Transcript سکته مغزی(CVA)

)CVA(‫سکته مغزی‬
Adult Stroke: 2010 American Heart Association Guidelines for
Cardiopulmonary Resuscitation and Emergency
Cardiovascular Care
‫دکتر بهروز هاشمی‬
‫متخصص طب اورژانس‬
‫دانشگاه علوم پزشکی شهید بهشتی‬
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Introduction
Third leading cause of death in the united states.
Significant improvements in stroke care due to:
I. Integrating public education,
II. 911 dispatch,
III. Prehospital detection and triage,
IV. Hospital stroke system development,
V. Stroke unit management
“D’s of Stroke Care”
 Detection: Rapid recognition of stroke symptoms
 Dispatch: Early activation and dispatch of emergency
medical services (EMS) system by calling 911
 Delivery: Rapid EMS identification, management, and
transport
 Door: Appropriate triage to stroke center
 Data: Rapid triage, evaluation, and management within the
emergency department (ED)
 Decision: Stroke expertise and therapy selection
 Drug: Fibrinolytic therapy, intra-arterial strategies
 Disposition: Rapid admission to stroke unit, critical-care
unit
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Management Goals
The overall goal of stroke care is to minimize
acute brain injury and maximize patient
recovery.
The chain of 7 D recommended.
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‫شناسایی عالئم اولیه و اطالع به‬
‫اورژانس ‪115‬‬
‫ارزیابی توسط ‪ 115‬و انجام اقدامات اولیه‪:‬‬
‫‪ABC‬‬
‫ارزیابی عمومی و پایدارسازی‪:‬‬
‫‪ABC & VS‬‬
‫‪ O2‬در صورت نیاز‬
‫رگ گیری و ارسال نمونه‬
‫چک ‪ BS‬و درمان‬
‫ارزیابی سیستم عصبی‬
‫فعال سازی تیم سکته مغزی‬
‫‪CT Or MRI‬‬
‫‪ECG‬‬
‫بررسی توسط تیم سکته مغزی‪:‬‬
‫بررسی تاریخچه بیمار‬
‫زمان شروع عالئم‬
‫معاینه نرولوژیک‬
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‫شناسایی سکته‬
‫تعیین زمان شروع عالئم‬
‫سنجش قند خون‬
‫اطالع به بیمارستان مقصد‬
‫مشاوره با‬
‫نرولوژیست یا‬
‫نروسرجن‬
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‫سی تی اسکن‬
‫خونریزی نشان‬
‫میدهد؟‬
‫بررسی امکان‬
‫شروع‬
‫فیبرینولیتیک‬
‫‪rtPA‬‬
‫بستری در بخش‬
‫مراقبتهای ویژه‬
‫آسپیرین‬
‫عدم استفاده از‬
‫داروهای ضد انعقادی‬
‫و ضد پالکتی برای‬
‫‪ 24‬ساعت‬
Stroke Warning Signs
Time is gold: Community and professional
education is essential.
Signs & Symptoms:
I. Sudden weakness or numbness of the face, arm,
or leg, especially on one side of the body
II. Sudden confusion
III. Trouble speaking or understanding
IV. Sudden trouble seeing in one or both eyes
V. Sudden trouble walking, dizziness, loss of balance
or coordination
VI. Sudden severe headache with no known cause.
EMS
Education to EMS personnel due to minimize
delays in prehospital:
• Dispatch
• Assessment
• Transport
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Stroke Assessment Tools

