NueroVascular RN
Quiz yourself by thinking what should be in
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| Stroke is _______ leading cause of death | 5th
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| What percent is Ischemic events? Hemmorrhagic events? | I - 80%
H - 20%
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| What race has highest hemm strokes | Asian & Finns, AA > white
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| Define Stroke | rapid syndrome of sudden onset, non-epileptic neurologic deficit
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| what is ischemic infarct | dead tissue at core
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| What is common to happen after infarction? | Hemmorrhagic transformation HT`
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| What is penumbra | potentially viable brain tissue surrounding core infarction
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| What is Framingham Study | 1950s, Mass, about risk factors for stroke and CAD
HTN single most imp risk factor, Incr total chol, decr HDL, whole grain reduce risk, Elev C protein in women risk for carotid atherosclerosis, New L BBB,
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| What is GCNKSS Gr. Cinn/North KY study | First ever stroke in AA > whites young/middle age, HTN/DM risks, prior stroke, 1st degree relative with hx of ICH
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| Northern Manhattan Stroke Study (NOMASS) | Carotid atherosclerosis White>AA/non hispanics, risks: HTN, DM, smoke, hyperchol, abd obesity, afib white/hisp > AA
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| Strong Heart Study | Native Am, >DM, smoke, obesity
HTN = Arizona > Oklahoma Native Am, binge drinking
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| Southwest US Native Am. Stroke Study | Long time to get to hospital, common HTN, DM, alcohol consumption, prev. stroke/TIA, obesity
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| ReGARDS | born in stroke belt incr risk for stroke
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| What % of strokes are first time? What % need institutional care? | 70%
20%
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| Non-modifiable risk factors for stroke | Age: doubles 10y after 55y, >AA
Race: AA greatest risk
Gender: men > women
Family hx: paternal side > risk
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| Modifiable risk factors | CAD, HTN, smoke, DM, afib, diet, sickle cell, obesity, (post menopausal) hormone replacement, incr chol.
< mod. risks = alcohol/oral contrac/migraine/sleep disorders/hypercoag/inf dis/acute inf
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| ABCD2 Score | prediction for severity stroke with TIA:
1 - >60y
1 - BP >140/90
2 - wkn, 1 - speech w/o wkn
2 - >60min, 1 - 10-59min
1 - DM
<4 = low, 4-5 = mod, >5 = high risk
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| What r 5 cat of TOAST - Trial of org in acute stroke tx | way to categorize what caused ischemic stroke.
5 categories:
1.Lg aa atherosclerosis - occl/stenosis lg major aa
2.Cardioembolism - afib/MI/inf endocarditis/myxoma
3. Lacunar - htn,dm,smoke,hyperchol
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| What r 5 cat of TOAST | 4. other etiology: hypercoag/venous thromb/vasculitis/art diss/cocaine/fat emboli
5. undertermined cause (cryptogenic): incomplete workup/workup with no source
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| What included in work up for stroke | brain imaging ( ct,mri)
vasc imaging cta/mra/tcd/cranial ultra
cardiovasc H/P: hrt snds/holman/12 ecg/caps
/pulses/jug dist/bp
Duplex ultra: carotid/vertebral
Echo/TEE
Labs: Protein C,S/antithrombin III incr
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| IPH/ICH most common cause | HTN #1, #2 Cocaine (ICH)
trauma, amyloid angiopathy/aneurysm/vasculitis/alc abuse/cocaine/neoplasms/infections
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| Where are IPH's usually | subcortical region, near lateral ventricles (BG/thal)
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| 2nd most common hemm stroke | aneurysmal SAH, >women, ICA
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| Studies to incr public detection | FAST - 80% s/s face/arm/speech/time
FLASH - 90% s/s face/leg/arm/speech/HA
BE FAST - improve posterior stroke balance/eyes
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| Who uses EMS more? | AA, hemm stroke, incr in stroke severity, unemployed
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| Stroke Severity Scales | Los Angeles Motor Score - LAMS: lg vessel occl: face 0-1/grip 0,1,2/arm strength 0,1,2
Shortened NIH, sNIHSS 8 items
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| What should EMS not do with stroke | lower bp, give glucose IV, give excessive IV volume
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| What is Golden Hour for tx stroke? | initial MD eval - 10 min
stroke team notified - 15 min
CT - 25 min
CT/labs interpreted - 45 min
tPA - 60m
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| Golden 1/2 Hour | MD/stroke - arrival
CT - 10m
CT/labs read - 25m
tPA - 30m
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| How many triage levels? What level need to have for stroke/TIA? | 5 levels
Level 2 for stroke/TIA
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| What is med risk for cardio-embolism | PFO, L atrial turbulence (smoke), post op, mitral prolapse
