What is Emergency Medicine - How should I handle hypertension in a patient who has recently suffered an ischemic stroke?
Reduced vascular damage is a benefit of lowering blood pressure, but again, higher than average blood pressures could be required to achieve the best brain perfusion. If the patient has another comorbid condition that might benefit from reduced blood pressure, or if their systolic or diastolic blood pressure is less than 220 or 120 mmHg, the AHA recommendations advise gradually lowering their blood pressure by 15%. (e.g., heart failure, dissection, pre-eclampsia). However, within the first 24 hours after receiving tPA, the patient's blood pressure needs to be kept at 180/105.
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What is Emergency Medicine -How should I handle ICH in the presence of tPA ?
Within 24 hours of taking tPA, the patient should be evaluated for ICH if they experience a sudden neurologic decline, a new headache, nausea, or vomiting. The tPA should be stopped right away, a non-contrast head CT should be done, and blood samples should be sent for laboratory analysis (i.e., type and crossmatch, PT, PTT, platelets, fibrinogen). The treatment of ICH following the administration of tPA has not been the subject of prospective data collection; however, expert opinions are provided in guidelines that advise 10 units of cryoprecipitate, 6-8 units of platelets (or one single donor unit), and neurosurgical consultation for potential hematoma evacuation. Other reversal agents are an option, however they are debatable. Examples include FFP, PCC, and TXA. What is Emergency Medicine -Which medical conditions qualify patients for mechanical thrombectomy?10/31/2022 What is Emergency Medicine -Which medical conditions qualify patients for mechanical thrombectomy?
Patients were a part of the early investigations on IR-guided mechanical thrombectomy. Aged 18 with an NIHSS of.6, little functional impairments prior to the stroke, and a CT scan showing signs of an LVO with salvageable tissue whose most recent normal state occurred less than six hours ago The five greatest randomized controlled trials (RCTs) combined into the HERMES meta-analysis demonstrated a significant patient functional advantage to thrombectomy in this group (NNT52.6) without an increased risk of mortality or ICH at 90 days. Since then, the DEFUSE3 trial and the DAWN trial have studied thrombectomy between 6 and 24 hours, and both have shown improvements in functional outcomes when compared to standard of care. The last few years have seen tremendous promise for embolectomy, and as additional trials are released, its indications will probably continue to grow. What is Emergency Medicine -When should I check a patient for an large vessel occlusion (LVO) if they have stroke symptoms?
When to obtain a CTA to assess for LVO is a topic on which there is no clear agreement. When compared to other LVO prediction models, the NIHSS fared the best, according to a 2018 meta-analysis. For LVO on CTA, a score of.6 had an 87% sensitivity and 52% specificity, whereas a value of.10 had a 73% sensitivity and 74% specificity. It is crucial to follow institutional policies and engage with your consultants early in the patient's course because neither of these thresholds has an appropriate sensitivity or specificity on their own. What is Emergency Medicine -How do I deal with a patient who has a major vessel occlusion (LVO)?10/31/2022 What is Emergency Medicine -How do I deal with a patient who has a major vessel occlusion (LVO)? LVO patients should be treated in the same manner as other stroke patients, including the possible injection of tPA. tPA administration shouldn't be postponed because the use of IV thrombolytics does not prevent a patient from obtaining mechanical thrombectomy. Vascular imaging, usually computed tomography angiography (CTA), which may detect clots and reveal blood flow through big vessels, is necessary for the detection of LVO.
What is Emergency Medicine -A large vessel occlusion, or LVO, is what?
LVO occurs when a considerable deficit results from the sizeable infarct caused when a major cerebral vessel is blocked by a clot near its proximal end. These lesions' close proximity and size make it possible to perform an IR-guided mechanical thrombectomy, in which the vessel is cannulated, the clot is broken up, and it is suctioned out to restore blood flow. What is Emergency Medicine -What should I do after administering tPA?
According to current recommendations, intensive care unit (ICU) admission should last for at least 24 hours, with periodic neurologic examinations to check for post-tPA bleeding For the first 24 hours, it's also advised to refrain from using other antithrombotic medications like heparin, warfarin, aspirin, ticlopidine, and clopidogrel, keep your blood pressure under 180/105, and stay away from invasive procedures like venipuncture, catheter insertion, and nasogastric tube placement. What is Emergency Medicine -Do you need informed permission before administering tPA? Depending on the institutional policies, different informed consent requirements may apply. But with each of these patients, the collaborative decision-making process is vitally important. The patient or a substitute decision maker should, if at all feasible, be fully informed of the risks, advantages, and alternatives to tPA. It's crucial to further clarify what might happen if the patient has the ability to refuse. Even without thrombolytic therapy, patients frequently experience some functional gains. It is acceptable and recommended by the AHA to administer tPA without a formal consent in patients whose current functional status makes it difficult for the patient to assess his or her knowledge.
What is Emergency Medicine -Why is the use of tPA for acute ischemic stroke controversial?10/31/2022 What is Emergency Medicine -Why is the use of tPA for acute ischemic stroke controversial?
The debate is complicated on many levels. The majority of trials testing tPA in ischemic stroke reveal an increased risk of ICH and related comorbidities without a mortality benefit, which worries tPA critics. Conflicts of interest have also been a source of worry because the drug company sponsors many of the larger trials. Proponents point out that these studies indeed demonstrate a considerable increase in patients' functional mobility and capacity for independent living, a crucial result considering the prevalence of disability following stroke in the world. What is Emergency Medicine -What about a patient who awakens with signs of a stroke?
About 20% of patients who report with stroke either have an uncertain last normal or wake up with a neurologic disability, which puts them beyond the thrombolytic window and disqualifies them for tPA. However, over the past few years, a number of studies have attempted to compare the area of the infarct and the area of dead tissue using two different MRI modalities (DWI and FLAIR), in an effort to identify which patients may have salvageable tissue and benefit from IV thrombolytics regardless of when they last experienced normalcy. This patient cohort was randomly assigned to either tPA or standard care in the WAKE-UP trial, which had improved functional results but was underpowered and had an increase in ICH in the tPA group. However, rather than utilizing the time of the last known normal, selecting thrombolytic candidates may be done in the future using sophisticated imaging modalities. |
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