•
•

•
•

•
•
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
The Cincinnati Prehospital Stroke Scale
Facial droop(Pic1)
Normal—both sides of face move equally
Abnormal—one side of face does not move as well as the other
side
Arm drift (Pic2)
Normal—both arms move the same or both arms do not move at
all (other findings, such as pronator drift, may be helpful)
Abnormal—one arm does not move or one arm drifts down
compared with the other
Abnormal speech
Normal—patient uses correct words with no slurring
Abnormal—patient slurs words, uses the wrong words, or is unable
to speak
Sensitivity= 59%
Specificity= 89%
Prehospital Management and Triage
ABC:
• Aspiration/ hypoventilation
• O2 supply if SPO2<94% or Unknown
• Cardiopulmonary support
• There are no data to support initiation of
hypertension intervention in the prehospital
environment.
• If SBP<90mmHg, fluid recommended.
Time of onset of symptoms
Initial ED Assessment and
Stabilization
 ED personnel should assess the patient with suspected
stroke within 10 minutes of arrival in the ED.
• ABC + O2 supply
• BS Glucometry
• Blood sample(CBC, PT/PTT/INR, BS) and Treponin
• ECG
 Doctor :
• Neurologic PhExam
• Order Brain CT
• Alert Neurologist
ECG
• ECG does not take priority over the CT scan
but may identify a recent AMI or arrhythmias
(eg, atrial fibrillation) as the cause of an
embolic stroke.
• If the patient is hemodynamically stable,
treatment of other arrhythmias, including
bradycardia, premature atrial or ventricular
contractions, or asymptomatic atrioventricular
conduction block, may not be necessary.
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Cardiac monitoring
During the first 24 hours of evaluation in
patients with acute ischemic stroke to detect
atrial fibrillation and potentially lifethreatening arrhythmias.
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Arteial HTN for reperfusion candidates
No reperfusion if BP> 185/110
Treat by:
a) Labetalol 10–20 mg IV over 1–2 minutes, may
repeat 1,
b) Nicardipine IV 5 mg/hr, titrate up by 2.5 mg/hr
every 5–15 minutes, maximum 15 mg/hr; when
desired blood pressure reached, lower to 3
mg/hr
c) Other agents (hydralazine, enalaprilat, etc) may
be considered when appropriate.
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No reperfusion
Consider lowering blood pressure in patients with
acute ischemic stroke if SBP>220 mm Hg or
DBP>120 mm Hg
Consider blood pressure reduction as indicated
for other concomitant organ system injury:
 Acute myocardial infarction
 Congestive heart failure
 Acute aortic dissection
 A reasonable target is to lower blood pressure by
15% to 25% within the first day.
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Control Blood pressure in ICH
SBP> 200 or MAP>150
• Reduction of Bp is necessary.
• Continious IV infusion
SBP>180 or MAP>130 + NO elevated ICP:
• Map of 110 or BP about 160/90
• IV medication
SBP>180 or MAP>130 + Suspicion of elevated ICP:
• Monitoring ICP & reduction of BP
• CPP> 60-80 mmHg
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Imaging
• Brain CT or MRI
• These should be completed within 25
minutes.
• Interpreted within 45 minutes.
• No hemorrhage on the CT means indication
for rtPA.
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Fibrinolytic Therapy
• The treating physician should review the
inclusion and exclusion criteria for IV
fibrinolytic therapy.
Fibrinolytic Therapy
Review the inclusion and exclusion criteria for
IV fibrinolytic therapy
Perform a repeat neurologic examination
Discuss the risks and potential benefits of the
therapy with the patient or family
If the patient’s neurologic signs are
spontaneously clearing administration of
fibrinolytics may not be required.
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Anticoagulant & Antiplatelet
Neither anticoagulant Nor antiplatelet
treatment may be administered for 24 hours
after administration of rtpa until a repeat CT
scan at 24 hours shows no hemorrhagic
transformation.
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Adverse reaction
• ICH: A meta-analysis of 15 published case
series/symptomatic hemorrhage rate of 5.2%
of 2639 patients treated.
• Orolingual angioedema(1.5%)
• Acute hypotension
• Systemic bleeding(0.4%)
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Stroke Care
• The benefits from treatment in a stroke unit are
comparable to the effects achieved with IV rtpa.
• Careful observation :
i. Monitoring of blood pressure
ii. Monitoring of neurologic status
iii. Prevention of hypoxia,
iv. Management of hypertension,
v. Optimal glucose control,
vi. Maintenance of euthermia,
vii. Nutritional support.
• Prevention of complications associated with stroke (eg,
aspiration pneumonia, deep venous thrombosis, urinary
tract infections).
• Secondary stroke prevention.
Blood Pressure Management
• In those patients for whom recanalization is not
planned, more liberal acceptance of hypertension
is recommended, provided no other comorbid
conditions require intervention.
• Normal saline, administered at a rate of
approximately 75 to 100 mL/h, is used to
maintain euvolemia as needed.
• In stroke patients who may be relatively
hypovolemic, careful administration of IV normal
saline boluses may be appropriate.
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Glycemic Control
• Hyperglycemia is associated with worse
clinical outcome in patients with acute
ischemic stroke, but there is no direct
evidence that active glucose control improves
clinical outcome.
• Use insulin when the serum glucose level is
greater than 185 mg/dL in patients with acute
stroke.
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Temperature Control
Hyperthermia in the setting of acute cerebral
ischemia is associated with increased
morbidity and mortality and should be
managed aggressively.
Treat fever 37.5°c .
There are limited data on the role of
hypothermia specific to acute ischemic stroke.
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Dysphagia Screening
• All patients with stroke should be screened for
dysphagia before they are given anything by
mouth.
• A simple bedside screening evaluation:
 sip and swallow water without difficulty
 a large gulp of water and swallow.
• Medications may be given in jam.
• Any patient who fails a swallow test may be given
medications such as aspirin rectally or, if
appropriate for the medication, IV, IM, or SQ.
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Seizure prophylaxis
Not recommended.
Patients who experience a seizure,
administration of anticonvulsants is
recommended to prevent more seizures.
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‫خسته نباشید‬