Abordaje del EVC en Urgencias 🧠🚨 Algoritmo práctico #Codigocerebro

Understanding Stroke Management in Emergency Settings

Importance of Timely Identification and Treatment

• The phrase "time is brain" emphasizes the urgency in identifying and treating strokes, particularly ischemic strokes, which often present without pain, leading to delays in care.

• It is crucial not to assume the type of stroke (ischemic or hemorrhagic) based solely on clinical presentation; imaging such as a CT scan is necessary for accurate diagnosis.

Protocol for Ischemic Stroke Treatment

• Neurologists or neurosurgeons do not need to be present before initiating thrombolysis for ischemic stroke patients if done timely and correctly.

• Thrombolysis should not be delayed due to the unavailability of an intensive care unit (ICU); immediate treatment is essential.

Understanding Stroke Types and Pathophysiology

• The video will introduce a practical algorithm for managing ischemic stroke patients in emergency departments, relevant globally beyond just Mexico or Latin America.

• An ischemic stroke occurs due to obstruction of cerebral blood flow, commonly affecting the middle cerebral artery.

Risk Factors and Symptoms

• Most ischemic strokes are caused by either thrombotic events (due to atherosclerosis) or embolism (often from cardiac sources like atrial fibrillation).

• Sudden onset symptoms include motor deficits typically on one side of the body and speech disturbances such as dysarthria.

Assessment Tools: Cincinnati Scale

• The Cincinnati Prehospital Stroke Scale helps identify focal neurological deficits quickly; it includes facial droop, arm weakness, and speech difficulties.

• Each component scored can indicate a high likelihood (>70%) of an acute stroke event when at least one point is identified.

Timing Considerations in Stroke Management

• Identifying the time when symptoms first appeared is critical; this establishes the "time zero" for treatment decisions.

• If a patient wakes up with deficits, time zero may be considered as prior to sleep unless otherwise documented.

Cerebrovascular Events: Assessment and Management

Initial Assessment of Patients

• In cases of suspected cerebrovascular events, patients presenting with symptoms should be assigned a "red code" or "brain code" and directed to a critical care area for immediate assessment.

• Vital signs including blood pressure, oxygen saturation, heart rate, glucose levels, and temperature must be monitored closely as they are crucial indicators of the patient's condition.

Differential Diagnosis Considerations

• Certain conditions like hypoglycemia or arrhythmias can mimic stroke symptoms; thus, it is essential to differentiate between true cerebrovascular accidents (CVA) and other causes of focal deficits.

• The concept of "Todd's paralysis," which occurs post-seizure, should not be mistaken for an ischemic or hemorrhagic stroke.

Neurological Evaluation Tools

• The National Institute of Health Stroke Scale (NIHSS) is emphasized for evaluating the severity of strokes. It assesses consciousness level and various neurological functions.

• A detailed evaluation using NIHSS includes checking motor function in limbs, facial paralysis, language abilities, and sensory responses.

Imaging Protocols

• Within 20 minutes of presentation, a non-contrast CT scan (CT brain attack) should be performed to rule out hemorrhagic strokes before considering thrombolysis.

• Understanding the clinical presentation differences between ischemic and hemorrhagic strokes is vital; while ischemic strokes may present gradually, hemorrhagic strokes often lead to abrupt deterioration.

Thrombolysis Considerations

• If imaging shows no evidence of bleeding but there are significant motor deficits or speech alterations, the patient may still qualify for reperfusion therapy.

• The ASPECTS scale is critical in assessing eligibility for thrombolysis by evaluating the extent of damage in specific brain regions affected by arterial occlusion.

Key Imaging Techniques

Understanding the ASPECT Scale and Thrombolysis

Overview of Cerebral Arteries and Ischemia

• The M1 segment is identified as the anterior part of the middle cerebral artery, with M3 being its posterior section. The presence of tissue loss in these areas indicates potential ischemia.

Importance of the ASPECT Scale

• The ASPECT scale consists of 10 territories within the middle cerebral artery's circulation, which helps assess damage. A score reflects how many areas are affected: for example, a score of nine indicates one area is damaged.

Candidacy for Thrombolysis

• Patients with an ASPECT score below seven (i.e., six or lower) are not candidates for thrombolysis due to high risk factors like hemorrhage.

• If a patient has no hemorrhage and an ASPECT score of seven or higher, they may be eligible for thrombolysis treatment.

Contraindications for Thrombolysis

• Key contraindications include an NIHSS score less than four or greater than 25 points, indicating either mild severity or severe conditions that complicate treatment.

• Additional contraindications involve recent surgeries, significant bleeding risks, and specific laboratory values such as low platelet counts or elevated INR levels.

Managing Blood Pressure Before Treatment

• A blood pressure reading above 185/110 mmHg is a contraindication; however, it can be managed by controlling blood pressure before considering thrombolysis.

• If thrombolysis is not planned due to contraindications, blood pressure management can be relaxed over 24 hours without urgency.

Special Considerations in Patient Selection

• In exceptional cases where patients have unique circumstances (e.g., artists), decisions regarding thrombolysis may require consensus between medical staff and family members.

