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)CVA(سکته مغزی Adult Stroke: 2010 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care دکتر بهروز هاشمی متخصص طب اورژانس دانشگاه علوم پزشکی شهید بهشتی www.83638.persianblog.ir Introduction Third leading cause of death in the united states. Significant improvements in stroke care due to: I. Integrating public education, II. 911 dispatch, III. Prehospital detection and triage, IV. Hospital stroke system development, V. Stroke unit management “D’s of Stroke Care” Detection: Rapid recognition of stroke symptoms Dispatch: Early activation and dispatch of emergency medical services (EMS) system by calling 911 Delivery: Rapid EMS identification, management, and transport Door: Appropriate triage to stroke center Data: Rapid triage, evaluation, and management within the emergency department (ED) Decision: Stroke expertise and therapy selection Drug: Fibrinolytic therapy, intra-arterial strategies Disposition: Rapid admission to stroke unit, critical-care unit www.83638.persianblog.ir Management Goals The overall goal of stroke care is to minimize acute brain injury and maximize patient recovery. The chain of 7 D recommended. www.83638.persianblog.ir شناسایی عالئم اولیه و اطالع به اورژانس 115 ارزیابی توسط 115و انجام اقدامات اولیه: ABC ارزیابی عمومی و پایدارسازی: ABC & VS O2در صورت نیاز رگ گیری و ارسال نمونه چک BSو درمان ارزیابی سیستم عصبی فعال سازی تیم سکته مغزی CT Or MRI ECG بررسی توسط تیم سکته مغزی: بررسی تاریخچه بیمار زمان شروع عالئم معاینه نرولوژیک www.83638.persianblog.ir شناسایی سکته تعیین زمان شروع عالئم سنجش قند خون اطالع به بیمارستان مقصد مشاوره با نرولوژیست یا نروسرجن www.83638.persianblog.ir سی تی اسکن خونریزی نشان میدهد؟ بررسی امکان شروع فیبرینولیتیک rtPA بستری در بخش مراقبتهای ویژه آسپیرین عدم استفاده از داروهای ضد انعقادی و ضد پالکتی برای 24ساعت Stroke Warning Signs Time is gold: Community and professional education is essential. Signs & Symptoms: I. Sudden weakness or numbness of the face, arm, or leg, especially on one side of the body II. Sudden confusion III. Trouble speaking or understanding IV. Sudden trouble seeing in one or both eyes V. Sudden trouble walking, dizziness, loss of balance or coordination VI. Sudden severe headache with no known cause. EMS Education to EMS personnel due to minimize delays in prehospital: • Dispatch • Assessment • Transport www.83638.persianblog.ir Stroke Assessment Tools • • • • • • The Cincinnati Prehospital Stroke Scale Facial droop(Pic1) Normal—both sides of face move equally Abnormal—one side of face does not move as well as the other side Arm drift (Pic2) Normal—both arms move the same or both arms do not move at all (other findings, such as pronator drift, may be helpful) Abnormal—one arm does not move or one arm drifts down compared with the other Abnormal speech Normal—patient uses correct words with no slurring Abnormal—patient slurs words, uses the wrong words, or is unable to speak Sensitivity= 59% Specificity= 89% Prehospital Management and Triage ABC: • Aspiration/ hypoventilation • O2 supply if SPO2<94% or Unknown • Cardiopulmonary support • There are no data to support initiation of hypertension intervention in the prehospital environment. • If SBP<90mmHg, fluid recommended. Time of onset of symptoms Initial ED Assessment and Stabilization ED personnel should assess the patient with suspected stroke within 10 minutes of arrival in the ED. • ABC + O2 supply • BS Glucometry • Blood sample(CBC, PT/PTT/INR, BS) and Treponin • ECG Doctor : • Neurologic PhExam • Order Brain CT • Alert Neurologist ECG • ECG does not take priority over the CT scan but may identify a recent AMI or arrhythmias (eg, atrial fibrillation) as the cause of an embolic stroke. • If the patient is hemodynamically stable, treatment of other arrhythmias, including bradycardia, premature atrial or ventricular contractions, or asymptomatic atrioventricular conduction block, may not be necessary. www.83638.persianblog.ir Cardiac monitoring During the first 24 hours of evaluation in patients with acute ischemic stroke to detect atrial fibrillation and potentially lifethreatening arrhythmias. www.83638.persianblog.ir Arteial HTN for reperfusion candidates No reperfusion if BP> 185/110 Treat by: a) Labetalol 10–20 mg IV over 1–2 minutes, may repeat 1, b) Nicardipine