stroke management

Stroke ManagementStroke Management

Chemeketa Community CollegeChemeketa Community College

Peggy AndrewsPeggy Andrews

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The "Golden Hour" of The "Golden Hour" of Acute Ischemic StrokeAcute Ischemic Stroke

>> A Look at Current Stroke A Look at Current Stroke TreatmentTreatment

What's Changed in 2000? “EMS systems should implement a prehospital stroke protocol to evaluate and rapidly identify patients who may benefit from fibrinolytic therapy, similar to the protocol for chest pain patients” (Class IIb).“Patients who may be candidates for fibrinolytic therapy should be transported to hospitals identified as capable of providing acute stroke care, including 24-hours availability of CT scan and interpretation.” (Class IIb).“Stroke presenting with 3 hours should be triaged on an emergent basis with urgency similar to acute ST-elevation myocardial infarction.”

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Acute StrokeAcute Stroke

Where are we today?Where are we today? Public poorly informedPublic poorly informed Response time too slowResponse time too slow Presentation too latePresentation too late Hospitals ill preparedHospitals ill prepared

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Models for the "Golden Models for the "Golden Hour"Hour"

TraumaTrauma Times studied/defined Times studied/defined Centralized trauma center systemCentralized trauma center system Mortality LowMortality LowAMIAMI Similar door-drug/groin benchmarks for Similar door-drug/groin benchmarks for

reperfusionreperfusion Decentralized systemDecentralized system Treatment data strongly supportsTreatment data strongly supports

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AMI - exampleAMI - example

The paradigm has shiftedThe paradigm has shifted Chest pain - patients know to call 911Chest pain - patients know to call 911 Rapid access to EMSRapid access to EMS

– Early recognitionEarly recognition ECGECG S/SS/S Rapid TransportRapid Transport

Team, protocols, drugs in the EDTeam, protocols, drugs in the ED ““Door to Drug” in 30 MinutesDoor to Drug” in 30 Minutes

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Why Care?Why Care?

Impact of StrokeImpact of Stroke 3rd leading cause of death in U.S.3rd leading cause of death in U.S. Leading cause of adult disabilityLeading cause of adult disability 750,000 new cases/year in U.S.750,000 new cases/year in U.S.

– 150,000 deaths/year150,000 deaths/year – 1/3 Under age 651/3 Under age 65

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Forces of ChangeForces of Change

1.1. Public expectationsPublic expectations – Aware of “Draino for the Braino”Aware of “Draino for the Braino”

2.2. Medical - legal pressuresMedical - legal pressures 3.3. Managed care cost concernsManaged care cost concerns

- Long term vs Short Term- Long term vs Short Term

4.4. New/better treatmentsNew/better treatments 5.5. Physicians‘ willing/able to Physicians‘ willing/able to

treat treat - Evidenced based medicine- Evidenced based medicine

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Organized Stroke Care Organized Stroke Care Saves LivesSaves Lives

21% reduction in early mortality21% reduction in early mortality 18% reduction in 12 month 18% reduction in 12 month

mortalitymortality Decreased length of hospital stayDecreased length of hospital stay Decreased need for institutional Decreased need for institutional

carecare

Source: Source: Jorgenson, Stroke, 1994Jorgenson, Stroke, 1994

http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&list_uids=8266390&dopt=Abstract

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What are we talking about here?What are we talking about here?

Ischemic Stroke (84%)Ischemic Stroke (84%) Hemorrhagic Stroke (16%)Hemorrhagic Stroke (16%)

– These have very different needsThese have very different needs– Philosophy in treatment takes a different Philosophy in treatment takes a different

directiondirection

Traumatic Brain Injury (TBI)Traumatic Brain Injury (TBI)– Not talking about today – PHTLSNot talking about today – PHTLS

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Ischemic StrokeIschemic Stroke

HYPOperfusionHYPOperfusion Embolic (20% had a-fib)Embolic (20% had a-fib) ThromboembolicThromboembolic

GOAL of TreatmentGOAL of Treatment– 1. Restore Circulation1. Restore Circulation– 2. Stop Ischemia2. Stop Ischemia

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What is this What is this rt-PArt-PA

Recombinant Tissue Recombinant Tissue Plasminogen ActivatorPlasminogen Activator

Review of clotting cascadeReview of clotting cascade– Collagen ExposedCollagen Exposed

Vessel injuryVessel injury DamageDamage Long term wearLong term wear EmbolusEmbolus

