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Stroke

  • Ddx

    • neuro (TIA, seizure), cardio (MI, arrhythmia), infection (UTI, pneumonia), environmental (hypothermia, CO exposure), DKA, head trauma, psych (dementia, delirium)
  • Admission orders for ischemic stroke

    • Admit: Floor
    • Diagnosis: Acute Ischemic Stroke
    • Condition: Guarded
    • Vital Signs: q 4 hours. Neuro checks q 2 hours for the first 24 hours, then q 4 hours.
    • Allergies:
    • Nursing:
      • O2, maintain sat > 93%
      • Capillary blood glucose q 6 hours
    • Diet: NPO, then Heart healthy diet after cleared by speech/swallow eval
    • Activity: Bedrest, then per PT consult, strict Fall Precautions
    • Labs:
      • CBC with platelet qday
      • Chem qday
      • LFTs
      • Coags: PT, PTT
      • EKG
      • head CT, noncontrast
      • Carotid doppler
      • Echocardiogram in AM
      • Lipid panel in AM
    • IV: NS at 50 mL/h. Avoid Glucose. Heplock IV when tolerating PO
    • Special:
      • Neuro consult
      • Speech/swallow consult
      • PT/OT consult
      • social work RE: discharge location
    • Medications:
      • consult neuro for tPA
      • Aspirin 325 mg PO qd
      • Acetaminophen 650 mg q 6 hours for 48 hours to prevent fever
      • Docusate 100 mg PO bid
      • Heparin 5000 units SQ q 8 hours
    • Call HO: temp > 38 C, SBP > 200 or < 120, HR > 100
    • Discharge
      • criteria:
        • neurologically stable
        • tolerating PO or feeding tube
        • safe d/c destination
      • meds: statin if LDL > 100
      • education: smoking cessation
      • f/u in 2 weeks
  • Initial labs

    • head CT (find out ischemic vs hemorrhagic stroke)
    • EKG (afib causes embolic stroke)
    • glc
    • CMP, CBC, coags
  • Initial tx

    • O2 10 LPM via NRM
  • Other labs

    • Utox
    • cardiac enzymes
    • echo
    • MRI, MRA
    • carotid duplex
    • FLP to assess atherosclerosis risk
  • Tx for ischemic stroke

    • if onset within 3 hr, then rt-PA
    • heparin (delayed for 3 d in large cardioembolic stroke)
    • ASA 300mg/d
    • permissive hypertension (tx if SBP > 220 or DBP > 120)
    • add warfarin if afib
  • Tx if hemorrhagic stroke

    • SAH: nimodipine 60mg q6h (vasospasm), phenytoin
    • pre-stroke BP is the goal. If unknown, permissive HTN.
  • Tx if PMH sickle cell

    • exchange transfusion
  • Other tx and orders

    • speech/swallow assessment to avoid aspiration
    • address modifiable risk factors: cholesterol, smoking, HTN, afib
  • HPI

    • onset (important for tPA window)
    • quality: describe how you felt
    • baseline and present functional status
    • have you taken any medication
  • ROS

    • head trauma
    • fever
    • syncope
    • headache, visual changes
    • chest pain, palpitations
    • dyspnea
    • cough, sputum, hemoptysis
    • abdominal pain, nausea, vomiting, diarrhea
    • hallucinations
  • PMH

    • diabetes
    • thyroid
    • cirrhosis
    • psych
  • Meds

    • new meds
  • SH

    • EtOH, tob, narcotics, amphetamines, other illicit drugs, environmental exposure
  • Px

    • responsiveness
    • cranial nerves
    • pupils, papilledema
    • rash
    • strength, reflex, sensation
    • coordination
    • cardio
    • pulm
    • abd
  • Localization

    • internal capsule (lacunar): pure motor
    • thalamus (posterior ventral nucleus of lateral thalamus): pure sensory
    • Medial pontine syndrome: basilar paramedian dmg causing contra weakness (CST), contra sens loss (DCML), ipsi eye no abduct (CN 6)
    • Lateral pontine syndrome: AICA dmg causing contra pain/temp loss (spinothalamic), ipsi horner (hypothalamospinal), ipsi face sens & motor (trigem nuc, CN7), ipsi deaf, vertigo (CN8), ipsi ataxia (cerebellar penduncle)
    • Medial medullary syndrome: anterior spinal artery dmg causing contra weakness (CST), contra sens loss (DCML), ipsi tongue deviation (CN 12)
    • Lateral medullary syndrome: PICA dmg causing contra pain/temp (spinothalamic), ipsi horner (hypothalamospinal), ipsi face sensory (trigem), ipsi hearing/balance (CN 8), swallowing (CN 9, 10)
  • Pimp Qs

    • vasospasm is most common mortality for SAH

  • Print | Citations

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