Stroke Simulation

Question 1

Modifiable stroke risk factors?

Answer 1

HTN
Smoking
DM
AFib
Poor diet/sedentary lifestyle
Obesity
PAD
Heart disease
Drug and alcohol abuse

Question 2

Interventions to address stroke risk factors?

Answer 2

Lifestyle modifications (diet exercise, smoking cessation, etc.)
BP management
Anti-thrombotic therapy
Statins

Question 3

Possible stroke interventions by subtype?

Answer 3

Ischemic - IV tPA if candidate, endovascular therapy

Hemorrhagic - hemostasis

Question 4

Steps in patients presenting with stroke-like symptoms:

Answer 4

1. ABCs
2. CC and HPI, time last known well (assess tPA treatment window),
3. Monitor, vitals and glucose, PIV x2, labs (BMP, CBC, PT/INT, PTT (consider T&S, ETOh, tox screen, troponin I, lipid panel, A1C, LFTs, pregnancy test)), patient’s weight, EKG (do not delay CT for labs/EKG)
4. Neurologic assessment (NIHSS, FAST), call code stroke/stroke kit
5. Ensure patient is stable - STAT Non-contrast head CT
6. Determine IV tPA eligibility

Question 5

Stroke mimics?

Answer 5

Hypoglycemia
Psychogenic
Seizures (w/ post-ictal paralysis)
CNS infections
Brain tumors
Drug toxicity
Demyelinating disorders
Complicated migraine
HTNive encephalopathy (HA, delirium, seizure)

Question 6

NINDS treatment windows?

Answer 6

Door to expertise <10 minutes
Door to CT initiation <25 minutes
Door to CT interpretation <45 minutes
Door to needle time <60 minutes

Question 7

Indications to treat BP in patients presenting with extreme HTN and IV tPA candidates?

Answer 7

Extreme - SBP >220, DBP >120

IV tPA candidates - SBP >185, DBP>110

Question 8

Rx BP in IV tPA candidates?

Answer 8

Labetalol 10-20 mg IV over 1-2 minutes, may repeat 1x

OR

Nicardipine 5 mg/hr IV, titrate up by 2.5 mg, give every 5-15 minutes to max dose of 15 mg/hr

Question 9

Once IV tPA has been given, what should be done?

Answer 9

Monitor VS/neuro assessment:
-Q15 minutes for first 2 hours
-Q30 minutes for next 6 hours
-Q1 hour for 6-24 hours
Asseess signs and symptoms of bleeding
Maintain SBP <180 and DBP<105

Question 10

Time window for IV tPA?

Answer 10

Ischemic stroke from 0 to 3-4.5 hours of time last known well

Question 11

Contraindications to tPA use?

Answer 11

CT with evidence of hemorrhage, hypodensity >1/3 hemisphere
BP >185/110
Glucose <50
History of ICH, stroke, or major head trauma within 3 months
Seizure at onset (unless thought to be due to stroke)
Noncompressible puncture of artery or organ <7 days
INR>1.7
Recent heparin with increased PTT
Platelet count <100,000

Question 12

Contraindications to using tPA from 3-4.5 hours?

Answer 12

Age >80
Any warfarin use
NIHSS >25
Previous stroke AND diabetes

Question 13

Relative contraindications to tPA use?

Answer 13

Recent surgery or major trauma <14 days
Pregnancy
GI or urinary tract hemorrhage <21 days
MI <3 months
Rapidly improving or minor neuro deficits likely to result in iminimal or no deficit

Question 14

tPA dose?

Answer 14

0.9 mg/kg (max dose 90 mg)
Usually reconstituted 100 mg/100 mL
Dose must be independently verified by licensed provider
Administer 10% of total dose as bolus over 1 minute
Infuse remaining dose over 60 minutes
Call pharmacy for dosing support

Question 15

Management of warfarin-associated ICH?

Answer 15

If on warfarin with elevated INR
Give Vitamin K (phytonadione) 5-10 mg IV (over 20-60 minutes not to exceed >1 mg/min)
KCentra (IV prothrombin complex concentrate)
Consider 2-4 units FFP

Question 16

K-Centra dosing?

Answer 16

If INR 2 to <4: 25 IU/kg (max 2500)

If INR 4-6: 35 IU/kg (max 3500)

If INR >6: 50 IU/kg (max 5000)

Question 17

Contraindications to KCentra?

Answer 17

Patient on/given recombinant activated factor seven (rFVIIa)

Patient Hx of HIT or DIC

Question 18

ICH management

Answer 18

Reverse coagulopathy if present (obtain weight for dosing)
Admit to neuro ICU
Early BP lowering limits hematoma expansion but hasn’t been established to improve outcomes, optimal targets remain uncertain
Consider neurosurgery consult
Elevated BP, temperature, glucose, intracranial pressure, and seizure activity have been associated with poor outcomes