– Clotting factors aggregateClotting factors aggregate

– Fibrin Repair (Bond-O)Fibrin Repair (Bond-O)

– FIBRINOLYSISFIBRINOLYSIS

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Intra-Intra-venousvenous fibrinolysis for fibrinolysis for acute acute ISCHEMICISCHEMIC stroke stroke

Class IClass IIV - t-PA within IV - t-PA within 3 hours3 hours of onset of onset

Class IndeterminateClass IndeterminateIV - t-PA between 3 and 6 hours of IV - t-PA between 3 and 6 hours of onsetonset

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Intra-Intra-arterialarterial thrombolysis thrombolysis TPA, Urokinase, Anti-plateletTPA, Urokinase, Anti-platelet

– All experimental in the 3-6 hour windowAll experimental in the 3-6 hour window– Lower doses, delivered right to clotLower doses, delivered right to clot

Snare devicesSnare devices– Reach in and grab itReach in and grab it– Vessels sometimes too small to get intoVessels sometimes too small to get into

Mechanical devicesMechanical devices– Angiojet – rotating bladeAngiojet – rotating blade– UltrasoundUltrasound– LasersLasers

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With rt-PA, considering With rt-PA, considering 1,000 eligible patients:1,000 eligible patients:

Hospitalization costs = $1.7 million moreHospitalization costs = $1.7 million more

Rehabilitation costs = $1.4 million lessRehabilitation costs = $1.4 million less

Nursing home costs = $4.8 million lessNursing home costs = $4.8 million less

564 quality-adjusted life-years saved564 quality-adjusted life-years saved

Source: Fagan, Neurology 1998


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NIH National Symposium NIH National Symposium RecommendationsRecommendations

Door-to-MD:Door-to-MD:>> 10 minutes10 minutes Door-to-Neurologic Expertise:Door-to-Neurologic Expertise:

>> 15 minutes15 minutes Door-to-CT scan:Door-to-CT scan:>> 25 minutes25 minutes Door-to-CT Interpretation:Door-to-CT Interpretation:

>> 45 minutes45 minutes Door-to-Drug:(80% compliance)Door-to-Drug:(80% compliance)

>> 60 minutes60 minutes Door-to-Admission:Door-to-Admission:>> 3 hours3 hours

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Stroke Chain of Survival & Stroke Chain of Survival & RecoveryRecovery

Detection: Detection: Early recognitionEarly recognition

Dispatch: Dispatch: Early EMSEarly EMS activationactivation

Delivery: Delivery: Transport &Transport & managementmanagement

Door: Door: ED triageED triage

Data: Data: ED evaluation &ED evaluation & managementmanagement

Decision: Decision: Specific therapiesSpecific therapies

Drug: Drug: Thrombolytic &Thrombolytic & future agentsfuture agents

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Dispatch & Delivery: Dispatch & Delivery: Transport & ManagementTransport & Management

ABC’sABC’s Stroke recognitionStroke recognition Establish time of onsetEstablish time of onset Perform neurological evaluationPerform neurological evaluation Check glucoseCheck glucose Early hospital notificationEarly hospital notification Rapid transportRapid transport

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Cincinnati Pre-Hospital Cincinnati Pre-Hospital Stroke ScaleStroke Scale

Facial DroopFacial Droop

Normal:Normal: Both sides of face move Both sides of face move

equallyequally

Abnormal: Abnormal: One side of face does not One side of face does not

move at allmove at all

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Arm DriftArm Drift

Normal:Normal: Both arms move equally or Both arms move equally or

not at allnot at all

Abnormal:Abnormal: One arm drifts One arm drifts

compared to the othercompared to the other

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SpeechSpeech

Normal: Normal: Patient uses correct words Patient uses correct words

without slurringwithout slurring

Abnormal:Abnormal: Slurred or inappropriate Slurred or inappropriate

words or mutewords or mute

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NIH Stroke ScaleNIH Stroke Scale ItemItem DescriptionDescription RangeRange

1a1a LOCLOC 0 – 30 – 31b1b LOC QuestionsLOC Questions 0 – 20 – 2 1c1c LOC CommandsLOC Commands 0 – 20 – 2 22 Best GazeBest Gaze 0 – 20 – 2 33 Best VisualBest Visual 0 – 30 – 344 Facial PalsyFacial Palsy 0 – 30 – 355 Motor Arm LeftMotor Arm Left 0 – 40 – 4 66 Motor Arm RightMotor Arm Right 0 – 40 – 4 77 Motor Leg LeftMotor Leg Left 0 – 40 – 4 88 Motor Leg RightMotor Leg Right 0 – 40 – 4 99 Limb AtaxiaLimb Ataxia 0 – 20 – 2 1010 SensorySensory 0 – 20 – 2 1111 NeglectNeglect 0 – 20 – 2 1212 DysarthriaDysarthria 0 – 20 – 2 1313 Best LanguageBest Language 0 – 30 – 3

