Emergency and Critical Care Management of the Stroke Patient Rachel Garvin, MD Assistant Professor,...

Emergency and Critical Care

Management of the Stroke Patient

Rachel Garvin, MDAssistant Professor, Neurosurgery

Assistant Professor, Emergency MedicineAssistant Professor, Neurology

Neurocritical Care

Emergency Medicine Grand RoundsFebruary 11, 2015

Let’s start with a case…

Mr. B• 44 yo M presents to the ED with altered mental

status• He was at work, became aphasic and then

unresponsive• On arrival to ED, BP 240/130, HR 80, sats 95% T

99.8• GCS E1 V1 M4. Brainstem reflexes intact. Pupils

3mm and sluggishly reactive• Wife arrives and reports the patient has a history

of HTN and did not take his meds• No ASA, coumadin or plavix

Initial Head CT

Mr. B continued• Neurosurgery is consulted and informs

wife that there is no surgical intervention• Patient given 10mg labetalol and started

on cardene drip• Repeat exam now shows E1 V1 M2. No

corneals, + cough, + gag. Pupils 2mm very sluggish

• Patient taken to the ICU for medical management and repeat CT/CTA done on the way up to the unit

Repeat CT/CTA 3 hours later

Goals of this lecture• Definitions and Stats• Anatomy• Blood pressure goals• The anti-coagulated patients• Seizure prophylaxis• To monitor or not?• What about sodium?• Temperature and glucose• Surgical Intervention

Stroke: Definition• Disruption of blood flow to the brain

o Ischemic StrokeoHemorrhagic stroke• Intracerebral Hemorrhage• Subarachnoid Hemorrhage

Numbers• 795,000 strokes/year• 5th leading cause of death• #1 cause of preventable disability• Mean lifetime cost of ischemic stroke $140,000• Among >65yr olds 6 month post ischemic stroke:

o 26% were completely dependento 26% in a nursing homeo 35% depression

Stroke Centers• Primary (110 in Texas, 11 in San Antonio)

o Staffing and infrastructure to stabilize and tx most stroke pts

• Comprehensive (12 in Texas, 0 in San Antonio)oDx and tx those needing high intensity

txo Specialized physicians and imagingoResource center

Anatomy

Anatomy

Structure and Function

Blood-Brain Barrier

Edema is on a continuum

http://www.asnr.org/neurographics/2/2/1/18.jpg

NIHSS

Isn’t the damage done?

• The initial insult is the primary injury

• Goal is to minimize secondary injuryoExpansionoEdemao Infarction

You Can Make A Difference!

ABC’s always come 1st• Airway needs to be assessed • BreathingoOxygenationoVentilation

• CirculationoHypertensive on presentationoHypotensive on presentation

BP goals

140? 160? 180? 220? 185?

Ischemic Stroke• No tPA vs. tPAo<220/120o<180/105

• When to normalize blood pressureoAre there ICP issues?oWhat about the penumbra?

BP lowering agents• Metoprolol• Hydralazine• Nitroprusside• Nitroglycerine

• Labetalol• Nicardipine• Enalaprilat

Do I need an arterial line?

• Hypo/Hypertension and titrating drips

• Intubated patient needing frequent ABG’s

Can patients with stroke be hypotensive?

• Many risks for cardiac compromise

• May require pressors and/or inotropes to maintain CPP/MAP

• Levophed +/- dobutamine or epi depending on systolic function

The Insula

Myocardial stunning

Thin blood = more blood

• Aspirin, PlavixoNo evidence to support giving platelets

• Coumadino PCCs work faster than FFP but not

shown to change outcomesoVitamin K should be given

• Dabigatran, Rivaroxiban

Seizures

Seizures• Ischemia leads to

glutamate release in AIS

• Mostly seen with cortical infarcts but can be seen in subcortical infarcts as well

• Blood is a cortical irritant in ICH

Do I need an EEG?• Patient that never

follows commands• Patient was

following commands and now not

• Patient with fluctuating neurologic exam

Seizure Prophylaxis• ICHoRoutine prophylaxis not indicated

• IschemicoRoutine prophylaxis not indicated

To monitor or not?