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| What is TIA | sudden focal neurologic disablity, resolves in 24h, 300,000 annually
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| CHADS2 | 1 - CHF
1 - HTN
1 - >75y
1 - DM
2 - hx stroke/TIA
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| ED assessment/work up | ABCs, disability, non-contrast CT/MRI, labs, ecg, h/p: LKN, handedness, allergies, prev stroke/TIA, risk for CAD, drug/alcohol use, anticoag meds, hx brain hem/trauma, sx hx
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| Stroke mimics: can you use tPA | Yes. Conv. Dis, htn enceph, hypogly, complicated migraine, sz, AMS
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| What scale is used for Hemm? | GCS 3- unresponsive, 15- normal
Eyes: 1 no open, 2 pain, 3 speech, 4, spont
Verbal: 1 no verbal, 2 incomp sounds, 3 inapp words, 4 confused, 5 oriented
Motor: 1 none, 2 Decer, 3 decor, 4 withdraw, 5 localize pain, 6 obeys commands
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| Which neuroimaging is 100% sensitive for blood? | Non-contrast CT
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| CTA is good to determine | Lg vessel occl, not lacunar
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| Which part of MRI is best for acute stroke confirmation | DWI - diffusion weighted imaging, w/in min. Ischemia = White
MRP - detect presence/abscence viable tissue
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| which type of stroke is TCD used with | SAH - blood flow in lg aa
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| Which lab test is needed prior to tPA? | Blood glucose
Coumadin - need INR
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| When is a lumbar puncture usually ordered, what kind of stroke? | SAH
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| Gen mgmt of all acute stroke pts | temp, NPO, card enzymes, arrhythmias, bp parameters, hyperglycemia, HOB
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| What are BP parameters for hemm & ischemic | H: <160/90
I: untreated = permissive 220/110
treated= <185/110, then <180/105 after bolus tPA
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| What is correct glycemic control | 80 - 140 mg/dL
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| What is correct HOB for hemm & ischemia | H: 30 deg
I: 0 deg, pt turned to side 20% incr blood flow
Zodiac trial - only did lg vessels
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| How many bones in skull and name | 8 bones: frontal/temporal(2)/parietal(2)/occipital/sphenoid/ethmoid
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| What is total cranial volume made up of and how much | 1400-1500ml: CSF, brain tiss, blood
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| What are sutures of skull | Sagittal - b/n 2 parietal
Coronal - parietal to frontal
Lambdoidal - parietal to occipital
Squamosal - joins parietal, temp, occ
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| How many total vertebrae? How many cervical, thoracic, sacral, coccygeal? | total 33: 24 vertebral & 2 fused ( atlas C1, axis C2)
Cerv 7, thor 12, sacral 5, coccy 4
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| Name meningeal coverings of brain and spinal cord | Dura mater - strong, b/n bone & dura mater
Arachnoid mater - thin, loose surround brain, contains lg vessels, below subarachnoid space
Pia mater - adheres to brain, choroid plexus
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| Where is CSF manufactured | choroid plexus in Pia mater
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| Name and locate three ventricles in brain | Lateral (2): horns
Third ventricle: b/n laterals & connected by foramen of Monro
Fourth ventricle: connected by aqueduct of Syvius
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| What is communicating vs non-communicating hydrocephalus | comm: obstruction/lack of absorption
non comm: obstruction in ventricle system
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| How much CSF is produced hour? day? total system volume? | Hour: 20ml/h
day: 500ml/day, total vol: 150ml
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| What is cellular structure/fx of neuron | Dendrites: impulse reception
Cell body: metabolic fx of cell
Axon: carries impulse away
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| What makes up the Circle of Willis | Anterior and Posterior circulation
Connection of 3 comm aa (AcomA, PcomA (2)
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| Where does the ant. and post. circ originate | common carotid CCA, R CCA: innominate aa/L CCA: aorta
Post: subclavian aa, R innominate, L aorta
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| What is considered the Ant. circulation and leads off ICA | Ophthalmic aa OA
PcomA: post comm. aa
MCA: supply to deep subcortical area
ACA: linked together by AcomA
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| What is posterior circulation include | Vertebral aa give off post inf cerebellar aa PICA
Vertebral fuse to Basilar aa
Basilar gives off to PCA (thalm), SCA, pontine, AICA
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| What % of circle of willis is ideal? Most common missing segments? | Only 50%
1. ACA, 2. One of the PcomA, 3. 1st seg of PCA
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| What is the cerebral cortex | 80% of brain wt.
