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STROKEIntroductionsecond leading cause of death worldwide
world health organization Fact sheet N310 : The top 10 causes of
deathIntroduction
. .. 2556PathophysiologyGo S, Worman DJ.Chapter 161. Stroke,
Transient Ischemic Attack, and Cervical Artery
Dissection.In:Tintinalli JE, Stapczynski J, Ma O, Cline DM, Cydulka
RK, Meckler GD, T.eds.Tintinalli's Emergency Medicine: A
Comprehensive Study Guide, 7e.New York, NY: McGraw-Hill; 20111
Injury is related to the loss of oxygen and glucose substrates
necessary for high-energy phosphate production
Subsequent factors, such as edema and mass effect, may
exacerbate the initial insult.
2 Neurologic symptoms are manifest within seconds because
neurons lack glycogen, so energy failure is rapidIf the cessation
of flow lasts for more than a few minutes,infarction or death of
brain tissue results. When blood flow is quickly restored, brain
tissue can recover fully and the patients symptoms are only
transient: this is called atransient ischemic attack(TIA). The
definition of TIA requires that all neurologic signs and symptoms
resolve within 24 h without evidence of brain infarction on brain
imaging.
Stroke has occurred if the neurologic signs and symptoms last
for >24 h or brain infarction is demonstrated.4Stroke Type87 %13
%3 %10 %Go S, Worman DJ.Chapter 161. Stroke, Transient Ischemic
Attack, and Cervical Artery Dissection.In:Tintinalli JE,
Stapczynski J, Ma O, Cline DM, Cydulka RK, Meckler GD,
T.eds.Tintinalli's Emergency Medicine: A Comprehensive Study Guide,
7e.New York, NY: McGraw-Hill; 2011Thrombotic Atherosclerosis.
Vasculitis Arterial dissection Polycythemia Hypercoagulable
state
Symptoms often have gradual onset and may wax and wane
Embolic Account for 20% of ischemic strokes. Typically sudden in
onset.
Hypoperfusion Cardiac failure resulting in systemic
hypotensionDiffuse injury pattern in watershed regions. Symptoms
may wax and wane with hemodynamic factors
IntracerebralIntraparenchymal hemorrhage from previously
weakened arteriolesHypertension Amyloidosis anticoagulation
Vascular malformations Cocaine use Risks include advanced age,
history of stroke, tobacco or alcohol use.
Nontraumatic subarachnoidBerry aneurysm rupture Vascular
malformation rupture5Risk factors
Smith WS, Johnston S, Hemphill J, III.Cerebrovascular
Diseases.In:Kasper D, Fauci A, Hauser S, Longo D, Jameson J,
Loscalzo J.eds.Harrison's Principles of Internal Medicine, 19e.New
York, NY: McGraw-Hill; 2015.Clinical featuresSudden onsetFocal
involvement of the central nervous systemLack of rapid resolution
deficits persist for at least 24 hours to distinguish stroke from
transient ischemic attack Vascular : referable to the territory of
a particular cerebral blood vessel.Middle cerebral artery
distribution : Contralateral hemiparesis and hemisensory lossthe
face and upper extremity are more affected than the lower
extremityaphasia if the infarct involves the dominant cerebral
hemisphereAnterior cerebral artery distribution:Contralateral
hemiparesis and hemisensory loss the lower extremity is more
affected than the upper extremityPosterior cerebral artery
distribution:Contralateral hemiparesishomonymous
hemianopsia,amnesiaBasilar artery distribution:Quadriparesis,
dysarthria, dysphagia, diplopia.
Kemp WL, Burns DK, Brown TG.Chapter 11. Neuropathology.In:Kemp
WL, Burns DK, Brown TG.eds.Pathology: The Big Picture.New York, NY:
McGraw-Hill; 2008.Lacunar infarct
Lacunar infarctPure motor stroke/hemiparesisAtaxic
hemiparesisDysarthria/clumsy handPure sensory strokeMixed
sensorimotor strokeocclusionof one of the penetratingarteriesthat
provides blood to the brain's deep structures. Patients who present
with symptoms of a lacunar stroke, but who have not yet had
diagnostic imaging performed
Pure motor stroke/hemiparesis(most common lacunar syndrome:
33-50%) hemiparesisorhemiplegiathat typically affects the face,
arm, or leg of one side.Dysarthria,dysphagia, and transient sensory
symptoms may also be present.
