Thursday, March 8, 2018

Management of Stroke

Hello, seeker of knowledge! Let’s see how we manage one the most common emergencies in medicine, stroke or cerebrovascular accident.


PRE-HOSPITAL CARE:

Cincinnati Pre-Hospital Stroke Scale (CPSS) helps make a prompt diagnosis and includes FAST -

Face drooping

Arm weakness

Speech difficulty

Time to call Emergency Medical Services

HOSPITAL CARE:



TIA = Transient Ischemic Attack
ABC = Airway, Breathing and Circulation
BGL = Blood Glucose Level; Both HYPO- and HYPER- glycemia are to be corrected
Hhg = Hemorrhage
Lytes=Electrolytes; ABG =Arterial Blood Gas; RFT=Renal Function Test; LFT=Liver Function Test
rTPA = recombinant tissue plasminogen activator
ASA = Acetyl Salicylic Acid = Aspirin
UFH = Unfractionated Heparin;  LMWH = Low Molecular Weight Heparin

ADDITIONAL INVESTIGATIONS MAY BE DONE - PROVIDED THROMBOLYSIS, IF INDICATED PER CT - IS NOT DELAYED


TREATMENT PRINCIPLES:

To minimize:
Ischemic penumbra (area around umbra/ ischemia)
Secondary brain injury
Risk of recurrence


THROMBOLYSIS:

INDICATIONS -

Mnemonic: ADD 1/3rd to CT after consent

Age 18 years or more
Diagnosis of Acute Ischemic Stroke(AIS)
Duration of symptoms 4.5 hours or less
AIS involves more than 1/3rd MCA territory
CT reveals no hemorrhage or edema
Consent of the patient or surrogate decision maker

CONTRAINDICATIONS -

Mnemonic: SHIP BLAST

Stroke in the last 3 months
Head injury in last 3 months
Intracranial hemorrhage
Prothrombin Time > 15 sec
BP > 185/110
Lumbar puncture in last 7 days
Anticoagulants use / Arterial puncture in last 7 days
Surgery within last 14 days
Thrombocytopenia < 100,000

PRECAUTIONS:
No anti-thrombotics for 24 hours
No Foley’s catheter for 2 hours

ADVERSE DRUG REACTIONS:
Intra-cranial hemorrhage
Allergy


ANTI-COAGULANTS:

INDICATIONS:

Mnemonic: My L.A.P.D. job

Recent MI
Left ventricle aneurysm or dyskinesia
Atrial fibrillation
Prosthetic heart valve
Deep vein thrombosis prophylaxis


MEDICINE PEARL: MI and stroke have essentially the same pathophysiology. Clots blocking arteries! However, we give DUAL anti-platelet therapy [DAPT], i.e. Aspirin and Clopidogrel for MI while there’s only Aspirin administered to a patient with stroke.


NURSING CARE:
Bowel and bladder care
Prevention and treatment of bed sores

REHABILITATION:
Use of walkers and crutches
Full range of active and passive joint movements


FURTHER READING:
Other rehabilitative therapies offered
Risk factors and preventive strategies
Alternative drugs and procedures


Hope this helps. Happy studying!
-- Ashish Singh.

2 comments:

  1. Nice notes! Thanks a lot for your effort.

    ReplyDelete
  2. Thank you so much! I'm happy it helps you. Let me know if you need any particular topic, I'd try my best. :)

    ReplyDelete

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