IV 5 mg/hr, titrate up by 2.5 mg/hr every 5–15 minutes, maximum 15 mg/hr; when desired blood pressure reached, lower to 3 mg/hr c) Other agents (hydralazine, enalaprilat, etc) may be considered when appropriate. www.83638.persianblog.ir No reperfusion Consider lowering blood pressure in patients with acute ischemic stroke if SBP>220 mm Hg or DBP>120 mm Hg Consider blood pressure reduction as indicated for other concomitant organ system injury: Acute myocardial infarction Congestive heart failure Acute aortic dissection A reasonable target is to lower blood pressure by 15% to 25% within the first day. www.83638.persianblog.ir Control Blood pressure in ICH SBP> 200 or MAP>150 • Reduction of Bp is necessary. • Continious IV infusion SBP>180 or MAP>130 + NO elevated ICP: • Map of 110 or BP about 160/90 • IV medication SBP>180 or MAP>130 + Suspicion of elevated ICP: • Monitoring ICP & reduction of BP • CPP> 60-80 mmHg www.83638.persianblog.ir Imaging • Brain CT or MRI • These should be completed within 25 minutes. • Interpreted within 45 minutes. • No hemorrhage on the CT means indication for rtPA. www.83638.persianblog.ir Fibrinolytic Therapy • The treating physician should review the inclusion and exclusion criteria for IV fibrinolytic therapy. Fibrinolytic Therapy Review the inclusion and exclusion criteria for IV fibrinolytic therapy Perform a repeat neurologic examination Discuss the risks and potential benefits of the therapy with the patient or family If the patient’s neurologic signs are spontaneously clearing administration of fibrinolytics may not be required. www.83638.persianblog.ir Anticoagulant & Antiplatelet Neither anticoagulant Nor antiplatelet treatment may be administered for 24 hours after administration of rtpa until a repeat CT scan at 24 hours shows no hemorrhagic transformation. www.83638.persianblog.ir Adverse reaction • ICH: A meta-analysis of 15 published case series/symptomatic hemorrhage rate of 5.2% of 2639 patients treated. • Orolingual angioedema(1.5%) • Acute hypotension • Systemic bleeding(0.4%) www.83638.persianblog.ir Stroke Care • The benefits from treatment in a stroke unit are comparable to the effects achieved with IV rtpa. • Careful observation : i. Monitoring of blood pressure ii. Monitoring of neurologic status iii. Prevention of hypoxia, iv. Management of hypertension, v. Optimal glucose control, vi. Maintenance of euthermia, vii. Nutritional support. • Prevention of complications associated with stroke (eg, aspiration pneumonia, deep venous thrombosis, urinary tract infections). • Secondary stroke prevention. Blood Pressure Management • In those patients for whom recanalization is not planned, more liberal acceptance of hypertension is recommended, provided no other comorbid conditions require intervention. • Normal saline, administered at a rate of approximately 75 to 100 mL/h, is used to maintain euvolemia as needed. • In stroke patients who may be relatively hypovolemic, careful administration of IV normal saline boluses may be appropriate. www.83638.persianblog.ir Glycemic Control • Hyperglycemia is associated with worse clinical outcome in patients with acute ischemic stroke, but there is no direct evidence that active glucose control improves clinical outcome. • Use insulin when the serum glucose level is greater than 185 mg/dL in patients with acute stroke. www.83638.persianblog.ir Temperature Control Hyperthermia in the setting of acute cerebral ischemia is associated with increased morbidity and mortality and should be managed aggressively. Treat fever 37.5°c . There are limited data on the role of hypothermia specific to acute ischemic stroke. www.83638.persianblog.ir Dysphagia Screening • All patients with stroke should be screened for dysphagia before they are given anything by mouth. • A simple bedside screening evaluation: sip and swallow water without difficulty a large gulp of water and swallow. • Medications may be given in jam. • Any patient who fails a swallow test may be given medications such as aspirin rectally or, if appropriate for the medication, IV, IM, or SQ. www.83638.persianblog.ir Seizure prophylaxis Not recommended. Patients who experience a seizure, administration of anticonvulsants is recommended to prevent more seizures. www.83638.persianblog.ir خسته نباشید