Ataxic hemiparesis(second most frequent lacunar syndrome)
cerebellar and motor symptoms, including weakness and clumsiness,
on the ipsilateral[3]side of the body. It usually affects the leg
more than it does the arm; hence, it is known also as homolateral
ataxia and crural paresis. The onset of symptoms is often over
hours or days.
Dysarthria/clumsy hand dysarthria and clumsiness (i.e.,
weakness) of the hand, which often are most prominent when the
patient is writing.
Pure sensory strokelMarked by persistent or transient numbness,
tingling, pain, burning, or another unpleasant sensation on one
side of the body.
Mixed sensorimotor strokehemiparesis or hemiplegia with
ipsilateral sensory impairment9
2010 American Heart Association Guidelines for Cardiopulmonary
Resuscitation and Emergency Cardiovascular Care Science1. Identify
signs and symptoms of possible stroke Activate Emergency
ResponseStroke recognition and EMS care
sensitivity = 66%, specificity = 87% for acute strokeGo S,
Worman DJ.Chapter 161. Stroke, Transient Ischemic Attack, and
Cervical Artery Dissection.In:Tintinalli JE, Stapczynski J, Ma O,
Cline DM, Cydulka RK, Meckler GD, T.eds.Tintinalli's Emergency
Medicine: A Comprehensive Study Guide, 7e.New York, NY:
McGraw-Hill; 2011The early detection of stroke must begin with the
general public.
prehospital setting to improve rapid neurologic screening for
stroke
If any of the three items is abnormal, sensitivity = 66%,
specificity = 87% for acute stroke
3 stroke 85%12Stroke recognition and EMS careLos Angeles
Prehospital Stroke Screen6 criteriaAge >45 yNo history of
seizure disorderNew onset of neurologic symptoms in last 24
hPatient ambulatory at baseline (prior to event)Blood glucose level
of 60400 mg%Obvious asymmetry in any of the following examinations
facial smile/grimacegriparm strengthsensitivity = 91% , specificity
= 97% for acute stroke Go S, Worman DJ.Chapter 161. Stroke,
Transient Ischemic Attack, and Cervical Artery
Dissection.In:Tintinalli JE, Stapczynski J, Ma O, Cline DM, Cydulka
RK, Meckler GD, T.eds.Tintinalli's Emergency Medicine: A
Comprehensive Study Guide, 7e.New York, NY: McGraw-Hill;
2011Patient ambulatory at baseline (prior to event) :
If answers to all items 16 are "Yes" or "Unknown," sensitivity =
91% (95% CI [76%98%]), specificity = 97% (95% CI [93%99%]) for
acute stroke.6]
LAPSS
13Stroke recognition and EMS care
1646 1669
EMS personnel should quickly ascertain the time of onset of the
patient's symptoms, giving particular attention to bystander
accounts to clarify details, because stroke patients may be poor
historians
ABC vital sign resusciatate oxygen if SpO2 < 94% onsetDTX142.
