[P] Medicine Management & Administration



Admit to: __HDU __ICU__Acute 8 Ward. Diagnosis: Ischemic stroke. _____________ _____________ _____________ _____________The presence of onset headache and vomiting favor the diagnosis of ICH or SAHcompared with a thromboembolic stroke, while the abrupt onset of impaired cerebral function without focal symptoms favors the diagnosis of SAH.Acute stroke differential diagnosis Migraine Intracerebral hemorrhage Head trauma Brain tumorTodd’s palsy (paresis, aphasia, neglect, etc., after a seizure episode)Functional deficit (conversion reaction)Systemic infectionToxic-metabolic disturbances (hypoglycemia, acute renal failure, hepatic insufficiency, exogenous drug intoxication).Condition: __Critical __Serious __Fair __StableVital Signs: Vital signs and neurochecks q30minutes for 6 hours, then q60 minutes for 12 hours. Call physician if:BP > 185/105, <110/60; P >120, <50;R>24, <10; T >38.5’C; or change in neurologic status.Activity: Bed-rest.Nursing: Inputs and outputs (I’s and O’s), Head-of-bed at 30 degrees, Turn q2h when awake, Range of motion exercises qid. Foley catheter,eggcrate mattress. Guaiac stools. Bleeding precautions: check puncture sites for bleeding or hematomas. Apply digital pressure or pressure dressing to active compressible bleeding sites.Diet: NPO except medications for 24 hours, thendysphagia ground diet with thickened liquids ONLY if swallowing and cough reflexes tested adequate. IV Fluids and Oxygen: 0.45% normal saline at 100cc/h. Oxygen at 2 L per minute by nasal cannula. Special Medications:Ischemic Stroke <3 hours:Tissue plasminogen activator (t-PA, Alteplase) is indicated if the patient presents within 3 hours of onset of symptoms and the stroke is non-hemorrhagic; 0.9 mg/kg (max 90 mg) over 60 min. Give 10% of the total dose as an initial bolus over 1 minute.Repeat CT scan or MRI 24 hours after completion of tPA. Begin heparin if scan results are negative for hemorrhage.Heparin 12 U/kg/h continuous IV infusion, without a bolus. Check aPTT q6h to maintain 1.2-1.5 x pleted Ischemic Stroke >3 hours:Aspirin enteric coated 325 mg PO qd ORClopidogrel (Plavix) 75 mg PO qd ORAspirin 25 mg/dipyridamole 200 mg (Aggrenox) 1 tab PO bid ORAspirin 325 mg PO qd PLUS Clopidogrel (Plavix) 75mg PO qdMedical Considerations.Anticoagulant use is a common cause of intracerebral hemorrhage. Thus, the prothrombin and partial thromboplastin time and the platelet count should be checked. The effects of warfarin are corrected with intravenous vitamin K and fresh frozen plasma (typically 4 units) in patients with intracerebral hemorrhage.A drug overdose can mimic an acute stroke. In addition, cocaine, intravenous drug abuse, and amphetamines can cause an ischemic stroke or intracranial hemorrhage. Hyponatremia and thrombotic thrombocytopenic purpura (TTP) can present with focal neurologic deficits, suggesting the need for measurement of serum electrolytes and a complete blood count with platelet count.Hyperglycemia, defined as a blood glucose level >108 mg/dL, is associated with poor functional outcome from acute stroke at presentation. Stress hyperglycemia is common in stroke patients, although newly diagnosed diabetes may be detected. Treatment with fluids and insulin to reduce serum glucose to less than 300 mg/dL is recommended.Hypoglycemia can cause focal neurologic deficits mimicking stroke. The blood sugar should be checked and rapidly corrected if low. Glucose should be administered immediately after drawing a blood sample in "stroke" patients known to take insulin or oral hypoglycemic agents.Fever. Primary central nervous system infection, such as meningitis, subdural empyema, brain abscess, and infective endocarditis, need to be excluded as the etiology of fever. Common etiologies of fever include aspiration pneumonia and urinary tract infection. Fever may contribute to brain injury in patients with an acute stroke. Maintaining normothermia is recommended after an acute stroke. Prophylactic administration of acetaminophen (1 g four times daily) is more effective in preventing fever than placebo (5 versus 36 percent).Blood pressure management. Acute management of blood pressure (BP) may vary according to the type of stroke.Ischemic stroke. Blood pressure should not be treated acutely in the patient with ischemic stroke unless the hypertension is extreme (diastolic BP above 120 mm Hg and/or systolic BP above 220 mm Hg), or the patient has active ischemic coronary disease, heart failure, or aortic dissection. If pharmacologic therapy is given, intravenous labetalol is the drug of choice.Intracranial hemorrhage. With ICH, intravenous labetalol, nitroprusside, or nicardipine, should be given if the systolic pressure is above 170 mm Hg. The goal is to maintain the systolic pressure between 140 and 160 mm Hg. Intravenous labetalol is the first drug of choice in the acute phase since it allows rapid titration.Symptomatic Medications:Famotidine (Pepcid) 20 mg IV/PO q12h.Omeprazole (Prilosec) 20 mg PO bid or qhs.Docusate sodium (Colace) 100 mg PO qhsBisacodyl (Dulcolax) 10-15 mg PO qhs or 10 mg PR prn.Acetaminophen (Tylenol) 650 mg PO/PR q4-6h prn temp >38°C or headache.Extras: Chest x-ray, ECG, CT without contrast or MRI with gadolinium contrast; carotid duplex scan; echocardiogram,24-hour Holter monitor; swallowing studies.Physical therapy consult for range of motion exercises; neurology and rehabilitation medicine consults. Neuroimaging studies are used to exclude hemorrhage as a cause of the deficit, to assess the degree of brain injury, and to identify the vascular lesion responsible for the ischemic puted tomography. In the hyperacute phase, a non-contrast CT (NCCT) scan is usually ordered to exclude or confirm hemorrhage. A NCCT scan should be obtained as soon as the patient is medically stable.Noncontrast CT. Early signs of infarction include: Subtle parenchymal hypodensity, which can be detected in 45 to 85 percent of cases. Early focal brain swelling is present in up to 40 percent of patients with early infarction and also has been adversely related to outcome. A hyperdense middle cerebral artery (MCA) can be visualized in 30 to 40 percent of patients with an MCA distribution stroke, indicating the presence of thrombus inside the artery lumen (bright artery sign).Transcranial Doppler ultrasound (TCD) visualizes intracranial vessels of the circle of Willis. It is a noninvasive means of assessing the patency of intracranial vessels.Carotid duplex ultrasound is as a noninvasive examination to evaluate extracranial atherosclerotic disease. It may help to establish the source of an embolic stroke, but is not used acutely.Labs: CBC, glucose, BUN, Creatinine, Na+, K+, CO2, Cl-, fasting lipid profile, VDRL, ESR; drug levels, INR/PTT, UA. Lupus anticoagulant, anticardiolipin antibody. ................
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