2 hemispheres separated by corpus collosum
4 lobes: frontal/temp/parietal/occipital
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| What is major fx of Brodmanns Area 4 | Voluntary motor fx: Motor strip
ACA territory ( esp leg) and some MCA (lower facial wkn)
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| Where is Area 44: Broca's area | Left MCA, frontal lobe
Expressive aphasia: spoken/written lang. word finding,
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| Where is 9-11, cognitive fx area | ACA behind forehead seen in SAH
affects orientation, memory, insight, judgement, arithmetic/abstract thinking
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| Where is Area 1-3, primary sensory | Parietal lobe
sup ACA, inf MCA
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| Where is area 5 & 7: somesthetic assoc | MCA
extinction, stereognosia (tell what object it is), graphesthesia (write on skin and decipher)
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| What is are 39 & 40, Wernicke's area | Left MCA
receptive lang.
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| Where is area 41 & 28 | Temporal lobe, MCA
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| What does Occipital lobe show | visual integration & pathways
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| What does Area 17 & 18 primary visual cortex affect | PCA territory
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| Where would you find cortical blindness stroke | top of the BA or PCA occl.
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| Where is homonymous hemianopia found | always post. to chiasm
Lg parietal - MCA
Medial occipital - PCA
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| Double vision would indicate which part of brain | brain stem infarct
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| Internal capsule is which distrubution | MCA
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| Thalami is | PCA distribution
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| What does cerebellum control | fine motor coordination, equilibrium/balance, ataxia, ipsilateral side affected stroke, vertigo
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| Brainstem stroke affects | LOC, double vision, cardiac, resp, vomiting, sneezing, hiccups
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| What does cerebrum control | association, motor, sensory, contralateral
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| Name cranial nerves | 1 - smell, 2 - vision, 3,4,6 - EOM extraocular mvmt,
5-corneal reflex(S)/maxillary(S)/Mandibular(S)(M) teeth clench, 7-facial(S)(M), 8-acoustic/balance,
9,10-glosso/vagal, swallow, 11-spinal acc, 12-hypogloss, tongue mvmt
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| Where is midbrain and what are infarct findings | From thalamus to pons, CN3,4
pupil dilate, EOM dysfx, decr LOC, (M)(S) disrupt
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| Where is Pons and infarct findings | from pons to medulla oblongata, CN5,6,7,8
Pneumotaxic ctr: inhibit depth of resp/incr rate
apneustic ctr: promotes inspiration
gaze/diplopia, EOM dysfx, decr LOC, (M)(S), resp arrest
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| Where is Medulla oblongata and infarct findings | from pons to spinal cord, CN8,9,10,11,12
cardiac/vasomotor ctrs
decr LOC, card/vasomotor dysfx, hearing loss, dysphagia, quadriplegia
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| What is important about basiar art thrombosis | Most misdiagnosed, hiccups, weird s/s, diplopia, vertigo, cortical blindness
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| Diff bn cortical and brainstem infarct | Above brainstem: loss (M)(S) same side with face
brainstem: CN deficit same side as infarct, but opp extremity (M)(S), sudden loss of consciousness in non-hemm
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| When should you do NIH? Scoring is from 0 - _______ Best NIH monitoring p tPA | admission, discharge, 1 x shift, and any changes
Score: 0 - 42
baseline pretx, post tPA, q4h
q15-30 focused neuros, deterioration/improvemnet
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| What does ICH score predict | death in 30 day, 0- best prognosis, 6- dead.
