cont it
Definition
nimodipine 60 mg q 4 hrs
21 days
Term
seizure tx for subarrachoind hemmor
Definition
can do during the ACUTE STAGE
dont do it chronically!!!!!
Term
other intervention for hemmrohg to reduce cerebral edema
Definition
mannitol .35mg/kg q 8 hrs
monitor for osmolalaltoy (want 300-310)
Term
what do you give if subarachnoid pt has vasospasm
Definition
dopamine 3 mg/kg/min *increases bleed risk
Term
*dexmethasone used before mannitol, but since icnrease infxand glucose dont use as much
Definition
Term
surgery for hemorrhagic pt indicated if:
Definition
bleed need surface
not comatose
(if cerebellar cna do within 2 days)
Term
intervention for hemiparesis:2
Definition
OT
PT
Term
intervention for contractures and tone problems:3
Definition
PT
OT
mmuscle relaxants(baclofen)
Term
intervention for neuropathic/phantom pain:3
Definition
PT
TCA
neurontin
Term
if pt has swallowing difficulties, what med intervention
Definition
crush/liq meds only
Term
neurogenic incontinence (no nerves to bladder) or functional (physcial defects prevent restroom use) interventions:
Definition
no medicaitons, bc they are for urge incont!!!!
Term
what meds are indicated for vascular dementia
Definition
none
Term
lack of awareness of deficits (part right sided stroke) intervention
Definition
repeat enforcement of safety pre cautions, supervise
Term
post stokree depressin often seen in what side
Definition
left side
Term
intervention for depression
Definition
TCAs vs SSRIs (TCAs have anticholinergic so maybe SSRI like fluoxetine
* if done within 3 mo more ADL funct
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