Clinical EMS assessments and actions2. Clinical EMS assessments and
actions
Stroke.2013;44:870-947 ABC vital sign resusciatate oxygen if
SpO2 < 94% onsetDTX
163. Immediate general assessment and stabilization
Immediate general assessment and stabilization
Assess ABCs, V/S, Pulse oximetryNPOStrict bedrest with head of
bed elevated to 30 degreesOxygen HypoxiaIV isotonic crystalloids
DehydrationLab for CBC, Coagulogram, BS, BUN, Cr, Elyte, Trop IDTX
; treat if hypoglycemiaPerform neurological screening
assessmentActivate stroke teamEmergent NC CT-scan within 25
min12-lead EKG
Go S, Worman DJ.Chapter 161. Stroke, Transient Ischemic Attack,
and Cervical Artery Dissection.In:Tintinalli JE, Stapczynski J, Ma
O, Cline DM, Cydulka RK, Meckler GD, T.eds.Tintinalli's Emergency
Medicine: A Comprehensive Study Guide, 7e.New York, NY:
McGraw-Hill; 2011Dehydration may contribute to poor stroke outcomes
secondary to increased blood viscosity, hypotension, recurrent
strokes, and venous thromboembolism.57,59 normalized with
administration of IV crystalloid. However, volume expansion and
hemodilution have not been shown to improve outcomes
significantly,60 except possibly in severely polycythemic stroke
patients.8,61However, volume expansion and hemodilution have not
been shown to improve outcomes significantly,60 except possibly in
severely polycythemic stroke patients.8,61
Routine oxygen administration does not improve outcomes in mild
to moderate stroke.43 Routine oxygen supplementation is not
indicated in mild to moderate stroke,43 but keep oxygen saturation
92%.8
Because of the close association between stroke and cardiac
abnormalities, it is important to assess the cardiovascular status
of patients presenting with acute stroke. Baseline
electrocardiogram and cardiac biomarkers may identify concurrent
myocardial ischemia or cardiac arrhythmias. Troponin is preferred
because of its increased sensitivity and specificity over creatine
phosphokinase or creatine phosphokinaseMB.
18stabilizationHyperpyrexiaassociated with increased morbidity
and mortalityno conclusion of benefit of normalizing BTprobably
reasonable to treat febrile stroke patients with antipyretics
diligently search for the cause of the
hyperthermia.Hyperglycemialess favorable outcomes with
hyperglycemiaGlycemic control has been recommendedKeep 140 180
mg%Go S, Worman DJ.Chapter 161. Stroke, Transient Ischemic Attack,
and Cervical Artery Dissection.In:Tintinalli JE, Stapczynski J, Ma
O, Cline DM, Cydulka RK, Meckler GD, T.eds.Tintinalli's Emergency
Medicine: A Comprehensive Study Guide, 7e.New York, NY:
McGraw-Hill; 2011Dehydration may contribute to poor stroke outcomes
secondary to increased blood viscosity, hypotension, recurrent
strokes, and venous thromboembolism.57,59 However, volume expansion
and hemodilution have not been shown to improve outcomes
significantly,60 except possibly in severely polycythemic stroke
patients.8,6119Neurological screening assessmentGo S, Worman
DJ.Chapter 161. Stroke, Transient Ischemic Attack, and Cervical
Artery Dissection.In:Tintinalli JE, Stapczynski J, Ma O, Cline DM,
Cydulka RK, Meckler GD, T.eds.Tintinalli's Emergency Medicine: A
Comprehensive Study Guide, 7e.New York, NY: McGraw-Hill; 20114.
Immediate neurologic assessment by stroke team or designee
Immediate neurologic assessment by stroke team or
designeeStroke.2013;44:870-947 Review patient history
presence of associated symptomsmedical historyexclude as many
stroke mimics as possible SeizureSyncopeBrain neoplasm or
abscessHypoglycemia
Stroke.2013;44:870-947 sudden onset of symptoms suggests an
embolic or hemorrhagic stroke, whereas a stuttering or waxing and
waning deficit suggests a thrombotic or hypoperfusion-related
stroke.
A history of Valsalva maneuver immediately preceding a
thunderclap headache or sudden onset of symptoms suggests a
ruptured cerebral aneurysm, whereas a recent history of neck trauma
or manipulation suggests cervical artery dissection.
Risk factors for vessel thrombus include hypertension, diabetes
mellitus, and coronary atherosclerotic disease. In contrast, atrial
fibrillation, valvular replacement, or recent myocardial infarction
suggest embolism.
Transient neurologic deficits occurring in the same vascular
distribution suggest underlying vascular disease consistent with a
thrombotic stroke, whereas transient deficits involving different
vascular distributions suggest embolism. Although adjunctive
history can be helpful in determining the type of stroke,
exhaustive or unduly prolonged attempts to elicit nonessential
history should never delay therapy.