contains: GCS, ICH vol, Intraventricular component, Supra vs Infratentorial, Age
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| what is Modified Rankin Score for | disablility score, 0-6, intervention when score 0-1
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| What are absorptions/color for CT | air - black/none, CSF - black/low, White matter - darker gray/low med, Gray matter - lighter gray/high med, Blood - white/high, Bone - bright white/high
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| How to read CT | start at base of brain and moves superiorly to top of skull, looking through bottom of feet to top of head, mirror image - L side reflects right brain, vice versa
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| Adv/Disadv for CT | Adv: fast, good for lesions
dis: poor resolution, 6-8h delay b4 stroke shows
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| What are early/late signs for stroke on CT | early: clot in vessel, hyperdense aa
late: hypodensity, darkened, subacute inf
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| What is scoring for Modified Ranking Score | 0- no s/s
1- able to carry out usual activities/duties
2- slight disable, can look after self w/o assistance
3- mod disable, some help, can walk w/o assistance
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| What is scoring for MRs | 4- mod severe disable, not walk w/o assist, not do
bodily needs w/o assist
5- Severe disable, bedridden, incontinent
6- dead
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| NIH scoring LOC | 0- alert
1- not alert, arousable
2- needs repeated stimulation, obtunded, req strong painful stimuli to make mvmnts
3- Reflex motor response, totally unresponsive, flaccid
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| NIH Questions: Month/Age | 0-answers mo/age
1- ans one correctly, intubated, sev dysarthria
2-both incorrect/no answer, aphasic/stuporous not responding
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| NIH Commands to open/close hand/eyes | 0- obeys both
1- obeys one
2- Not obey/respond
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| NIH EOMs: horizontal eye mvmt, doll's eyes used if needed | 0- Normal
1- Partial gaze palsy, can come to ctr, but goes back
2- Forced deviation/total gaze paresis
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| NIH Visual Fields: upper/lower, confrontation | 0-no loss
1- partial hemianopia
2- complete hemianopia
3- bil hemianopia, blindness/cortical
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| NIH Facial Palsy: smile, raise eyebrows, grimace with noxious stimuli | 0- normal symmetric mvmt
1- minor paralysis, flattened nasolabial fold
2- Partial paralysis: total paralysis lower face only
3- complete paralysis lower/upper face
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| NIH Motor Arm: Count of 10 Left & right | 0- No drift
1- drift
2- some effort against gravity
3- No effort against gravity
4- No mvmt
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| NIH Motor Leg: Count of 5, Left & right | 0-No drift
1- drift
2- some effort
3- no effort
4- no mvmnt
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| NIH Limb ataxia: Finger to nose, heel to shin | 0- absent
1- present in one limb
2- present in two limbs
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| NIH Sensory: sensation, grimace, withdrawal | 0- Normal, no loss
1- mild to mod, dull, less sharp
2- severe to total loss, not aware of being touched
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| NIH Language: aphasia | 0- no aphasia
1- mild to mod
2- severe
3- mute, global: no speech/auditory comprehension
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| NIH Dysarthria: slurred speech | 0- normal
1- mild to mod: slur some words
2- unintelligible
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| NIH Extinction/Inattention | 0- No abnomality
1- visual, tactile, auditory, spatial, personal
inattention, or to bil sensory
2- profound in >1 sensory, not recognize hand, etc
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| What is watershed infarct | b/n regions
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| which area is worst/best outcome for ICH: cortical, BG, thalamus, Pontine, Cerebellar | Worst: Pontine
Best: Basal Ganglia, most common IPH,
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| What should you r/o with Intraventricular hemm | Presence of ACA or AcomA aneurysm, usually is expansion of hemm in BG, IPH
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| Where is SAH | Bleeding in subarachnoid space, usually from aneurysm rupture or trauma, "star" appearance or "hanging chicken"
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| What is 1st s/s SAH | thunder clap HA
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| What is tx and appearance of amyloid angiapathy hemm | more round and no tx can be done, more on surface
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| what are CTP scans for | Looking to save penumbra and ischemic penumbra, measures tiss perfusion, usuall for "wake up" strokes
