anticoagulation in strokes

Anticoagulation in Strokes

Guidelines for the Early Management of Adults With Ischemic StrokeA Case Study

References: Stroke 2007;38:1655 2007 American Heart Association, Inc.

1100: You are admitting a 68 yr old female to Observation from the ER with diagnosis of TIA. She has a history of hypertension, controlled with Atenolol. Other meds: ASA 81mg daily and Multivitamins.ER course: Admitted to ER per EMS @ 0800with complaints of facial numbness and left sideweakness. Symptoms resolved 30 min. afterarrival. CT was negative for hemorrhagic stroke.Initial NIH Stroke Scale assessment was 2. Her ER admission BP was 190/110 which Decreased to 160/94 without treatment.

What additional information do you need? Red flags? What do you

suspect? Interventions?

CATEGORY SCORE - DESCRIPTION Date/Time: 0830SCORE:

Date/TimeSCORE:

Date/TimeSCORE:

Date/TimeSCORE:

Date/TimeSCORE:

1a. Level of Consciousness (LOC)

0 Alert 2 Stuporous1 Drowsy 3 Comatose 0

1b. LOC Questions (Month/Age)

0 Answers both correctly1 Answers one correctly (intubation)2 Both incorrect

01c. LOC Commands (open/close eyes, make fist/let go)


01.Best Gaze(Horizontal eye movement)

0 Normal 1. Partial gaze palsy2 Forced deviation

01.Visual Fields(finger counting or visual threat)

0 No visual loss1 Partial hemianopia2 Complete hemianopia3 Bilateral hemianopia

01.Facial Palsy(show teeth, raise eyebrows, and close eyes)

0 Normal symmetrical movement1 Minor palsy2 Partial palsy3 Complete palsy

05a. Right Arm Motor(palms down, raise arm 90 degrees if sitting, 45 degrees if lying down, for 10 seconds)

0 No drift1 Drift2 Some effort with gravity2 No effort with gravity33 No movement9 Amputation, joint fusion (no score)

0

5b. Left Arm Motor See 5a

1

National Institute of Health Stroke Scale

6a. Right Leg Motor(30 degrees for 5 seconds)

See 5a

06b. Left Leg Motor See 5a

01.Limb Ataxia(Finger-nose-finger, heel up and down shin)

0 Absent1 Present in 1 limb2 Present in 2 or more limbs9 Amputation, joint fusion (no score)

0

1.Sensory(pin prick to face, arm, leg, bilaterally)

0 Normal1 Partial loss2 Severe to total loss

11.Best Language(describe picture, name, items, read sentences)

0 No aphasia1 Mild-to-moderate aphasia2 Severe aphasia3 Total aphasia

0

10. Dysarthria(repeat list of works)

0 Normal articulation1 Mild-to-moderate slurring2 Unintelligible or worse9 Intubation/other physical barrier

0

11. Extinction & Inattention 0 No abnormality1 Partial inattention2 Complete inattention

0Do not include 9's from categories 5,6,7, & 10.

TOTAL SCORE (0-42)SIGNATURE 2

1100 Initial admission assessment: Abbreviated NIH Stroke scale remains unchanged at 0.1a. Right Arm Motor(palms down, raise arm 90 degrees if sitting, 45 degrees if lying down, for 10 seconds)


0



See 1a

02b. Left Leg Motor See 1a


0 Alert 2 Stuporous1 Drowsy 3 Comatose 0

4. Best Language(describe picture, name, items, read sentences)




0TOTAL SCORE

SIGNATURE 0

What additional information do you need? Red flags? What do you

suspect? Interventions?

• VS: BP-168/90 HR-72 R -16

• T- 98.1 SaO2 96% on RA

1300: You answer the call light. Family at bedside tell you she “can’t

talk or move her arm. NIH Assessment:CATEGORY SCORE - DESCRIPTION Date/Time:

0830SCORE:

Date/Time 1300SCORE:

Date/TimeSCORE:

Date/TimeSCORE:

Date/TimeSCORE:


0 Alert 2 Stuporous1 Drowsy 3 Comatose 0 1



0 11c. LOC Commands (open/close eyes, make fist/let go)


0 01.Best Gaze(Horizontal eye movement)


0 11.Visual Fields(finger counting or visual threat)


0 0



0 1



0 0


1 3


See 5a

0 06b. Left Leg Motor See 5a

0 31.Limb Ataxia(Finger-nose-finger, heel up and down shin)


0 2



1 21.Best Language(describe picture, name, items, read sentences)


0 1



0 1


0 0Do not include 9's from categories 5,6,7, & 10.

TOTAL SCORE (0-42)SIGNATURE 2 16

What additional information do you need? Red flags? What do you suspect? Interventions?

• VS: BP-210/120 HR-88 R-20 T-98.5

• SaO2 – 94%

You report to the doctor and a stat head CT is ordered.

