Morning Conference

Presented by Ext. Sorawit Boonyathee

20 December 2012

Chief Complaint

• ผปวยชาย อาย 68 ป

• ออนแรงซกซาย 2 ชวโมงกอนมาโรงพยาบาล

• Arrived at ER 14.30 น.

• Vital Sign แรกรบ

– Blood Pressure 127/77 mmHg

– Pulse rate 84 /min

– Respiratory rate 20 /min

– Oxygen Sat 99 % (Room Air)

จาก CHIEF COMPLAINT และ VITAL SIGN แรกรบ TRIAGE ?

Triage

• Emergency

• เนองจากผปวยสงสยภาวะ Stroke และ On set อยในชวงทสามารถ Activated Fast track ได

หลงจากนนจะตองประเมนเบองตนอยางไร ?

Primary Survey

• Airway

– Can talk, no stridor, dysarthria

• Breathing

– Clear and equal breath sound both lungs, O2 sat 99%

• Circulation

– BP 127/77 mmHg, PR 84 /min, no external bleeding

• Disability

– E4V5M6, pupil 3 mm RTLBE

การวนจฉยแยกโรคและการสงตรวจเบองตน ?

Stroke ?

• Cincinnati Prehospital Stroke Scale (CPSS)

“F A S T” – Facial Droop

– Arm Drip

– Speech Problems

– Time

• Risk Assessment for Stroke – 1 problem = risk 72% 3 problems = 85%

Differential Diagnosis

• Stroke -> Ischemic or Hemorrhage

• Stroke mimic – Hypoglycemia or hyperglycemia -> DTX = 130 mg%

– Syncope / Presyncope

– Seizures and postictal state

– Intracranial Mass (Space occupying lesion)

– Functional hemiparesis (Psychiatric Disease/Syndrome)

– Encephalopathy

– Migraine

Laboratory Investigation for Stroke Fast Tract

• DTX

• CBC with platelet -> Decrease Platelet

• BUN, Cr, Electrolyte – High BUN (Uremic encephalopathy)

– Hyponatremia

• Coagulogram -> INR and PT Prolong ?

• Electrocardiogram -> AF or Myocardial Infarction ?

• Cardiac Enzyme

• Chest x-ray

ขอมลประวตผปวย และการตรวจประเมนทางระบบประสาท ?

History Taking

• 2 hrPTA (12.30 น.) ขณะก าลงนงรบประทานอาหาร ผปวยมอาการออนแรงแขนขาซกซาย ปากเบยวดานซาย มอาการพดไมชด

• ไมมอาการหนามดหรอเปนลม ไมมอาการชกเกรงแขนขา รสกตวดตลอดเวลา

• ไป รพช. (13.00 น.) ประเมน Motor power Lt side = 0

• และ (13.30 น.) ประเมน Motor power Lt side = III -> Refer

Physical Examination

• Vital Sign :

– BP 127/77 mmHg, PR 84 /min, RR 20 /min, O2 Sat 99 % (RA)

• HEENT :

– No pale conjunctivae, no icteric sclerae, no carotid bruit

• Heart :

– Totally irregular, PMI at Lt 6th ICS MCL, PSM Grade III at LPSB + apex, DRM Grade II at Apex

• Lungs :

– Clear and Equal Breath sound both lungs, no adventitious sound

Physical Examination (Cont.)

• Abdomen :

– Soft, not tender

• Extremities :

– No edema, no deformity, capillary refill < 2 sec

Physical Examination (Cont.)

• Neuro Exam:

– E4V5M6, Pupil 3 mm RTLBE, Good Orientation

– Motor power

– Reflex 2+ all

– Sensory Intact

– Cranial Nerve -> Full EOM, Facial Weakness Lt UMNL, Dysarthria

V III+

V II+

National Institute of Health Stroke Scale (NIHSS)

• 1a. level of consciousness 0

• 1b. Question (Age and month) 0

• 1c. Commands (Open/closed eyes, Grip hand) 0

• 2 Best Gaze (Horizontal EOM) 0

• 3. Visual Field 0

• 4. Facial Palsy Lt 1

• 5. Motor Arm Lt 1

National Institute of Health Stroke Scale (NIHSS)

• 6. Motor Leg Lt 2

• 7. Limb Ataxia (Finger to nose, Heel to knee) 0

• 8. Sensory 0

• 9. Best Language (name object, read, writing) 0

• 10. Dysarthria 1

• 11. Extinction/Neglect 0

• Summary NIHSS Score in this Patient 5

NIHSS and Patient Outcomes

• Total scores range from 0-42 with higher values representing more severe infarcts – >25 Very severe neurological impairment

– 15-24 Severe impairment

– 5-14 Moderately severe impairment

– <5 Mild impairment

– Adams, HP, et al. (1999). Neurology: 53: 126-131.

• A 2-point (or greater) increase on the NIHSS administered serially indicates stroke progression. It is advisable to report this increase.