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| In MRI, which is better for disease definition, T1 or T2 | T2, CSF- white, Fat- dark
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| What is GRE, gradiant Recall Echo in MRI | Rules out blood, microbleeds may be detected
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| What does the FLAIR show in MRI | older stroke, dating/timing of stroke onset, if neg and DWI pos, give tPA, shows 4-6h after stroke
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| Name MRI sequences | 1- GRE id blood
2- DWI ischemia
3- FLAIR timing of onset, old isch changes
4- MRA vascular imaging`
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| What is gold standard imaging for vascular | Catheter Angiography, IR, uses 1/2 of dye of CTA, invasive, can have IA rescue, safe to due p tPA
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| What is HOB for sheath mgmt | <15 deg
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| What is doppler shift | ultrasound to describe mvmt of blood away/towards probe
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| What is duplex imaging | image lg vessels in neck, see plaque & blood, stable(hyperechoic)/unstable(hypoechoic) plaque,
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| What is transcranial dopper TCD | flow of blood thru lg vessels in circle of willis, detect vasospasm (risk @ 5-7d), monitor tPA, brain death, sickle cell
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| What is risk of vasospasm? Tx of vasospasm | ischemia
Tx: Triple H therapy: hemodilution/hypervolemia/htn
Meds: Nimodipine(neuroprotective effect, not lessen spasm, Mg, statin
Intra Art tx: angioplasty, verapamil inf
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| What was result of NINDs tPA stroke study | Got tPA FDA approved and standard of care
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| What is tPA dosing | 0.90mg/kg, total dose 90mg
Waste 10cc, give 10% as bolus, then remaining 90% inf over 1 hour.
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| What should BP be b4 tPA and during/after | b4: 185/110
after: 180/105
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| what are inclusion/exclusion criteria for tPA | incl: clear time of onset w/n 180 min of tx, deficits on NIH, neg CT for hemm
Excl: prev stroke/trauma w/n 3 mos onset, major sz w/n 14 days, hx ICH, SBP>185/110, improve TIA
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| What are more excl of tPA | s/s SAH, hx GI/urin hemm past 21d, art px prev 7d, Sz Todd's paralysis(mimic), incr PTT, <100,000platelet, BG <50; >400
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| At 3 mos, what % of pt w/ no deficits after tPA | 12%, no incr death, age not a factor, severe NIH not a factor, sICH rate 6.4%, 30% more likely to have mRS 0-1 @ 3 mos
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| What time frame should IV tPA be adm to acute stroke | w/n 4.5h
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| What are the drug choices to manage BP wtih tPA | labatelol 10-20mg q 5-15m up to total 150mg IVP
Nicardipine drip: rapid onset/offset, less titrations
Cleviprex: incr med 1-2mg = decr 2-4mg of BP, rapid
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| what are contraindications of labatelol | asthma, CHF, heart block
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| what is Poiseuille's Law | incr in extremity size = decr BP, cuff too lg
decr extremity = incr BP, cuff too small
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| What is BP monitoring after tPA | BP q 15 x 2h, 30m x 6h, 1h x 16h, q4h
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| Post tPA mgmnt | No invasive procedure, No antiplatelet/anticoag for 24h
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| What is % for recanalization wtih tPA | 13-38%, better if tx is started earlier
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| Lg vs sm vessel occl tx wtih tPA results | Lg vessel: less likely to respond, need IR
Sm. vessel: very well tx
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| What rare complication with tPA is more common with AA and pt taking ACE/ARBs? | oropharyngeal edema, may need intubation/drugs
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| What defines a symptomatic ICH during tx of tPA? | >4 pts from original NIH + IPH on non-contrast CT
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| Pt can't get tPA, what r IA tx, (intra-arterial) options? | thrombectomy, drip tPA directly on clot, angioplasty, stenting
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| List Guideline Classification for IA tx | Class 1: (strong) Benefit >>> risk
Class IIa: benefit>>risk (tx reasonable)
Class IIb: benefit > risk (tx may be considered)
Class III: risk > benefit (harm) no tx
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| What is the TICI score? | Done for Thrombolysis cerebral infusion after tx
Grade 0: no perfusion
G1: penetration w min. perf
G2: partial perf, G2a/2b: better
G3: complete perf
Goal is 2b/3 w/n 6h of stroke onset
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| What high risks are included with ICH | HTN, >55y, anticoag therapy, amyloid angiopathy, smoke, alcohol use, asians (highest), AA 65-74y, white older age