Table 161-5 Differential Diagnoses of Consequence for Acute
Stroke Symptoms23
Stroke.2013;44:870-947 Perform neurological examination
the National Institutes of Health Stroke Scale
(NIHSS)11-category (15-item) score range of 0 to 42 5 to 10
minutesyields reproducible resultshigh interrater
reliabilitycorrelates with infarct volumeGo S, Worman DJ.Chapter
161. Stroke, Transient Ischemic Attack, and Cervical Artery
Dissection.In:Tintinalli JE, Stapczynski J, Ma O, Cline DM, Cydulka
RK, Meckler GD, T.eds.Tintinalli's Emergency Medicine: A
Comprehensive Study Guide, 7e.New York, NY: McGraw-Hill; 2011NIHSS
1a. Level of Consciousness 1b. LOC Questions: 1c. LOC Commands: 2.
Best Gaze: 3. Visual: 4. Facial Palsy: 5. Motor Arm: 6. Motor Leg:
7. Limb Ataxia: 8. Sensory: 9. Best Language: 10. Dysarthria: 11.
Extinction and Inattention (formerly Neglect):
Go S, Worman DJ.Chapter 161. Stroke, Transient Ischemic Attack,
and Cervical Artery Dissection.In:Tintinalli JE, Stapczynski J, Ma
O, Cline DM, Cydulka RK, Meckler GD, T.eds.Tintinalli's Emergency
Medicine: A Comprehensive Study Guide, 7e.New York, NY:
McGraw-Hill; 2011265. Does CT scan show hemorrhage?
intracranial hemorrhage
Theerachai Chaitusaney . Emergency neuroradiology, Department of
Radiology King Chulalongkorn Memorial Hospital Hyperacute
infarction Sign of early cerebral ischemia on NECT (MCA territory)
Detected in 67% of cases (imaged within 3 hours) Stroke
2013;44(3):870-947 291. Loss of gray-white differentiation -Insular
ribbon & cortical ribbon sign
Dr Yuranga Weerakkodyet al. Loss of the insular ribbon sign :
http://radiopaedia.org/articles/loss-of-the-insular-ribbon-sign
2.Gyral swelling (effacement of the cortical sulci)
Theerachai Chaitusaney . Emergency neuroradiology, Department of
Radiology King Chulalongkorn Memorial Hospital 3. Hyperdense MCA
sign
Frank Gaillard. Hyperdense MCA :
http://radiopaedia.org/images/31613A case of sudden onset of left
hemiparesis
Theerachai Chaitusaney . Emergency neuroradiology, Department of
Radiology King Chulalongkorn Memorial Hospital Does CT scan show
hemorrhageYes consult neurosurgeon
No probable acute ischemic stroke; consider fibrinolytic
therapy
5. Use of IV rtPA for acute ischemic stroke
Fibrinolytic therapyThe National Institutes of Health/NINDS
studyIV rtPA within 3 hours of stroke onsetat 3 months OR for a
favorable outcome in patients treated with rtPA was 1.7 (p =
.008)
The European Cooperative Acute Stroke Study III (ECASS)expansion
of the rtPA treatment window to 4.5 hoursOR favored patients
treated with rtPA [OR = 1.34; 95% CI (1.02% to 1.76%)]mortality was
similar in both groups N Engl J Med 333(24): 1581, 1995.
N Engl J Med 359(13): 1317, 2008.NINDS study54 was a randomized
double-blind trial comparing IV rtPA with placebo
Benefit was found regardless of ischemic stroke subtype and was
sustained 1 year after therapy. Symptomatic intracerebral
hemorrhage attributable to rtPA occurred in 6.4% (45% mortality) of
patients in the rtPA group, whereas symptomatic intracerebral
hemorrhage occurred in 0.6% (50% mortality) of those in the placebo
group. Despite this increased rate of intracerebral hemorrhage, the
mortality rate at 3 months was not significantly different for the
treatment and placebo groups (17% vs. 21%, respectively)
Based on these data, AHA/ASA issued a 2009 scientific
advisory71,72 that recommended rtPA should be administered to
eligible patients who present between 3 and 4.5 hours of an acute
stroke, as long as they met the ECASS criteria (Table 161-10).