Why? What do you anticipate?

t-PA STROKE EXCLUSION CRITERIAGUIDELINES ONLY, ADDITIONAL CONSIDERATIONS MAY APPLY

TO INDIVIDUAL PATIENTS

Absolute Contraindications: Acute focal neurologic deficit not on the basis of focal ischemia. Not medically evaluated & treatment begun within 3hrs. of onset of

symptoms. <18 years, > 77 (relative contraindication) Female of child bearing potential without neg. pregnancy test. Patient or representative unable to understand & give informed consent. Sensory loss, ataxia, or dysarthria alone. Sustained uncontrolled BP >180/105, need for IV tx to BP One or more seizures at onset. Hemorrhagic stroke, mass effect, or edema on baseline CT Suspicion of subarachnoid hemorrhage Intracranial neoplasm, AV malformation or aneurysm. Known bleeding diathesis, illness with high risk of bleeding. Severe complicated medical illness such as metastatic cancer or AIDS that

would complicate treatment.

Preexisting neurologic, psychiatric or other illness that would complicate treatment. Major surgery within the last 14 days GI or GU hemorrhage within the last 21 days Previous cerebral infarction within the last 3 months Arterial puncture at non-compressible site within the last 7 days Taking Coumadin or Heparin within previous 48 hours or receives low molecular weight heparinoids. Platelet count below 100,000 Blood Glucose <50 - >400 Significant head trauma within the last 3 months History of intracranial hemorrhage. Rapidly improving neurologic deficit. PT >15 seconds

Relative Contraindications: Severe neurological deficits at discretion of neurologist. Age >77 years Serious trauma in the last 14 days. Acute myocardial infarction. Pericarditis or subacute bacterial endocarditis Significant liver or kidney dysfunction Diabetic hemorrhagic retinopathy Occluded arterial/venous cannula at seriously infected site.

THROMBOLYTIC THERAPY PATIENT SELECTION CHECKLIST/HISTORY

HAVE YOU HAD ANY OF THE FOLLOWING:• Recent surgery (within 4 - 6 weeks)• Recent dental procedure (within 2-3 days)• Falls or severe trauma (chest, head, back, abdomen) in the past monthBruises, abrasion,

cutsStrep infection (in last 3 months)• History of allergic reaction to streptokinaseDO YOU HAVE A HISTORY OF• Hypertension - diastolic >110 and/or systolic >180• Blood clotting problems/bleeding disorders• Carcinoma/cancer• Ulcers• Recent bloody/tarry stools or vomited blood in past 2 weeks• Active tuberculosis• Stroke, aneurysm, intracranial neoplasm, AV malformation• Back or head surgery (in last 2 months)• Heart valve infection/left heart thrombus (in last 2 months)• Severe skin or mucous membrane disease• CPR• Diabetic retinopatthy, hemorrhagic ophthalamic condition• Advanced liver or kidney disease• Recent drug or alcohol ingestion• Diabetes (if yes, how long) IDDM or NIDDM• PREGNANT OR GIVEN BIRTH WITHIN THE LAST 10 DAYSHave you taken in the last

48hrs.

The Head CT is negative for hemorrhagic stroke. He asks you to page the neurologist on call.

• What do you anticipate?

Guidelines for Early Management of Adults with Ischemic Stroke:

• D. Conclusions and RecommendationsIntravenous administration of rtPA is the only FDA-approved medical therapy for treatment of patients with acute ischemic stroke.3 Its use is associated with improved outcomes for a broad spectrum of patients who can be treated within 3 hours of stroke onset. Earlier treatment (ie, within 90 minutes) may be more likely to result in a favorable outcome. Later treatment, at 90 to 180 minutes, also is beneficial. Patients with major strokes (NIHSS score >22) have a very poor prognosis, but some positive treatment effect with rtPA has been documented.329 Because the risk of hemorrhage is considerable among patients with severe deficits, the decision to treat with rtPA should be made with caution. Treatment with rtPA is associated with symptomatic intracranial hemorrhage, which may be fatal. In the original NINDS trials, the risk of symptomatic bleeding was 6%.100 Recent community-based studies and registries report lower rates of hemorrhage.269,330–333 Recommendations for the management of intracranial hemorrhage after treatment with rtPA are provided in the AHA Stroke Council’s updated guideline statement on management of intracerebral hemorrhage, which is being issued contemporaneously with this statement. The best methods for preventing bleeding complications are careful selection of patients and scrupulous ancillary care, especially close observation, and monitoring of the patient with early treatment of arterial hypertension. Factors that affect decisions about administration of rtPA are outlined in Table 11, and the treatment regimen for administration of rtPA is included in Table 12. Case series have suggested that thrombolysis may be used in patients with seizures at the time of presentation when evidence suggests that residual deficits are due to ischemia rather than the postictal state.334,335 The use of anticoagulants and antiplatelet agents should be delayed for 24 hours after treatment.