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| What is 6 mos mortality rate post-ICH | 30-50%, < independence in 6 mos,
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| Describe scoring for ICH score | Score 0 = 0 death in 30 days
1 = 14% death
2= 28% death
3=70% death
4= 95% death
5&6 = 100% death
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| Indicators for ICH scoring | GCS 3/4 - 2pts, 5-12 - 1 pt, 13-15 - 0pt
ICH volume: >30ml 1 pt, <30ml - 0 pt
IVH: Yes - 1pt, No - 0pt
Infratentorial: Yes - 1pt, No - 0pt
Age: >80 - 1pt, <80 - 0pt
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| What is significance of CT "spot sign" | probably active bleeding expansion, 72% in 24h, most common loaction for ICH is BG d/t HTN. 2nd: amyloid angiopathy in cortical/parieto/occipital (surface)
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| What are clinical s/s of ICH | impaired LOC, vomiting, severe HA, severe HTN
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| Ways to manage ICH | airway mgmt, INR >1.4 needs reverse anticoag, BP reduction 160/90, CPP 60-80mm Hg (MAP-ICP=CPP)
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| What is first tier therapy to manage ICP | ventriculostomy w CSF drainage, then manitol, hypertonic solutions, HOB 30deg, hyperventilation, sedation
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| What is second tier therapy to manage ICP | Hemicraniectomy, hypothermia, barbituate coma
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| Are prophylactic sz medication necessary in ICH | No, only if see sz.
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| When is surgery benefit in ICH? | Sx not usually help
Sx better in cerbellar hemm >3cm to prevent herniation
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| Who is most common for SAH | women, 40-60y, Japanese, black>white, htn, smoke, alcohol, cocaine
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| Most common aa affected by SAH | Base of Circle of Willis: PcomA from ICA, AcomA - ACA, MCA
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| What are most common forms of aneurysms? Which aneurysm type most likely to rupture? What size is an aneurysm needing sx | Berry/sacular - 80-90%
>7mm, worst HA
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| What diagnostics determine SAH? What is gold standard? | Non-contrast CT
If CT neg, then lumbar px
CTA
Gold standard: catheter angiography
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| What scales are used to grade SAH severity | Hunt & Hess Grading Scale
World Federation of Neurological Surgeons Scale
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| What tx is best to prevent re-bleed | coiling/clipping
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| What monitoring is needed for SAH rupture | monitor cardiac enzymes/telemetry, monitor for SIRS(HR>90, RR>20, WBC<4/>12, T >38C), hydrocephalus, hyponatremia (AcomA), 30%, cerebral salt wasting - decr free water, isotonic IV fluids
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| Pt 40y has sz, mass effect on CT and hemm w/ HA....what likely is cause | AVM
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| What is formula for cardiac output CO | CO = SV + HR
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| what is SV: stroke volume | amt of blood ejected by heart with ea contraction
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| What is Frank-Starling Law | Preload stretches heart muscle, incr degrees of stretch result in improved contractility until muscle is over stretched, dilated, & flaccid
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| What is afterload | resistance in vasculature that heart muscle must overcome to eject volume`
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| What causes resistance to flow in heart | atheroscloerosis, art pressure, metabolic factors(incr CO2 = dilate/decr CO2=constrict), intracranial pressure (ICP), extracranial pressure (stenosis in carotids/vertebrals), blood viscosity (incr hematocrit)
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| What is primary method to autoregulation | Vasomotor reactivity
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| Where is the phlebostatic axis and what is it for? What is leveled at the tragus? | 0 line for BP monitoring
tragus: ICV
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| Normal hemodynamic values: cardiac output CO/MAP/SvO2/ICP/CPP | CO - 4-8L/min
MAP - 70-105 mm Hg
SvO2 - 60-75%
ICP - 0-15mm Hg
CPP - 70-100mm Hg
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| What is tidal volume | 5-8mf/Kg, volume of gas moved into/out of lungs in single normal insp or exp. Start with 8010ml/Kg and titrate down
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| What is Vital capacity and who benefits from monitoring this | volume of gas exhaled after the deepest possible inhalation. Guillan Barre pts
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| What factors reduce diffusion | pulm edema/thick membrane, fibrosis/surface area for gas exchange...