However, as of this writing, U.S. Food and Drug Administration
approval has not yet been granted for this use.36IV rtPA Within 3
HoursIV rtPA Within 3 HoursAHA/ASA Guideline 2013Inclusion
criteriaDiagnosis of ischemic stroke causing measurable
neurological deficitOnset of symptoms 185 mm Hg or diastolic
>110 mm Hg)Active internal bleedingAcute bleeding diathesis,
including but not limited toPlatelet count 1.7 or PT >15
secondsCurrent use of direct thrombin inhibitors or direct factor
Xa inhibitors with elevated sensitive laboratory tests (such as
aPTT, INR, platelet count, and ECT; TT; or appropriate factor Xa
activity assays)Blood glucose concentration 1/3 cerebral
hemisphere)Stroke.2013;44:870-947 In patients without history of
thrombocytopenia, treatment with IV rtPA can be initiated before
availability of platelet count but should be discontinued if
platelet count is 1.7 or PT is abnormally elevated by local
laboratory standards.
38IV rtPA Within 3 HoursAHA/ASA Guideline 2013Relative exclusion
criteriaOnly minor or rapidly improving stroke symptoms (clearing
spontaneously)PregnancySeizure at onset with postictal residual
neurological impairmentsMajor surgery or serious trauma within
previous 14 daysRecent gastrointestinal or urinary tract hemorrhage
(within previous 21 days)Recent acute myocardial infarction (within
previous 3 months)Stroke.2013;44:870-947 Recent experience suggests
that under some circumstanceswith careful consideration and
weighting of risk to benefitpatients may receive fibrinolytic
therapy despite 1 or more relative contraindications. Consider risk
to benefit of IV rtPA administration carefully if any of these
relative contraindications are present39IV rtPA Within 3 to 4.5
Hours IV rtPA Within 3 to 4.5 Hours AHA/ASA Guideline
2013Additional Inclusion and Exclusion CharacteristicsInclusion
criteriaDiagnosis of ischemic stroke causing measurable
neurological deficitOnset of symptoms within 3 to 4.5 hours before
beginning treatmentRelative exclusion criteriaAged >80
yearsSevere stroke (NIHSS>25)Taking an oral anticoagulant
regardless of INRHistory of both diabetes and prior ischemic
strokeStroke.2013;44:870-947 Management of Arterial
HypertensionManagement of Arterial Hypertensionnot candidates for
rtPAno active attempts made to lower blood pressure unless SBP
>220 mm Hg or DBP >120 mm Hgreduction targets 10% to 25%
within the first dayStroke. March 2013vol. 44no. 3870-947 outcomes
have also been associated with active attempts to lower blood
pressure,65 perhaps secondary to a resultant reduction in perfusion
to the ischemic penumbra of the damaged brainIt is difficult to
determine the ideal blood pressure for optimum outcomes, because
definitive data from randomized controlled trials are lacking.
Nevertheless, the current consensus guidelines of the AHA/ASA
dichotomize recommendations for hypertensive therapy based upon the
potential for acute reperfusion intervention43Management of
Arterial Hypertensioncandidates for rtPA
Stroke. March 2013vol. 44no. 3870-947 Labetalol, 1020 milligrams
IV over 12 min, may repeat x1 Use with caution in patients with
severe asthma, severe chronic obstructive pulmonary disease,
congestive heart failure, diabetes mellitus, myasthenia gravis,
concurrent calcium channel blocker use, hepatic insufficiency. May
cause dizziness and nausea. Pregnancy category C (D in second and
third trimesters).
or Nitroglycerin paste, 12 in. to skin Contraindicated in
patients with hypersensitivity to organic nitrates, concurrent use
of phosphodiesterase 5 inhibitors (sildenafil, tadalafil, or
vardenafil), or angle-closure glaucoma. Increases intracranial
pressure. Commonly causes headache. Pregnancy category C.
or Nicardipine infusion, 5 milligrams/h, titrate up by 2.5
milligrams/h at 5- to 15-min intervals; maximum dose, 15
milligrams/h; when desired blood pressure attained, reduce to 3
milligrams/h Use with caution in patients with myocardial ischemia,
concurrent use of fentanyl (hypotension), congestive heart failure,
hypertrophic cardiomyopathy, portal hypertension, renal
insufficiency, hepatic insufficiency (may need to adjust starting
dose). Contraindicated in patients with severe aortic stenosis. Can
cause headache, flushing, dizziness, nausea, reflex tachycardia.
