Stroke

Question 1

FAST

Answer 1

Face: droop
Arm: drifting arm
Speech: slurred speech
Time: how long have they been experiencing these symptoms

Question 2

TIA

Answer 2

caused by a temporary clot or block of blood flow

Question 3

Risk factors for stroke

Answer 3

HTN*, AF, females > males, African Americans, > 55 YOA, athlerosclerosis, DM, previous stroke, smoking, dyslipidemia, PFO, sickle cells

Question 4

What is the tie-frame for alteplase to be given

Answer 4

• within 3 hours of symptom onset
• within 4.5 hours of symptom onset in select patients
• within 60 min of hospital arrival

Question 5

Alteplase and BP

Answer 5

BP should be < 185/110 mmHg before initiating alteplase - can lower BP to be given alteplase
-keep BP < 180/205 for the first 24 hours after tx

Question 6

Bleeding contraindications to alteplase

Answer 6

-active bleed (ICH)
-conditions or labs that increase bleeding (INR > 1.7)
-drug interactions with bleeding risk

Question 7

Contraindications to alteplase

Answer 7

-active internal bleeding
-hx of recent stroke
- severe uncontrolled HTN
- prior ICH
- labs that indicate bleed
-conditions that increase bleeding risk
-tx of LMWH within 24 hours , use of direct thrombin inhibitor or direct factor xa inhibitor within the previous 48 hrs

Question 8

dosing of alteplase

Answer 8

0.9 mg/kg (maximum dose 90 mg)

Question 9

ASA

Answer 9

ASA 162-325 PO within 24-48 hours after stroke onset is recommended (should not be given within 24 hours of fibrinolytic therapy)

Question 10

HTN management

Answer 10

antihypertensives should be given to lower BP to give alteplase and to maintain BP for at least 24 hours after infusion.
-those who do not receive alteplase therapy may not require antihypertensive therapy unless severelt uncontrolled

Question 11

hyperglycemic management

Answer 11

140-180

Question 12

DVT ppx

Answer 12

SCDs or LMWH (after 24 hrs if treated with alteplase)

Question 13

Secondary prevention: HTN

Answer 13

goal < 130/80 mmhg

Question 14

Secondary prevention: HLD

Answer 14

high intensity statin - atorvastatin 80 mg

Question 15

Secondary prevention: DM

Answer 15

maintaining BG and A1c

Question 16

Secondary prevention: AF

Answer 16

anticoagulation

Question 17

non-cardioembolic stroke tx

Answer 17

ASA, aggrenox, or clopidogrel is recommended with 24-48 hr of symptom onset

Question 18

DAPT: clopidogrel and ASA

Answer 18

initiated within 24 hours of symptoms and continued for 21-90 days followed by anti-platelet monotherapy

Question 19

Hemorrhagic stroke tx

Answer 19

lower ICP - mannitol or hypertonic saline
-if clinical indication for seziures, do not ppx treat

Question 20

mannitol

Answer 20

inspect for crystals
-needs filter for infusion

Question 21

acute subarachnoid hemorrhage

Answer 21

3-21 day delay in bleed
-oral nimodipine to prevent vasospasm

Question 22

Nimodipine (Nymalize)

Answer 22

-do not administer IV - death and life threatening adverse events
-can take capsules and make oral solution