NIHSS and Patient Outcomes

• Initial score of 7 was found to be important cut-off point – NIHSS >7 demonstrated a worsening rate of 65.9%. – NIHSS <7 demonstrated a worsening rate of 14.8% and were almost twice (1.9x) as likely

to be functionally normal at 48 hours (45%). – (DeGraba et al.,1999)

• NIHSS <5 most strongly associated with D/C home • NIHSS 6-13 most strongly associated with D/C to rehab • NIHSS >13 most strongly associated with D/C to nursing facility • (Schlegel et al., 2003) • Likelihood of intracranial hemorrhage:

– NIHSS > 20 = 17% likelihood – NIHSS < 20 = 3% likelihood – (Adams et al., 2003)

หลงจากไดประวตและตรวจรางกายแลว จะตองท าอะไรตอ ?

CT Scan

• Hyperdense MCA

• Loss of Insular ribbon at Rt MCA territory,

จากผล CT SCAN ดงกลาว สรปการวนจฉยวาอยางไร และ จะใหการรกษาอยางไรตอไป ?

Diagnosis and Management

• Dx : Acute Ischemic Stroke (Right MCA)

• Management in Emergency Department :

– Candidate for rtPA ?

– Controlled Blood Pressure ?

Lab Result

EKG

Chest X-ray

Lab result

• CBC -> no anemia, no leukocytosis, platelet adequate

• BUN, Cr and Electrolyte -> within normal limited

• Coagulogram -> no PT or PTT prolong

• EKG -> Atrial Fibrillation rhythm, no ST – T change seen

• CXK -> Cardiomegaly, no infiltration seen

Check Indication and Contraindication for rtPA used

• Indication for IV rtPA

– Clinical diagnosis of ischemic stroke causing a measurable neurological deficit

– non-contrast CT showing no hemorrhage or well-established acute infarct

– Time of onset well established to be less than 4.5 hours

Check Indication and Contraindication for rtPA used

• Contraindication

– Prior stroke or head trauma within 3 months

– Recent myocardial infarction within 3 months

– GI Hemorrhage or GU hemorrhage within 21 days

– Major surgery within 14 days

– Arterial puncture at a noncompressible site within 7 days

– SBP > 185 or DBP > 110 mmHg, or aggressive treatment (IV medication) to achieve

Check Indication and Contraindication for rtPA used

• Contraindication – CT finding suggesting ICH, SAH, or hypodensity > 1/3 of cerebral

hemisphere – Suspicious of subarachnoid hemorrhage (Even if CT negative) – Seizure at onset – Hx. of intracranial hemorrhage or aneurysm or AVM or brain tumor – Platelet < 100,000 – Heparin use within 48 hours with PTT > 40 (or exceeding upper limits) – Oral anticoagulant use with INR > 1.7 – Known bleeding diathesis or other major disorder ass. with increased

bleeding – Glucose < 50 or > 400 mg/dl

Check Indication and Contraindication for rtPA used

• Additional Contraindication for patient treated between 3 - 4.5 hours

– Age > 80 years

– History of Prior Stroke and Diabetes mellitus

– Any anticoagulant use prior to admission (Even if INR < 1.7)

– NIHSS > 25 (Because suggestion to hemorrhage preferable)

– CT findings involving more than 1/3 of the MCA territory

In this Patient

• Candidate for rtPA -> Yes (3 hours -> 15.08 น.)

• Blood Pressure -> 110/60 mmHg (No need to controlled before start rtPA)

• Start rtPA (Dose 0.9 mg/kg) BW 44 kg

– Total dose of rtPA -> 39.6 mg

– 10% of total dose -> 3.96 mg IV bolus in 1 minute

– 90% of total dose -> 35.64 mg IV drip in 1 hour

PROGRESS CASE

Progress Case

• NIHSS Score (After treatment completed) – 1 hours -> 4 points

– 6 hours -> 2 points

– 12 hours -> 0 points

• Work up cause (Risk for embolism, atherosclerosis) – Echocardiogram -> RHD, Mild MS and MR, No clot, good LV

– Lipid profile and FBS -> normal -> Start Simvastatin + diet control

– รอนด Doppler carotid ultrasound

Progress Case

• Start Enoxaparin SC bridging Warfarin due to CHA2DS2 Vasc Score = Stroke (2) Age (1) -> 3

Condition Points

C Congestive heart failure (or Left ventricular systolic dysfunction) 1

H Hypertension: blood pressure consistently above 140/90 mmHg (or treated hypertension on medication)

1

A2 Age ≥75 years 2

D Diabetes Mellitus 1

S2 Prior Stroke or TIA or thromboembolism 2

V Vascular disease (e.g. peripheral artery disease, myocardial infarction, aortic plaque)

1

A Age 65 – 74 years 1

Sc Sex category (i.e. female gender) 1

Progress Case

• Discharge with Warfarin (2) 1 tab PO OD Keep (INR 2-3)

Thank you