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12 cranial nerves check12 cranial nerves check

II smell smell IIII visionvision IIIIII pupil pupil

constriction, eye constriction, eye movementmovement

IVIV downward gazedownward gaze VV facial sensationfacial sensation VIVI lateral eye lateral eye

movementmovement

VIIVII taste, frown, taste, frown, smilesmile

VIII hearing, balance VIII hearing, balance IXIX taste, gag, taste, gag,

swallowingswallowing XX voicevoice XIXI shoulder shrugshoulder shrug XIIXII tongue tongue

movementmovement

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PreparationPreparationKnow your stroke team before you need themKnow your stroke team before you need them Check glucoseCheck glucose Two large IV linesTwo large IV lines Oxygen as neededOxygen as needed Cardiac monitorCardiac monitor Continuous pulse-oxContinuous pulse-ox Stat non-contrast CT scanStat non-contrast CT scan ECGECG CXRCXR Get rt-PAGet rt-PA

>> Prepare to mix Prepare to mix>> Have pharmacy alerted Have pharmacy alerted

Discuss options with patient and familyDiscuss options with patient and family Contact primary care providerContact primary care provider

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American Heart Association American Heart Association RecommendationsRecommendations

OxygenOxygen Use to correct hypoxiaUse to correct hypoxia Suggestion that supernormal levels Suggestion that supernormal levels

may hurtmay hurt> > one year survival 69% 3L NC vs 73% one year survival 69% 3L NC vs 73% controlcontrol

GlucoseGlucose Maintain euglycemiaMaintain euglycemia Treat glucose > 300 mg/dl with insulinTreat glucose > 300 mg/dl with insulin

Source: Rønning, Stroke 1999



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True Time of OnsetTrue Time of Onset

How normal were they?How normal were they? What are they like at baseline?What are they like at baseline? Who saw them last?Who saw them last? Clearly no symptoms?Clearly no symptoms?

Times of referenceTimes of reference TelevisionTelevision The time the basketball game The time the basketball game

startedstarted

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Stroke Risk FactorsStroke Risk Factors

Modifiable risk Modifiable risk factorsfactors

High blood pressureHigh blood pressure Cigarette smokingCigarette smoking Transient ischemic Transient ischemic

attacksattacks Heart diseaseHeart disease Diabetes mellitusDiabetes mellitus HypercoagulopathyHypercoagulopathy Carotid stenosisCarotid stenosis

– BruitsBruits OtherOther

Non-modifiable risk Non-modifiable risk factorsfactors

AgeAge GenderGender RaceRace Prior strokePrior stroke HeredityHeredity

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Differential DiagnosisDifferential Diagnosis

Intracerebral hemorrhageIntracerebral hemorrhage Hypoglycemia / HyperglycemiaHypoglycemia / Hyperglycemia SeizureSeizure Migraine headacheMigraine headache Hypertensive crisisHypertensive crisis Epidural / SubduralEpidural / Subdural Meningitis / Encephalitis / Brain Meningitis / Encephalitis / Brain

abscessabscess TumorTumor

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What are the Options?What are the Options?

No thrombolyticsNo thrombolytics NothingNothing AspirinAspirin HeparinHeparin Intravenous rt-PAIntravenous rt-PAOtherOther Intra-arterial thrombolyticsIntra-arterial thrombolytics Investigative procedureInvestigative procedure

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Exclusions to ThrombolyticsExclusions to Thrombolytics Bleeding concernsBleeding concerns

– Stroke/head trauma in 3 Stroke/head trauma in 3 mosmos

– Major surgery<14 daysMajor surgery<14 days – Hx of intracranial Hx of intracranial

hemorrhagehemorrhage Seizures at the onset of Seizures at the onset of

strokestroke– SBP > 185 mm HgSBP > 185 mm Hg – DBP > 110 mm HgDBP > 110 mm Hg – Symptoms suggestive of Symptoms suggestive of

hemorrhagehemorrhage – GI hemorrhage within 21 GI hemorrhage within 21

daysdays – Urinary tract Urinary tract

hemorrhage within 21 hemorrhage within 21 daysdays

– Arterial puncture at non-Arterial puncture at non-compressible site < 7 compressible site < 7 daysdays

