Stroke (main): Difference between revisions
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==See Also== | ==See Also== | ||
*[[Transient Ischemic Attack (TIA)]] | |||
*[[CVA (tPA Criteria)]] | *[[CVA (tPA Criteria)]] | ||
*[[ | *[[CVA (Post-tPA Hemorrhage)]] | ||
==Source== | ==Source== |
Revision as of 06:09, 28 September 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 go to --> CVA (tPA Criteria)
- 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 potential candidate for tPA but BP > 185/110:
- Consider tPA
- 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)
Cerebellar Stroke
- Can be confused w/ acute vestibular syndrome (e.g. labyrinthitis)
- HINTS Exam can reliably distinguish the two (more effective than early DWI MRI)
- Head Impulse Testing
- Tests vestibulo-ocular reflex
- Have pt fix their eyes on your nose
- Move their head in the horizontal plane to the left and right
- If reflex is intact their eyes will stay fixed on your nose
- If reflex is abnormal their head will move 1st and then their eyes will "catch up"
- It is reassuring if the reflex is abnormal (due to dysfunction of the nerve)
- Nystagmus
- Benign nystagmus only beats in one direction no matter which direction their eyes look
- Bad nystagums beats in every direction their eyes look
- If pt looks left, get left nystagmus, if looks right, get right-beating nystagmus
- Test of Skew
- Vertical dysconjugate gaze is bad
- Alternating cover test
- Have pt look at your nose w/ their eyes and then cover one eye
- When rapidly uncover the eye look to see if the eye quickly moves to re-align
- Have pt look at your nose w/ their eyes and then cover one eye
- If any of the above are abnormal obtain full CVA w/u (including MRI)
- Head Impulse Testing
See Also
Source
- UpToDate
- AHA/ASA Acute Stroke Guidelines
- EMCrit