Pregnancy category C.44Give rtPAReview risks/benefits with patient
and familyInfuse 0.9 mg/kg (maximum dose 90 mg) over 60 min with
10% of the dose given as a bolus over 1 minIf severe headacheacute
hypertensionnausea or vomitingworsening neurological
examinationdiscontinue the infusion (if IV rtPA is being
administered) emergent CT scanCBC, Coagulogram, fibrinogen level,
G/M PRC, FFP, PC
Go S, Worman DJ.Chapter 161. Stroke, Transient Ischemic Attack,
and Cervical Artery Dissection.In:Tintinalli JE, Stapczynski J, Ma
O, Cline DM, Cydulka RK, Meckler GD, T.eds.Tintinalli's Emergency
Medicine: A Comprehensive Study Guide, 7e.New York, NY:
McGraw-Hill; 2011possible rtPA side effect of angioedema. Empiric
treatment recommendations include intravenous ranitidine,
diphenhydramine, and methylprednisolone.45After rtPAAdmit intensive
care or stroke unit for monitoringif the patient can be safely
managed , Delay placement of nasogastric tubesindwelling bladder
cathetersintra-arterial pressure catheters Obtain a follow-up CT or
MRI scan at 24 hours after IV rtPA before starting anticoagulants
or antiplatelet agents.
Go S, Worman DJ.Chapter 161. Stroke, Transient Ischemic Attack,
and Cervical Artery Dissection.In:Tintinalli JE, Stapczynski J, Ma
O, Cline DM, Cydulka RK, Meckler GD, T.eds.Tintinalli's Emergency
Medicine: A Comprehensive Study Guide, 7e.New York, NY:
McGraw-Hill; 201146hemorrhagic transformation
Theerachai Chaitusaney . Emergency neuroradiology, Department of
Radiology King Chulalongkorn Memorial Hospital Most sICHs occur
within the first 24 hours after intravenous rtPAany remaining
intravenous rtPA should be withheld.
Although no study has been conducted to determine the best way
to manage postintravenous rtPA hemorrhage, many rtPA-associated
hemorrhage protocols call for the use of cryoprecipitate to restore
decreased fibrinogen levels. A recent case report described the use
of tranexamic acid in the treatment of an intravenous
rtPAassociated hemorrhage in a Jehovahs Witness stroke patient.
After administration, no further hematoma expansion was noted
surgical hematoma evacuation may be considered depending on the
size and location of the hemorrhage and the patients overall
medical and neurological condition. Evacuation of a large
hemorrhage may be lifesaving, whereas smaller hematomas may be
tolerated without clinical relevance47Antiplatelet AgentsAspirin
within 48 hours of stroke prevention of recurrent strokes (NNT =
100)limited experience with the use of clopidogrel or
dipyridamoleCurrent AHA recommendations : Aspirin initial dose is
325 mgwithin 24 to 48 hours after stroke onsetwithin 24 hours of
rtPA is not
recommendedLancet.1997;349:16411649Lancet.1997;349:15691581 not
clear whether aspirin limited the neurological consequences of the
acute stroke itself
When the results of the International Stroke Trial and the
Chinese Acute Stroke Trial are
combinedLancet.1997;349:16411649Lancet.1997;349:15691581 number
needed to treat is 100, but aspirin is cost effective and adds no
risk to the outcome of ischemic stroke
data on the safety of antiplatelet agents when given within 24
hours of intravenous fibrinolysis are lacking.48ASA vs ASA +
Dipyridamole
