Managing CVA in ED Learning Objectives Is it a stroke? Diagnosis ...

More documents

Recommendations

Info

CVA look alikes tend to: Initial work-up • less prominent focal findings • Associated mental status changes (global brain dysfunction) • History and exam • Lab work • Imaging evolution in treatment options demand attention to pace of workup/treatments Important Acute CVA complications • Hypoxia/airway • Hypo/hypertension • Hypo/hyper glycemia • Fever associated with poorer outcomes • Seizures Complication Caveats • Airway interventions if needed • Oxygen for hypoxia (no help if not hypoxic) • Treat symptomatic hypoglycemia • Treat BP >220/120; no lytics till 150) CVA Etiology Timing/clinical course critical 15% 15% hemorrhagic • When did the stroke start 220% atherothrombotic cardio-embolic 25% unknown/rare • Is it dense/unchanging clinically • Is it “stuttering” or fluctuating in symptoms • Level of severity (NIHSS stroke scale) lacunar 25% 2
What about timing • If therapy available under 3 hrs most now recommend intervention • If therapy available under 4.5 hrs., some recommend • If therapy available under 6 hrs., a few still recommend NIHSS stroke scale • Tool for communication/decision-making • Higher scores correlate with higher mortality • www.strokecenter.org CVA Patient Imaging Options Acute Symptoms < 5 hrs. Or “stuttering” Assess/address complications Determine NIHSS Score Subacute >5hrs • CT scan • CT with contrast (CTA or CTP) Imaging •MRI Acute CVA ED Goal – Evaluation to CT read = 45 mins. CT scan (no contrast) • Remains as standard of care due to availability and sensitivity excluding blood • More sensitive than MRI for detecting blood • ECASS trial demonstrated that early signs of major cerebral infarction (e.g. sulcal effacement, mass effect, edema, and loss of the insular ribbon) are associated with an increased risk for intracerebral hemorrhage in patients who receive thrombolytic therapy. Subtle CT findings may increase risk of bleeds with lytics • Sulcal effacement • Edema • Mass effect • Loss of insular ribbon If you are certain that onset
Page 1: Managing CVA in ED Dave Moen, MD Me
Page 5 and 6: Clinical Caveats • ASA within 24
Page 7 and 8: Aggressive Interventional Options
Page 9 and 10: Clinical Outcomes Clinical Outcomes

Managing CVA in ED Learning Objectives Is it a stroke? Diagnosis ...

You also want an ePaper? Increase the reach of your titles

Delete template?

Save as template?