Algorithm for Thrombolysis in Stroke Management

Initial Considerations

• The speaker discusses the original description of a protocol, indicating that it should not limit the extension of treatment windows.

• Evaluation of a CT scan shows a score of seven points or more, confirming no contraindications for thrombolysis.

Thrombolytic Administration

• The primary medication used is alteplase (commercially known as Actilyse), administered at 0.9 mg/kg with a maximum dose of 90 mg.

• For a patient weighing 70 kg, the total dose would be 63 mg, with an initial bolus of 6.3 mg and the remainder given over one hour.

Alternative Treatments

• Tenecteplase (TNK) is gaining popularity; it can be given as a single bolus at 0.25 mg/kg, with no significant benefit from higher doses.

• Higher doses increase risks without added benefits; thus, sticking to recommended dosages is crucial.

Monitoring Post-Thrombolysis

• Continuous monitoring is essential: assess neurological status every 15 minutes for the first hour and then every half-hour for six hours.

• Vital signs should be checked hourly to track improvement in neurological scores (NIS).

Clinical Considerations and ICU Monitoring

• If deterioration occurs (e.g., NIS increases abruptly), thrombolysis must be halted immediately, and urgent imaging requested.

• Intensive care unit protocols include continuous cardiac monitoring and strict glucose control between 80 to 180 mg/dL.

Importance of Temperature Control

• Maintaining normothermia is critical since fever exacerbates neuronal death post-stroke; temperature management parallels sepsis protocols.

• Ensuring adequate cerebral perfusion pressure through proper blood pressure management is vital for patient recovery.

Final Protocol Steps

• If neurological decline occurs during treatment, thrombolysis should cease while further evaluations are conducted.

Infographic and Management of Ischemic Stroke

Introduction to Infographics

• The infographic discussed is originally conceived by Dr. Carla Janet Muñiz Hernández, who has transitioned from being a student to a master in her field.

• Viewers are encouraged to like, subscribe, and share the channel for more explicit material on critical patient management.

Monitoring and Management of Ischemic Stroke

• An infographic aids in monitoring ischemic stroke patients; it is based on an algorithm developed by Dr. Jesús Daniel López Tapia, an emergency physician.

Blood Pressure Management

• For candidates of fibrinolysis, blood pressure should be maintained below 185/110 mmHg; if not a candidate, permissive hypertension may be allowed.

• A target reduction of 15% in blood pressure over 24 hours is recommended for severe hypertension (e.g., >220/120 mmHg).

Glucose Levels

• Maintain glucose levels between 80 to 180 mg/dL; avoid hypoglycemia (<70 mg/dL), as it increases mortality risk in critically ill patients.

Temperature Control

• Normothermia is crucial for ischemic stroke patients; hypothermia should only be used in selected cases due to potential increased mortality risks.

Thrombolysis Protocol

• Emphasizes the importance of administering thrombolytics within 60 minutes from arrival at the hospital ("door-to-needle" time).

Oxygenation Guidelines

• Oxygen saturation should be maintained between 94% and 98%; both hypoxemia and hyperoxia can have detrimental effects.

Considerations for Thrombolysis Candidates

• Patients arriving with high blood pressure (e.g., >200/110 mmHg) may need treatment before thrombolysis can occur.

Mechanical Thrombectomy Options

• If not eligible for thrombolysis within the first 4.5 hours post-stroke onset, mechanical thrombectomy may be considered up to 24 hours later.

Imaging Techniques

• CT scans are preferred initially to rule out hemorrhage; MRI is reserved for specific situations where timing isn't clear.

Emergency Hypertensive Management

Management of Ischemic Stroke in Emergency Settings

Initial Treatment Protocol

• The onset time for treatment is between 5 to 10 minutes, with an effect duration of 3 to 6 hours. This protocol excludes pregnant patients, focusing on those with severe preeclampsia and no contraindications. A bolus intravenous administration is given to hypertensive patients with ischemic stroke to lower blood pressure.

Blood Pressure Management

• To remove the contraindication for thrombolysis, blood pressure must be reduced to between 25 and 35 mg per kilogram, followed by a continuous infusion of 2 to 4 micrograms per minute until achieving a mean arterial pressure target (less than 185/110 mmHg). Doses can later be increased cautiously from 5 to 20 micrograms per hour. Special care is advised for patients with heart block or systolic heart failure.

Cautions in Patient Care

• Attention is required when treating patients with atrioventricular blocks or those suffering from systolic heart failure and asthma due to potential complications during treatment. The speaker emphasizes the importance of careful monitoring in these cases.

Respecting Evidence-Based Medicine

• The speaker stresses that glucose solutions are not used according to their protocols, urging viewers to base comments on proper observations and evidence-based knowledge rather than incoherent remarks often seen in discussions about critical patient management. Respect for medical content is paramount.

Community Engagement and Resources

• New members joining the YouTube channel receive exclusive material related to critical patient management that isn't available publicly on YouTube. Infographics designed by Dr. Carla Muñiz can be downloaded for free from the website dedicated to intensive care resources, enhancing learning opportunities for viewers interested in this field.

Conclusion and Future Content