– Rx anticoagulantsRx anticoagulants

Possibly not indicated or Possibly not indicated or wrong diagnosiswrong diagnosis– Rapidly improving or Rapidly improving or

minor symptomsminor symptoms – Glucose < 50 or > 400 Glucose < 50 or > 400

mg/dlmg/dl Possible Setup for DIC/other Possible Setup for DIC/other

metabolic disordersmetabolic disorders– Heparin within 48 hoursHeparin within 48 hours– PTTPTT High High– PT HighPT High– INR HighINR High – Platelet count lowPlatelet count low

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Let’s talk about blood pressureLet’s talk about blood pressure

MAP – Mean Arterial Pressure (70-90 Normal)MAP – Mean Arterial Pressure (70-90 Normal)

ICP – Intracranial PressureICP – Intracranial Pressure– Normally about 0-15mmHgNormally about 0-15mmHg– >20 = Bad>20 = Bad

CPP – Cerebral Perfusion PressureCPP – Cerebral Perfusion Pressure– CPP=MAP-ICPCPP=MAP-ICP– CPP must be above 70mmHg for cerebral perfusionCPP must be above 70mmHg for cerebral perfusion

You do the mathYou do the math

3

)2( DiastolicSystolic

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IF CPP=MAP-ICPIF CPP=MAP-ICP

And we know that the body autoregulates And we know that the body autoregulates pressures to preserve itselfpressures to preserve itself– 80-90% of ischemic strokes present with 80-90% of ischemic strokes present with

elevated BPelevated BP– ICP may have risen because of EdemaICP may have risen because of Edema

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Studied:Studied:

– Multicenter Study – 372 patientsMulticenter Study – 372 patients– Compared Neuro outcome vs BP changes in Compared Neuro outcome vs BP changes in

first 24 hoursfirst 24 hours– If Diastolic BP decreased by >25% (even once)If Diastolic BP decreased by >25% (even once)

Poorer outcomes regardless of baseline diastolic BP Poorer outcomes regardless of baseline diastolic BP levels, Stroke location or use of HTN agentslevels, Stroke location or use of HTN agents

– NO EVIDENCE THAT LOWERING BP HELPSNO EVIDENCE THAT LOWERING BP HELPS Remember we’re still talking about ischemic strokesRemember we’re still talking about ischemic strokes

– FAIR Evidence that it harmsFAIR Evidence that it harms

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BP Treated in extreme casesBP Treated in extreme cases

““Gentle” management if Gentle” management if thrombolytic candidate:thrombolytic candidate:

SBP > 180 mm HgSBP > 180 mm Hg DBP > 110 mmDBP > 110 mm Hg Hg Choices:Choices: LabetalolLabetalol EnalaprilEnalapril NitropasteNitropaste

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Treatment Considerations: Who Treatment Considerations: Who will benefit from rt-PA?will benefit from rt-PA?

Patient agePatient age Co-morbid factorsCo-morbid factors

– Medical historyMedical history Risks of treatmentRisks of treatment

– Odds of PresentingOdds of Presenting

Benefits of TreatmentBenefits of Treatment– Odds of surviving Odds of surviving

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Treatment considerations (cont’d)Treatment considerations (cont’d)

Time from onsetTime from onset (Remember 3 hours) (Remember 3 hours) Stroke severityStroke severity Stroke subtypeStroke subtype

– Data driven here tooData driven here too CT findingsCT findings

– Assymetry = BadAssymetry = Bad– Density image – Tissue/fluid ratioDensity image – Tissue/fluid ratio

Charcoal=NormalCharcoal=Normal Dark = Higher density (more tissue than fluid)Dark = Higher density (more tissue than fluid)

– IschemiaIschemia Light = Lower density (More fluid than tissue)Light = Lower density (More fluid than tissue)

– HemorrhageHemorrhage– TumorTumor

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Which one is which?Which one is which?