(A) nonfatal stroke and (B) composite outcome of nonfatal
stroke, nonfatal myocardial infarction, and vascular
death.Stroke.2008;39:1358-1363ASA + clopidogrel vs ASA
Stroke.2014;45:492-503
5. Hemorrhagic stroke
Acute Phase of Hemorrhagic Stroke 1. Respiration
Hypoventilation, Coma, Aspiration ETT 2. TemperatureHyperpyrexia
Antipyretics, Tepid sponge3. Blood glucoseBG > 140 mg%
hyperglycemic control4. Fluid & ElectrolyteKeep fluid balanced
isotonic crystalloidCorrect electrolyte5. SeizureProphylaxis not
recommendedClinical seizures should be treated with antiepileptic
drugs, , , , , , , . 2556. . : 1. Respiration blood gas
3. Temperature cooling blanket 4. (Management of Blood Glucose)
> 140 ./. 5. (Prevention of Seizure) 6. Fluid & Electrolyte*
- dehydration overhydration isotonic solution normal saline = urine
output + 500 ml (insensible loss) 300 ml/1oC (37oC) - electrolyte
*
52
Acute Phase of Hemorrhagic Stroke 6. Hypertension
If no increased ICP keep MAP < 110 or BP 160/90 If BP >
200/150 Nitroprusside 0.25-10 g/kg/min IV Nitroglycerine 5 mg IV
then 1-4 mg/hr IVIf BP > 180/105Captopril 6.25-12.5 mg oralSmall
patch of nitroglycerine Hydralazine 5-10 mg IVNicardepine 5 mg/hr
IV If increased ICP keep MAP < 130 or SBP < 200Consider IV
medication while maintaining CPP > 60 mmHg
, , , , , , , . 2556. . : 2. Blood Pressure6 hypotension mean
arterial pressure (MAP) < 110 mmHg BP 160/90 (grade C) MAP =
Diastolic BP + 1/3 (Systolic BP - Diastolic BP) 2.1 systolic BP
> 200 mmHg MAP > 150 mmHg - Nitroprusside 0.25-10 g/kg/min 3
- Nitroglycerine 5 mg 1-4 mg/hr - 2.2 2.2 systolic BP = 180-200
mmHg DBP = 105-140 mmHg MAP > 130 mmHg - Captopril 6.25-12.5 mg
15-30 4-6 .. - Small patch of nitroglycerine - Hydralazine 5-10 mg
1-2 1-2 .. - Nicardepine 0.1-0.2 mg/ml 5 mg/hr. - nifedipine 2.3
Systolic BP = 180-200 mmHg MAP > 130 mmHg cerebral perfusion
pressure 60 mmHg
53increased intracranial pressure Clinical featuresSevere
headacheDrowsyVomitingDiplopiaMydriasisBradycardiawide pulse
pressure
, , , , , , , . 2556. . : increased intracranial pressure
TreatmentClear airway, ETT, Foleys catheterElevated head of bed
20-30 degreeAvoid compression of jugular veinHyperventilation20%
mannitol : loading dose 1 gm/kg IV in 20 min then 0.25-0.5 gm/kg
q6hrCheck serum osmolarity OD keep < 320 mOsm/l Avoid hypotonic
solution
, , , , , , , . 2556. . : 1. Clear airway Foleys catheter 2.
20-30 3. (jugular vein) 4. Hyperventilation PaCO2 = 30-35 mmHg 5. *
- 20% mannitol : loading dose 1 gm/kg 20 0.25-0.5 gm/kg 6 serum
osmolarity serum osmolarity < 320 mOsm/l (grade C) - 10%
glycerol 250 ml 30 6 - 50% glycerol 50 ml 4 - Furosemide 1 mg/kg
(grade C) 6. hypotonic solution 7. steroid 47,48
55
Adapted from:
http://www.ninds.nih.gov/news_and_events/proceedings/stroke_proceedings/recs-emerg.htm#emergency;
and Jauch EC. 2010 American Heart Association guidelines for
cardiopulmonary resuscitation and emergency cardiovascular
care.Circulation. 2010;122(18 suppl 3):S818-S828.Genentech USA,
Inc. Golden Hour of Acute Ischemic Stroke:
http://www.activase.com/iscstroke/golden-hour-acute-ischemic-stroke#Intracerebral
hemorrhageAHA guideline for hypertension
Intracranial pressure treatment algorithm
