Saturday, February 28, 2009
Acute treatment of stroke
Based on Tom Brott lecture-- many obvious guidelines are omitted and only a few of less obvious ones are listed below, based on my own discretion
*treat hypoxia
* treat fever
*cardiac monitoring for 24 hours
*Until more definitive data, cautious approach to treating BP in first 24 hours
* Alteplase guidelines for BP management also apply to other interventional procedures
* In first 24 hours, withholding meds for BP unless BP> 220-120
*Hypovolemia should be corrected
* Hypoglycemia should be corrected
* Beware of AE of angioedema with alteplase
* For arterial therapy, centers are encouraged to define criteria to credential
* ASA dose of 325 is now recommended within 24-48 hours
* Patients possibly needing neurosurgery (cerebellar infarct, major hemispheric infarct) should be transferred to a facility with that capability
* Hydrocephalus due to a cerebellar stroke can be treated with a drain
For hemorrhage:
* Use protamine/vit K to reverse anticoagulation if applicable
* Surgical removal dangerous cerebellar hemorrhage > 3 cm
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2 comments:
At our medical center, we hold antihypertensives for as long as 5 days out from stroke. I know there's no set guidelines but what's the general consensus? Thanks. -IM Resident
Amount of time not to treat HTN is not known nor likely univerally applicable. In general, lag to treatment of HTN post stroke is decreasing to 24-72 hour range. That said, if I thought perfusion to penumbral areas placed those areas at risk, due to low flow, I would maintain nontreatment of HTN for much longer on a case by case basis. This underlies the need to establish a mechanism for stroke, which occassionally can be omitted in IM
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