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| What improves ventilation/perfusion | HOB 45 deg, good lung down, prone
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| What is diff b/n PaO2 & SaO2 | PaO2: oxygen transported dissolved in blood serum
SaO2: oxygen transported in combination w hemoglobin
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| With FiO2, what is goal | PaO2 >60% produces SaO2 >90%, use FiO2<50%. Add PEEP to incr SaO2 b4 incr FiO2
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| pH/paCO2/PaO2/HCO norms | pH: 7.35-7.45
paCO2: 35-45
paO2: 90-100
HCO3: 22-26
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| in resp acidosis/alkolosis how do you adjust RR with paCO2 of 55, pH 7.34 | acidosis: incr RR
alkolosis: decr RR
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| What are factors with weaning success | LOC, hemodynamic stability, physiologic stability, sats, spontaneous ventilation, pulm mechanics
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| What are two non-invasive ventilations | Bipap: have to be able to take mask off and not be restrained. PS @ insp/ PEEP@ end of exp
Cpap: provided PEEP w/o pressure support
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| What is most preventalbe cause of death in hospitals | VTE: DVT/PE/post-thrombotic syndrome
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|
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| What is Virchow triad | factors of DVT: change in vessel wall (injury), pattern of blood flow(venous stasis), constituency of blood(hypercoag states)
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| What is best method for VTE/PE prevention? What is best dx of VTE? what is best dx of PE? | 1st: Medical mgmt: anticoags: lovenox
2nd: mechanical SCD
Dx: LE dopplar
PE dx: CT
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| What is Braden Scale for predicting pressure ulcer | 6 -skin breakdown risk
32 - no risk for skin breakdown
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| Factors influencing intensity/duration in Braden: Factors in skin/support tissues in Braden: | int/dur: Mobility/Activity/Sens perception
skin/tiss: moisture/friction/nutrition/age/art press
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| A pt with an infarct with left neglect, visual field deficits &/or tactile neglect, & incontinence likely is right or left brain | Right brain asoc with falls
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| Normal BP/prehtn/high stage 1/high stage 2 | normal BP 120-80
prehtn: 120-139/80-89
high Stage 1: 140-159/90-99
Hight Stage 2; >160/100
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| What is first line anti-htn drug givn with 2nd drug | thiazide diuretic w ACE in AA
Pro: cheap, effective
Con: dehydration, incr blood viscosity
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|
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| what is 2nd drug of choice to combine with thiazide diuretics | Ca. Ch. blockers
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|
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| When are BB best used for htn | CAD and afib
Pro: cheap
con: stopping can cause death, impotence/depression
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| What is best BP drug in stroke prevention/mgmnt | ACE/ARB
pro: stroke reduction/cardiac remodeling/renal protection
Con: not good to decr BP in pt that lack renin-based htn, avoid in preg, cough
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| When is okay to use Minoxidil | When no other agents lower BP, aggressive, monitor pericardal eff, combine with BB to prevent rebound tachy
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|
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| What dose is best for statins in stroke? When does statin reduce first ever stroke? | Dose: 80mg statin
First ever stroke prevention: elevated C-reactive protein
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|
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| when ASA best for stroke pts? Which is better ASA or Aggrenox? | when not on ASA before
Aggrenox bettern than ASA, risk is HA
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|
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| Which is best ASA or Plavix for stroke | Plavix to reduce event
Plavix + ASA to lower risk of embolic events, but not long term except wtih stents
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|
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| When is anticoagulation best used in relation of stroke prevention/mgmnt | cardioembolic stroke/crescendo TIA/hypercoag states/art dissection assoc w embolization/cerebral venous thrombosis
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|
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| Warfarin is best tx for young/old when? | warfarin is superior to placebo in reducing stroke risk.
Younger: no comorbidities than use ASA
Older: w comorb, use warfarin
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|
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| How to determine ciggarette pack year hx | # of yrs smoked X # of cigg smoked / 20
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|
||||
| medications to support smoking cessation | gum: up to 24 pcs/d, pack b/n teeth and gum
patch: >10cig/21mg, in 2wks/14mg, in 2wks/7mg
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|
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