ICP

To monitor or not?• Clinical picture + radiologic picture

o ICH• IVH• Altered mental status

o Ischemic Stroke• Hydrocephalus not usually an issue• Data to support?

What about Na+• Hyponatremia is

never warranted• Normo vs

hypernatremiaoDepends on

clinical picture and imaging

How much Na+ to give?

• Na+ mmol = body weight kg x proportion of body water x (desired Na+ - current Na+)

• 70kg x 0.6 x (150-140) = 420mmol

• Na+ mmol/concentration of Na+ solution

• 420/513 = 800 ml

Temperature Control• Hyperthermia

o Increase CMRO2o Increase CBFo Increase release of excitatory

neurotransmitterso Increased PCO2 production Hypothermia opposite of hyperthermia

Glucose Control• POC systems were not

developed for ICU patients

• POC systems do not take into account Hct

• POC blood glucose can have error rates up to 20-30% Example: 30% error from glucose of 100mg/dl = 70mg/dl

• Goal glucose levels 140-180

• Low threshold for insulin drip

• Data comes from NICE-SUGAR trial 2009

What about Surgical Intervention?

Mr. B Continued• Patient brought to ICU for aggressive medical

management• Cardene gtt initiated • Arterial line placed• 3% saline to get Na+ 145-150• Neurologic exam deteriorated• Family decided to move to comfort measures

Summary• Understanding anatomy and

pathophysiology are vital in managing stroke patients

• ABC’s always come first• Acting early to control certain

parameters is paramount in controlling secondary injury

Questions?

References• Camilo O, Goldstein LB. Seizures and Epilepsy After Ischemic Stroke. Stroke. 2004; 35: 1769-1775.• Connolly et al. Guideline for the Management of Aneurysmal Subarachnoid Hemorrhage: A Guideline for

Healthcare Professionals form the American Heart Association/American Stroke Association. Stroke. 2012; 43: 1711 – 1737

• Flechsenhar J, Woitzik J, Zweckberger K, Amiri H, Hacker W, Juttler E. Hemicraniectomy in the management of space-occupying ischemic stroke. Journal of Clinical Neuroscience 20 (2013) 6-12.

• Kahle et al. Molecular Mechanisms of Ischemic Cerebral Edema: Role of Electroneutral Ion Transport. Physiology 2009 (24): 257-265

• Lakhan SE, Pamplona F. Application of Mild Therapeutic Hypothermia on Stroke: A Systematic Review and Meta-Analysis. Stroke Research and Treatment. 2012

• Liang et al. Cytotoxic edema: mechanisms of pathological cell swelling. Neurosurg Focus 2009; 22 (5) E2• Linares G, Mayer SA. Hypothermia for the treatment of ischemic and hemorrhagic stroke. Crit Care Med 2009 37

(7): S 243• Mann et al. Accuracy of Glucometers Should Not Be Assumed. American Journal of Critical Care. 2007; 16: 531-

532• Morganstern et al. Guidelines for the Management of Spontaneous Intracerebral Hemorrhage: A guideline for

Healthcare Professionals From the American Heart Association/American Stroke Association. Stroke: 2010; 41: 2108-2129.

• Osvaldo C, Goldstein LB. Seizures and Epilepsy After Ischemic Stroke. Stroke 2004: 35: 1769-1775• Roger et al. Heart Disease and Stroke Statistics – 2012 Update: A Report From the American Heart Association.

Circulation. 2012; 125 e2-e220.• Ropper AH. Hyperosmolar Therapy for Raised Intracranial Pressure. N Engl J Med 2012.; 367: 746-52.• Sterns RH, Silver SM. Cerebral Salt Wasting vs SIADH: What is the Difference. J AM Soc Nephrol 2008. 19: 194-

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