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Factors Associated with Factors Associated with Increased Risk of ICHIncreased Risk of ICH

Treatment initiated > 3 hoursTreatment initiated > 3 hours Increased thrombolytic doseIncreased thrombolytic dose Elevated blood pressureElevated blood pressure NIHSS > 20 *NIHSS > 20 * Acute hypodensity or mass effect Acute hypodensity or mass effect **

** Even though increased r/o ICH, still with benefit vs. placeboEven though increased r/o ICH, still with benefit vs. placebo

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Stroke Treatment – AspirinStroke Treatment – Aspirin

Two important trials:Two important trials:>> International Stroke TrialInternational Stroke Trial>> Chinese Acute Stroke TrialChinese Acute Stroke Trial

Combined analysis (n=40,090)Combined analysis (n=40,090) Death / nonfatal strokes reduced Death / nonfatal strokes reduced

11%11% Don’t forget to check swallowingDon’t forget to check swallowing Local protocol drivenLocal protocol driven

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Stroke Treatment – HeparinoidsStroke Treatment – Heparinoids

Decreased recurrent ischemic Decreased recurrent ischemic strokesstrokes

Increased hemorrhagic eventsIncreased hemorrhagic events No net stroke benefitNo net stroke benefit

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The "Golden Hour" of The "Golden Hour" of Acute Ischemic StrokeAcute Ischemic Stroke

>> Case Study Case Study History:History: A 61 year old male, with acute A 61 year old male, with acute

aphasia, right facial droop, and aphasia, right facial droop, and right sided weakness.right sided weakness.

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12:30 12:30 Sudden onset while working in yard.Sudden onset while working in yard.

12:45 12:45 Family calls 911.Family calls 911.

13:05 13:05 Advanced squad evaluates neurologic Advanced squad evaluates neurologic deficits and glucose.deficits and glucose.

13:15 13:15 Squad notifies receiving hospital of Squad notifies receiving hospital of possible stroke patientpossible stroke patient

13:30 13:30 ED arrival. Initial evaluation by E.D. ED arrival. Initial evaluation by E.D. physician.physician.

13:45 13:45 Stroke Team arrives. NIHSS 18.Stroke Team arrives. NIHSS 18.

14:00 14:00 CT scan performed.CT scan performed.

14:15 14:15 Discuss with family and PMD.Discuss with family and PMD.

14:20 14:20 Labs back: gluc 97. BP remains 150/70’s.Labs back: gluc 97. BP remains 150/70’s.

14:20 14:20 CT reading back. No hemorrhage or early CT reading back. No hemorrhage or early signs of ischemiasigns of ischemia

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14:25 14:25 Checklist done. No exclusion Checklist done. No exclusion criteria met.criteria met.

14:30 14:30 Decision time.Decision time.14:35 14:35 IV rt-PA given. 0.9 mg/kg IV rt-PA given. 0.9 mg/kg

totaltotal >> 10% bolus10% bolus - 9 mg- 9 mg >> 90% over 1 hr - 81 mg90% over 1 hr - 81 mg

15:45 15:45 Patient goes to ICU. Report Patient goes to ICU. Report personally given to ICU staff.personally given to ICU staff.

15:50 15:50 Pathway actions begin (HOB, Pathway actions begin (HOB, BP parameters, aspiration BP parameters, aspiration precautions).precautions).

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24 Hour Follow-up24 Hour Follow-up

A 61 year old male, with acute A 61 year old male, with acute stroke, treated with rt-PA.stroke, treated with rt-PA.

Repeat NIHSS = 3:Repeat NIHSS = 3: VF intactVF intact No gaze palsyNo gaze palsy Mild facial palsyMild facial palsy Mild right arm driftMild right arm drift Mild dysarthriaMild dysarthria

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Hemorrhagic StrokeHemorrhagic Stroke

Treatment Goals – (Different)Treatment Goals – (Different)– 1. Reduce the risk of re-bleed1. Reduce the risk of re-bleed– 2. Reduce risk of continued bleeding2. Reduce risk of continued bleeding

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Hemorrhagic Stroke (16%)Hemorrhagic Stroke (16%)

Bleeding into or surrounding the brainBleeding into or surrounding the brain Intracerebral Hemorrhage (ICH)Intracerebral Hemorrhage (ICH)

– HTNHTN– Tumor/LesionsTumor/Lesions– Venous sinus thrombosisVenous sinus thrombosis

Drains from the dura materDrains from the dura mater

– Amyloid angiopathyAmyloid angiopathy Starch-like deposits on vessel walls- precursorStarch-like deposits on vessel walls- precursor

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Hemorrhagic Stroke (16%)Hemorrhagic Stroke (16%)

Bleeding into or Bleeding into or surrounding the brainsurrounding the brain

Sub-arachnoid Sub-arachnoid hemorrhage (SAH)hemorrhage (SAH)– Blood in arachnoid Blood in arachnoid

space, basal cisterns & space, basal cisterns & often intraventricularoften intraventricular Aneurysm ruptureAneurysm rupture TraumaTrauma Arteriovenous Arteriovenous

malformation (AVM)malformation (AVM)

