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Stroke Workshop
Case Scenario
Case Scenario
65 year old female with a history of DM and HTN
develops acute onset left face droop, left arm and
leg weakness. 118 is called and arrives within 15
minutes. Patient has a BP 200/110.
• What interventions should be provided in the field?
• Antihypertensive?
• Aspirin?
• Where should the patient be transported?
• Closest hospital?
Stroke Workshop
Field Management in Stroke
• Cardiac monitor, O2
• Blood sugar
• Reassurance / no pharmacologic intervention for
BP
• Time of onset documented; medications; physical
exam focusing on speech, facial droop, drift
• Rapid transport with notification of receiving
hospital
Stroke Workshop
Case Scenario
Patient arrives in the ED with unchanged blood
pressure, unchanged neurologic exam.
• What are the key components of history?
• What are the key components of the physical
exam?
• What laboratory tests should be ordered?
• Pharmacologic interventions?
Stroke Workshop
Key Components of the History
Stroke Workshop
Key Components of the History
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Time of onset
Head trauma, previous stroke
Known AVM or aneurysm
Major surgery within 14 days
Seizure
Medications: use of anticoagulants
Symptoms suggestive of MI / pericarditis
Symptoms suggestive of hemorrhage
• Severe headache
• Neck stiffness / Pain
• Nausea / vomiting
Stroke Workshop
Key Components of the Physical
Stroke Workshop
Key Components to the Physical
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ABC’S
Vital signs (BP both arms; presence of fever)
LOC (when depressed, consider other diagnoses)
Trauma exam
Neck exam
Cardiopulmonary exam
Stroke Workshop
Key Components of the Neuro Exam
Stroke Workshop
Neurologic exam
• Glasgow coma scale
• NIHSS: 15 Item measure: 42 Points
• < 4 Not a candidate for thrombolytics
• > 22 Increased risk for hemorrhage
Stroke Workshop
NIH Stroke Scale
• Level of
consciousness
• Orientation (month
and age)
• Follow commands
• Best gaze
• Visual fields
• Facial palsy
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Motor arm
Motor leg
Limb ataxia
Sensory
Best language
Dysarthria
Extinction and
inattention (neglect)
Stroke Workshop
What Laboratory Tests Should be
Ordered?
Stroke Workshop
What Laboratory Tests Should be
Ordered?
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Glucose
CBC and platelets
Electrolytes
PT, PTT
ECG
CXR
Noncontrast head CT
Stroke Workshop
Interventions?
Stroke Workshop
Blood Pressure Management in
Ischemic Stroke
• Systolic 185 - 220, Diastolic 105 - 120; Do not treat
for the first hour (consider benzodiazepines); if
persists, IV Labetolol, 10 mg.
• Systolic > 220 mm Hg or diastolic 121 - 140; 2
readings 20 min apart: Start Labatolol 10 MG IV.
Patients requiring more than 2 doses are not
candidates for t-PA
• Diastolic > 140 mm Hg; 2 readings 5 minutes apart:
Start Nitroprusside. Patient is not a candidate for t-PA
Stroke Workshop
Case Scenario
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Patient has a NIHSS score of 8
ECG is normal sinus
Glucose 140; Platelets 200 K
PT / PTT are normal
Head CT is read as “normal”
• What are the indications for t-PA?
Stroke Workshop
Indications for t-PA
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Symptoms less than 3 hours from onset
Symptoms not improving
No evidence of hemorrhage on CT
No recent head trauma, surgery, GI bleeding
No use of anti-coagulants
No known aneurysm, neoplasm
Blood pressure controlled
Stroke Workshop
Case Scenario
A decision is made to give t-PA.
• How is t-PA administered
• How is suspected intracranial
hemorrhage managed?
Stroke Workshop
Administering t-PA
• .9 mg/kg in a 1:1 dilution
• Maximum dose 90 mg
• 10% initial bolus over 1-2 minutes; the
rest infused over 60 minutes
• Monitor blood pressure
• Do not give heparin or aspirin!
Stroke Workshop
Management of Suspected Intracranial
Hemorrhage
• Discontinue t-PA
• Obtain immediate CT
• Check PT, PTT, platelet count, fibrinogen
level
• Prepare cryoprecipitate and fibrinogen (6-8
units)
• Prepare platelets (6-8 units)
• Obtain neurosurgical consultation
Stroke Workshop
Case Scenario
The patient received t-PA and within one hour her
strength was markedly improved.
She was admitted to the stroke unit where she was
monitored and began early rehabilitation
She was discharged home one week later with
minimal left sided weakness.
Stroke Workshop