Difference between revisions of "Stroke (main)"

(Created page with "==ER Work-Up== 0) Icon/Glu check 1) Head CT (non-con) 2) ECG (a. fib) 3) UA/Utox 4) CBC, Chem 7, LFTs, PT/PTT 4+) Trop (in elderly; poss silent MI) ==DDX Ischemi...")
 
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==ER Work-Up==
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==Work-Up==
  
  
0)  Icon/Glu check
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* Glucose check
 
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* CBC, chemistry, coags, troponin
1)  Head CT (non-con)
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* Lipid profile
 
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* Head CT
2)  ECG (a. fib)
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* ECG (a. fib)  
 
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* Also consider:
3)  UA/Utox
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* Pregnancy test
 
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* Utox
4)  CBC, Chem 7, LFTs, PT/PTT
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* TTE with bubble study
 
 
4+)  Trop (in elderly; poss silent MI)
 
 
 
 
   
 
   
  
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1) Thrombosis (atherosclerosis, vasculitis, dissection)
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* Thrombosis (atherosclerosis, vasculitis, dissection)
 
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* Embolic (cardiac -a.fib, valve, septic- CAS, hypercoagulable)
2)  Embolic (cardiac -a.fib, valve, septic- CAS, hypercoagulable)
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* Vasospasm
 
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* Hypotension/watershed  
3)  Vasospasm
 
 
 
4)  Hypotension/watershed
 
 
 
 
   
 
   
  
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A) Ischemic
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* Ischemic
 
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* Glycemic control
    1) <3 hrs -->  see Neuro: CVA (tPA Criteria)
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* Use insulin to maintain blood sugar < 185
 
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* Temperature control
    2) >3 hrs
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* Treat fever > 37.5 (99.5)  
 
 
          a) ASA (if ASA intolerant or failure, then Ticlopidine, Plavix, or Coumadin)
 
 
 
          b) HTN Control (no rx unless >220/120 -- labetolol, nitro, or esmolol gtt)
 
 
 
              -e.g. labetolol 5mg IV Q15min (max =300mg)
 
 
 
          c) Heparin only if cardiac embolic source/a-fib.
 
 
 
B) Hemorrhagic --> see Neuro: Intracranial Hemorrhage (ICH)
 
 
 
 
   
 
   
  
==Neuro Work-Up==
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* If pt is tPA candidate (CVA (tPA criteria and dosing)
 
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* Consider tPA
 
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* If give tPA DO NOT give antiplatelets/anticoagulants for at least 24 hours
5)  ESR, ANA, RPR, TSH
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* BP Control
 
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* If potential candidate for tPA but BP > 185/110:
6)  Guiac
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* Labetalol 10-20mg IV over 1-2min, may repeat x 1, OR
 
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* Nicardipine IV 5mg/hr, titrate up by 2.5mg/hr q5-15min, max 15mg/hr; when desired BP reached lower to 3mg/hr OR
7)  Fasting lipids
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* other agents (hydralazine, enalaprit, etc) may be considered when appropriate
 
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* If pt is NOT a tPA candidate:
8) Carotic US or MRA carotids
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* Aspirin
 
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* BP control
9) Echo w/double bubble
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* Only tx BP if > 220/120
 
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* Anticoagulation
 +
* Heparin only if cardiac embolic source/ a-fib  
 +
* Hemorrhagic
 +
* See Intracranial Hemorrhage (ICH)  
 
   
 
   
  
(YOUNG ONLY)
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==Source==
  
10)  HIV
 
  
11)  Factor V Leiden, homocystein, protein C&S
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8/12/07 DONALDSON (adapted from Smith, Lampe, NEJM '07)  
 
 
12) Lupus anticoagulant, anticardiolipin Ab
 
 
 
13)  AT III, RF, sickle cell
 
 
 
 
 
 
==Source==
 
  
 +
UpToDate
  
8/12/07 DONALDSON (adapted from Smith, Lampe, NEJM '07)
+
AHA/ASA Acute Stroke Guidelines
  
  

Revision as of 23:38, 1 March 2011

Work-Up

  • Glucose check
  • CBC, chemistry, coags, troponin
  • Lipid profile
  • Head CT
  • ECG (a. fib)
  • Also consider:
  • Pregnancy test
  • Utox
  • TTE with bubble study


DDX Ischemic

  • Thrombosis (atherosclerosis, vasculitis, dissection)
  • Embolic (cardiac -a.fib, valve, septic- CAS, hypercoagulable)
  • Vasospasm
  • Hypotension/watershed


Treatment

  • Ischemic
  • Glycemic control
  • Use insulin to maintain blood sugar < 185
  • Temperature control
  • Treat fever > 37.5 (99.5)


  • If pt is tPA candidate (CVA (tPA criteria and dosing)
  • Consider tPA
  • If give tPA DO NOT give antiplatelets/anticoagulants for at least 24 hours
  • BP Control
  • If potential candidate for tPA but BP > 185/110:
  • Labetalol 10-20mg IV over 1-2min, may repeat x 1, OR
  • Nicardipine IV 5mg/hr, titrate up by 2.5mg/hr q5-15min, max 15mg/hr; when desired BP reached lower to 3mg/hr OR
  • other agents (hydralazine, enalaprit, etc) may be considered when appropriate
  • If pt is NOT a tPA candidate:
  • Aspirin
  • BP control
  • Only tx BP if > 220/120
  • Anticoagulation
  • Heparin only if cardiac embolic source/ a-fib
  • Hemorrhagic
  • See Intracranial Hemorrhage (ICH)


Source

8/12/07 DONALDSON (adapted from Smith, Lampe, NEJM '07)

UpToDate

AHA/ASA Acute Stroke Guidelines