Intra-arterial Thrombolysis• Class I Recommendations

• Intra-arterial thrombolysis is an option for treatment of selected patients who have major stroke of <6 hours’ duration due to occlusions of the MCA and who are not otherwise candidates for intravenous rtPA (Class I, Level of Evidence B). This recommendation has not changed since previous guidelines.

• Treatment requires the patient to be at an experienced stroke center with immediate access to cerebral angiography and qualified interventionalists. Facilities are encouraged to define criteria to credential individuals who can perform intra-arterial thrombolysis (Class I, Level of Evidence C). This recommendation has been added since previous guidelines.

• Class II Recommendation

• Intra-arterial thrombolysis is reasonable in patients who have contraindications to use of intravenous thrombolysis, such as recent surgery (Class IIa, Level of Evidence C). This recommendation was not included in the previous guideline.

• Class III Recommendation

• The availability of intra-arterial thrombolysis should generally not preclude the intravenous administration of rtPA in otherwise eligible patients (Class III, Level of Evidence C). This recommendation has not changed from previous guidelines.

What have we forgotten?

• If systolic > 180 and/or diastolic > 105, notify MD. May consider:

Labetalol (Normodyne) 10mg IV over 1-2 min. May repeat and/or double q 10 min. up to total of 150mg.

Following first dose of Labetalol, infuse 2-8mg/min.

You have an order to begin TpA per protocol. Your patient weighs 80kg.

Time or Onset of Symptoms:

Presentation Time:

BP both arms, then VS q15 minContinuous cardiac & oximetry monitoring

NIH Stroke scale on admission & discharge & with changes in Neuro status, Neuro q 30 min.

ECG O2 2-5 L/NC to keep stas>95%

Stat head CT, without contrast. Reviewed with neurologist, (notify radiology of potential TpA patient) Physician may also consider portable CXR

Start IV – 2sites (1 with 3 way stopcock), no arterial/IM injectionsNS @ 50cc/hr or:

LAB: CBC, PT/INR/PTT, Chem 13, type & hold, UA, BHCG if indicated

Page to St. Als ER MD on call, will facilitate communication with Neurologist on call.

Life Flight on Standby TpA IV 0.9mg/kg total (max dose 90mg) 10% bolus over 1 min,

infuse remainder over 60 min. If intracranial hemorrhage is suspected (acute neurological

deterioration, new headache, sudden/acute hypertension, nausea/vomiting) notify MD & anticipate orders to: Discontinue TpA infusion STAT CT Stat PT,PTT, platelet count Type & cross Notify receiving Neurologist

1400:

• TpA bolus & Infusion started.

• Life Flight ETA 30 min.

• BP controlled with Labetalol infusion @ 2mg/min.

1420: Change in neuro status:

NIH Assessment:CATEGORY SCORE - DESCRIPTION Date/Time:

0830SCORE:


Date/Time 1420

SCORE:

Date/TimeSCORE:

Date/TimeSCORE:


0 Alert 2 Stuporous1 Drowsy 3 Comatose 0 1 2



0 1 21c. LOC Commands (open/close eyes, make fist/let go)


0 0 01.Best Gaze(Horizontal eye movement)


0 1 11.Visual Fields(finger counting or visual threat)


0 0 1



0 1 1



0 0 0


1 3 3


See 5a

0 0 06b. Left Leg Motor See 5a

0 3 31.Limb Ataxia(Finger-nose-finger, heel up and down shin)


0 2 2



1 2 21.Best Language(describe picture, name, items, read sentences)


0 1 2



0 1 2


0 0 1Do not include 9's from categories 5,6,7, & 10.

TOTAL SCORE (0-42)SIGNATURE 2 16 22

Red flags? What do you suspect? Interventions?

• The physician orders a stat CT but does not stop the infusion

• CT results are negative for hemmhoragic stroke.

• 1440: Life Flight arrives

NIH Assessment at time of transfer:CATEGORY SCORE - DESCRIPTION Date/Time:

0830SCORE:


Date/Time 1420

SCORE:

Date/Time1500SCORE:

Date/TimeSCORE:


0 Alert 2 Stuporous1 Drowsy 3 Comatose 0 1 2 0



0 1 2 01c. LOC Commands (open/close eyes, make fist/let go)


0 0 0 01.Best Gaze(Horizontal eye movement)


0 1 1 01.Visual Fields(finger counting or visual threat)


0 0 1 0



0 1 1 1



0 0 0 0


1 3 3 1


See 5a

0 0 0 06b. Left Leg Motor See 5a

0 3 3 11.Limb Ataxia(Finger-nose-finger, heel up and down shin)


0 2 2 1



1 2 2 11.Best Language(describe picture, name, items, read sentences)


0 1 2 1



0 1 2 1


0 0 1 0Do not include 9's from categories 5,6,7, & 10.

TOTAL SCORE (0-42)SIGNATURE 2 16 22 7

Questions?Discussion?

NIH Stoke Scale Practice

anticoagulation in strokes

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