conference_acute ischemic stroke
TRANSCRIPT
Morning Conference
Presented by Ext. Sorawit Boonyathee
20 December 2012
Chief Complaint
• ผปวยชาย อาย 68 ป
• ออนแรงซกซาย 2 ชวโมงกอนมาโรงพยาบาล
• Arrived at ER 14.30 น.
• Vital Sign แรกรบ
– Blood Pressure 127/77 mmHg
– Pulse rate 84 /min
– Respiratory rate 20 /min
– Oxygen Sat 99 % (Room Air)
จาก CHIEF COMPLAINT และ VITAL SIGN แรกรบ TRIAGE ?
Triage
• Emergency
• เนองจากผปวยสงสยภาวะ Stroke และ On set อยในชวงทสามารถ Activated Fast track ได
หลงจากนนจะตองประเมนเบองตนอยางไร ?
Primary Survey
• Airway
– Can talk, no stridor, dysarthria
• Breathing
– Clear and equal breath sound both lungs, O2 sat 99%
• Circulation
– BP 127/77 mmHg, PR 84 /min, no external bleeding
• Disability
– E4V5M6, pupil 3 mm RTLBE
การวนจฉยแยกโรคและการสงตรวจเบองตน ?
Stroke ?
• Cincinnati Prehospital Stroke Scale (CPSS)
“F A S T” – Facial Droop
– Arm Drip
– Speech Problems
– Time
• Risk Assessment for Stroke – 1 problem = risk 72% 3 problems = 85%
Differential Diagnosis
• Stroke -> Ischemic or Hemorrhage
• Stroke mimic – Hypoglycemia or hyperglycemia -> DTX = 130 mg%
– Syncope / Presyncope
– Seizures and postictal state
– Intracranial Mass (Space occupying lesion)
– Functional hemiparesis (Psychiatric Disease/Syndrome)
– Encephalopathy
– Migraine
Laboratory Investigation for Stroke Fast Tract
• DTX
• CBC with platelet -> Decrease Platelet
• BUN, Cr, Electrolyte – High BUN (Uremic encephalopathy)
– Hyponatremia
• Coagulogram -> INR and PT Prolong ?
• Electrocardiogram -> AF or Myocardial Infarction ?
• Cardiac Enzyme
• Chest x-ray
ขอมลประวตผปวย และการตรวจประเมนทางระบบประสาท ?
History Taking
• 2 hrPTA (12.30 น.) ขณะก าลงนงรบประทานอาหาร ผปวยมอาการออนแรงแขนขาซกซาย ปากเบยวดานซาย มอาการพดไมชด
• ไมมอาการหนามดหรอเปนลม ไมมอาการชกเกรงแขนขา รสกตวดตลอดเวลา
• ไป รพช. (13.00 น.) ประเมน Motor power Lt side = 0
• และ (13.30 น.) ประเมน Motor power Lt side = III -> Refer
Physical Examination
• Vital Sign :
– BP 127/77 mmHg, PR 84 /min, RR 20 /min, O2 Sat 99 % (RA)
• HEENT :
– No pale conjunctivae, no icteric sclerae, no carotid bruit
• Heart :
– Totally irregular, PMI at Lt 6th ICS MCL, PSM Grade III at LPSB + apex, DRM Grade II at Apex
• Lungs :
– Clear and Equal Breath sound both lungs, no adventitious sound
Physical Examination (Cont.)
• Abdomen :
– Soft, not tender
• Extremities :
– No edema, no deformity, capillary refill < 2 sec
Physical Examination (Cont.)
• Neuro Exam:
– E4V5M6, Pupil 3 mm RTLBE, Good Orientation
– Motor power
– Reflex 2+ all
– Sensory Intact
– Cranial Nerve -> Full EOM, Facial Weakness Lt UMNL, Dysarthria
V III+
V II+
National Institute of Health Stroke Scale (NIHSS)
• 1a. level of consciousness 0
• 1b. Question (Age and month) 0
• 1c. Commands (Open/closed eyes, Grip hand) 0
• 2 Best Gaze (Horizontal EOM) 0
• 3. Visual Field 0
• 4. Facial Palsy Lt 1
• 5. Motor Arm Lt 1
National Institute of Health Stroke Scale (NIHSS)
• 6. Motor Leg Lt 2
• 7. Limb Ataxia (Finger to nose, Heel to knee) 0
• 8. Sensory 0
• 9. Best Language (name object, read, writing) 0
• 10. Dysarthria 1
• 11. Extinction/Neglect 0
• Summary NIHSS Score in this Patient 5
NIHSS and Patient Outcomes
• Total scores range from 0-42 with higher values representing more severe infarcts – >25 Very severe neurological impairment
– 15-24 Severe impairment
– 5-14 Moderately severe impairment
– <5 Mild impairment
– Adams, HP, et al. (1999). Neurology: 53: 126-131.
• A 2-point (or greater) increase on the NIHSS administered serially indicates stroke progression. It is advisable to report this increase.