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Some Skull Ground RulesSome Skull Ground Rules

Monroe-Kellie HypothesisMonroe-Kellie Hypothesis– Intracranial space/volume constantIntracranial space/volume constant– Three components = ICPThree components = ICP

CSF – 100mLCSF – 100mL– Production/absorption is pressure drivenProduction/absorption is pressure driven

Blood – 150mLBlood – 150mL– Here lies the problemHere lies the problem

Brain – 1250mL (or grams)Brain – 1250mL (or grams)– Relatively constant (IS HRelatively constant (IS H22O minimally displaceable)O minimally displaceable)

BrainBloodCSF VVVK

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Head BleedsHead Bleeds

Still assuming a closed system (non-trauma)Still assuming a closed system (non-trauma) ICP will riseICP will rise BP will riseBP will rise

– Remember autoregulation (compensatory)Remember autoregulation (compensatory) If SBP>230 & DBP > 120If SBP>230 & DBP > 120

– Sodium Nitroprusside 0.5mcg/kg/minSodium Nitroprusside 0.5mcg/kg/min If SBP>180 & DBP >105If SBP>180 & DBP >105

– Labetolol 10mg/1-2min – Double q10 to 300mgLabetolol 10mg/1-2min – Double q10 to 300mg If Hypertensive, but not extremely highIf Hypertensive, but not extremely high

– LEAVE IT ALONELEAVE IT ALONE

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Benefits of playing with BPBenefits of playing with BP

Decrease EdemaDecrease Edema Limit size of damaged areaLimit size of damaged area Limit further vascular damageLimit further vascular damage

Might actually need a fluid bolusMight actually need a fluid bolus– 1 Hypotensive episode-mortality 30+ %1 Hypotensive episode-mortality 30+ %

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Risks of playing with BPRisks of playing with BP

TOO MUCHTOO MUCH TOO FASTTOO FAST

– Can extend stroke by eliminating tamponadeCan extend stroke by eliminating tamponade– Expose patients to medication reactionsExpose patients to medication reactions

GoalGoal– SBP < 160SBP < 160– DBP < 100DBP < 100

Sometimes use a 20% of original ruleSometimes use a 20% of original rule

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Respiratory ManagementRespiratory Management

Intubate patients with GCS < 8Intubate patients with GCS < 8 Paralyze & Heavily Sedate Paralyze & Heavily Sedate

– 1111thth commandment commandment Causes of Increased ICPCauses of Increased ICP

– GaggingGagging– PukingPuking– StressStress– Respiratory distressRespiratory distress

Cause increased intra-thoracic pressureCause increased intra-thoracic pressure Decreases cerebral drainageDecreases cerebral drainage

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Post-intubation – Use LA paralyticPost-intubation – Use LA paralytic Watch BP Carefully for hypotensionWatch BP Carefully for hypotension

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Hyper-oxygenateHyper-oxygenate DO NOT hyperventilateDO NOT hyperventilate

– COCO22 is POTENT vasodilator is POTENT vasodilator

– Hypocarbia causes cerebral vasoconstrictionHypocarbia causes cerebral vasoconstriction Vasoconstriction causes edemaVasoconstriction causes edema ICP’s may riseICP’s may rise CPP will dropCPP will drop Loss of autoregulation … Brain deathLoss of autoregulation … Brain death

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AdjunctsAdjuncts

SpOSpO22 Monitoring (Volume) Monitoring (Volume)

– Bag to keep sat’s at 95-100%Bag to keep sat’s at 95-100%– (This might be VERY slow)(This might be VERY slow)– 5-7mL/kg5-7mL/kg

COCO22 Monitoring (Rate) Monitoring (Rate)

– Bag slow enough to keep EtCOBag slow enough to keep EtCO22

28-3228-32 (40ish is normal)(40ish is normal)

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Other treatments consideredOther treatments considered

Osmotic DiureticsOsmotic Diuretics– Mannitol (comes in and out of favor)Mannitol (comes in and out of favor)

Anticonvulsant’sAnticonvulsant’s– Prevent seizuresPrevent seizures

Anti-emeticsAnti-emetics May operate on bleedersMay operate on bleeders

– Often too late by the time it is diagnosedOften too late by the time it is diagnosed

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QuestionsQuestions

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Some pictures, Just for funSome pictures, Just for fun

stroke management

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