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What are two causes of subarachnoid hemorrhage?
- 1) aneurisms
- 2) atreriovenous malformation (AVM)
What is the main risk factor in patients suffering from intraparenchymal hemorrhage?
List the non-modifiable risk factors.
- 1) age
- a. > 55 yrs
- 2) gender
- a. men
- 3) ethnicity
- a. african-american or hispanic
- 4) heredity
- 5) low birth weight
- a. < 2500 g
List the potentially modifiable risk factors.
- 1) hypertension
- 2) cardiac disease
- a. atrial fibrillation
- b. myocardial infarction
- c. heart failure
- 3) transient ischemic attack
- 4) diabetes
- 5) hyperlipidemia
- 6) lifestyle factors
- a. smoking
- b. obesity
- c. physical inactivity
- d. alcohol use
- e. IV drug use
- f. cocaine use
- 7) sickle cell disease
- 8) elevated homocysteine level
- 9) migraine
List the risk factors unique to women.
- 1) oral contraceptives
- 2) pregnancy
- 3) hormone replacement therapy
- 4) metabolic syndrome
- a. waist > 35.2 inches
- b. TG > 128
- 5) migraine headaches
What is the generic for t-PA?
At what BP level would you consider administering labetalol IV or nicardipine IV in a patient who has yet to receive t-PA?
SBP > 220 or DBP 121-140
At what BP level would you consider administering nitroprusside in a patient who has yet to receive t-PA?
DBP > 140
At what BP level would you consider administering labetalol IV or nicardipine IV in a patient who has received t-PA?
SBP 180-230 or DBP 105-120
At what BP level would you consider administering nitroprusside in a patient who has received t-PA?
DBP > 140
What is the generic for Nitropress?
What is the dose for labetalol IV?
- 10-20 mg doubled every 10-20 min.
- Maximum: 300 mg
- May be infused for 2-8 mg/min.
What is the dose for nicardipine IV?
What is the dose for nitroprusside IV?
Which thrombolytic is the only of its class that is approved for use in acute ischemic stroke?
Within what time frame is aspirin used in acute ischemic stroke?
within 48 hours
Within what time frame should t-PA be administered in a patient presenting with acute ischemic stroke?
within 3 or 4.5 hours
What inclusion criteria must a patient have before undergoing thrombolytic therapy?
- 1) > 18 years
- 2) diagnosis of ischemic stroke with marked neurological deficit
- 3) onset of stroke occured within 4.5 hours
What exclusion criteria must a patient not have before undergoint thrombolytic therapy?
- 1) intracranial hemorrhage
- 2) minor stroke or rapidly improving symptoms
- 3) suspicion of subarachnoid hemorrhage
- 4) active internal bleeding
- 5) platelet count < 100,000/mm3
- 6) heparin within 48 hours
- 7) use of anticoagulant and a PT > 15 seconds
- 8) intracranial surgery, serious head trauma, or previous stroke within 3 monts
- 9) major sugery or serious trauma within 14 days
- 10) recent arterial puncture
- 11) lumbar procedure within 7 days
- 12) intracranial hemorrhage, arteriovenous malformation, or aneurysm
- 13) seizure at stroke onset
- 14) recent AMI
- 15) SBP > 185 mm Hg or DBP > 110 mm Hg
What addition exclusion criteria must be considered when the onset of stroke occured more than 3 hours but less than 4.5 hours?
- 1) age > 80 years
- 2) current treatment of oral anticoagulants
- 3) NIH stroke scale score > 25
- 4) history of both stroke and diabetes
What is the approved dose of t-PA in acute ischemic stroke?
- 0.9 mg/kg
- Maximum: 90 mg
- The first 10% of the calculated dose is given as a bolus within the first minute, followed by an infusion of the rest for an hour.
What are the drug interactions with t-PA?
- 1) heparin
- 2) warfarin
- 3) aspirin
- 4) dipyridamole
- 5) ACEIs
How would you monitor for neurological symptoms in patients placed on t-PA?
- Every 15 min. during infusion.
- Every 30 min. for 6 hours after infusion.
- Every hour until 24 hours after the treatment.
How would you monitor BP in patient placed on t-PA?
- Every 15 min. for the first 2 hours.
- Every 30 min. for the next 6 hours.
- Every hour until 24 hours after treatment.
Is heparin indicated in use of acute ischemic stroke?
How long after t-PA therapy should you wait until heparin can be safely used in a patient?
After 24 hours
How long after t-PA therapy should you wait until ASA can be safely used in a patient?
After 24 hours.
What drugs are used in secondary prevention of acute ischemic stroke in patients who have had a non cardioembolic stroke?
- 1) aspirin
- 2) clopidogrel (Plavix)
- 3) aspirin + dipyridamole ER (Aggrenox)
- 4) ticlopidine (Ticlid)
What drugs are used in secondary prevention of acute ischemic stroke in patients who have had a cardioembolic stroke?
- 1) warfarin (Coumadin)
- 2) dabigatran (Pradaxa)
- 3) rivaroxaban (Xarelto)
What drugs should be used in all recovering ischemic stroke patients in addition to any antiplatlet/anticoagulant therapy that the patient was placed on?
- 1) ACEI or ARB and diuretic
- 2) statin
What dose of aspirin should be considered in patients undergoing secondary prevention of ischemic stroke?
What dose of clopidogrel (Plavix) should be considered in patients undergoing secondary prevention of ischemic stroke?
Is the use of aspirin in addition to clopidogrel recommended in patients undergoing secondary prevention of acute ischemic stroke?
No. It does not show to benefit more than using either agents alone.
When is aspirin + dipyridamole ER (Aggrenox) indicated in patients undergoing secondary prevention of acute ischemic stroke?
after the second stroke
What is the dose of dabigatran (Pradaxa)?
150 mg BID
Under what conditions would dabigatran (Pradaxa) be preferred over warfarin (Coumadin)?
When the CHADS score is greater than or equal to 1.
Which drugs increase dabigatran (Pradaxa) levels?
- 1) amiodarone
- 2) ketoconazole
- 3) antiplatelets
Which drugs decrease dabigatran (Pradaxa) levels?
- 1) St. John's Wort
- 2) PPIs
- 3) antacids
What drugs is used in the prevention of delayed ischemic stroke in a patient who has had developed subarachnoid hemorrhage?
What is the dose for Nimodine (Nimotop)?
60 mg q 4 hours (begun within 96 hours of onset) x 21 days.