NIHSS and Patient Outcomes
• Initial score of 7 was found to be important cut-off point – NIHSS >7 demonstrated a worsening rate of 65.9%. – NIHSS <7 demonstrated a worsening rate of 14.8% and were almost twice (1.9x) as likely
to be functionally normal at 48 hours (45%). – (DeGraba et al.,1999)
• NIHSS <5 most strongly associated with D/C home • NIHSS 6-13 most strongly associated with D/C to rehab • NIHSS >13 most strongly associated with D/C to nursing facility • (Schlegel et al., 2003) • Likelihood of intracranial hemorrhage:
– NIHSS > 20 = 17% likelihood – NIHSS < 20 = 3% likelihood – (Adams et al., 2003)
หลงจากไดประวตและตรวจรางกายแลว จะตองท าอะไรตอ ?
CT Scan
• Hyperdense MCA
• Loss of Insular ribbon at Rt MCA territory,
จากผล CT SCAN ดงกลาว สรปการวนจฉยวาอยางไร และ จะใหการรกษาอยางไรตอไป ?
Diagnosis and Management
• Dx : Acute Ischemic Stroke (Right MCA)
• Management in Emergency Department :
– Candidate for rtPA ?
– Controlled Blood Pressure ?
Lab Result
EKG
Chest X-ray
Lab result
• CBC -> no anemia, no leukocytosis, platelet adequate
• BUN, Cr and Electrolyte -> within normal limited
• Coagulogram -> no PT or PTT prolong
• EKG -> Atrial Fibrillation rhythm, no ST – T change seen
• CXK -> Cardiomegaly, no infiltration seen
Check Indication and Contraindication for rtPA used
• Indication for IV rtPA
– Clinical diagnosis of ischemic stroke causing a measurable neurological deficit
– non-contrast CT showing no hemorrhage or well-established acute infarct
– Time of onset well established to be less than 4.5 hours
Check Indication and Contraindication for rtPA used
• Contraindication
– Prior stroke or head trauma within 3 months
– Recent myocardial infarction within 3 months
– GI Hemorrhage or GU hemorrhage within 21 days
– Major surgery within 14 days
– Arterial puncture at a noncompressible site within 7 days
– SBP > 185 or DBP > 110 mmHg, or aggressive treatment (IV medication) to achieve
Check Indication and Contraindication for rtPA used
• Contraindication – CT finding suggesting ICH, SAH, or hypodensity > 1/3 of cerebral
hemisphere – Suspicious of subarachnoid hemorrhage (Even if CT negative) – Seizure at onset – Hx. of intracranial hemorrhage or aneurysm or AVM or brain tumor – Platelet < 100,000 – Heparin use within 48 hours with PTT > 40 (or exceeding upper limits) – Oral anticoagulant use with INR > 1.7 – Known bleeding diathesis or other major disorder ass. with increased
bleeding – Glucose < 50 or > 400 mg/dl
Check Indication and Contraindication for rtPA used
• Additional Contraindication for patient treated between 3 - 4.5 hours
– Age > 80 years
– History of Prior Stroke and Diabetes mellitus
– Any anticoagulant use prior to admission (Even if INR < 1.7)
– NIHSS > 25 (Because suggestion to hemorrhage preferable)
– CT findings involving more than 1/3 of the MCA territory
In this Patient
• Candidate for rtPA -> Yes (3 hours -> 15.08 น.)
• Blood Pressure -> 110/60 mmHg (No need to controlled before start rtPA)
• Start rtPA (Dose 0.9 mg/kg) BW 44 kg
– Total dose of rtPA -> 39.6 mg
– 10% of total dose -> 3.96 mg IV bolus in 1 minute
– 90% of total dose -> 35.64 mg IV drip in 1 hour
PROGRESS CASE
Progress Case
• NIHSS Score (After treatment completed) – 1 hours -> 4 points
– 6 hours -> 2 points
– 12 hours -> 0 points
• Work up cause (Risk for embolism, atherosclerosis) – Echocardiogram -> RHD, Mild MS and MR, No clot, good LV
– Lipid profile and FBS -> normal -> Start Simvastatin + diet control
– รอนด Doppler carotid ultrasound
Progress Case
• Start Enoxaparin SC bridging Warfarin due to CHA2DS2 Vasc Score = Stroke (2) Age (1) -> 3
Condition Points
C Congestive heart failure (or Left ventricular systolic dysfunction) 1
H Hypertension: blood pressure consistently above 140/90 mmHg (or treated hypertension on medication)
1
A2 Age ≥75 years 2
D Diabetes Mellitus 1
S2 Prior Stroke or TIA or thromboembolism 2
V Vascular disease (e.g. peripheral artery disease, myocardial infarction, aortic plaque)
1
A Age 65 – 74 years 1
Sc Sex category (i.e. female gender) 1
Progress Case
• Discharge with Warfarin (2) 1 tab PO OD Keep (INR 2-3)
Thank you