Based on guidelines set by NCS / German Society (2015)
LHI Lecture.pdf (powerpoint in PDF format)
NCS Evidence Based Guidelines for LHI
for neurocritical care experts
Based on guidelines set by NCS / German Society (2015)
LHI Lecture.pdf (powerpoint in PDF format)
NCS Evidence Based Guidelines for LHI
Common and Uncommon Etiologies of Hypoglycorrhachia in the Literature
ETIOLOGIES COMMONLY ASSOCIATED WITH HYPOGLYCORRHACHIA
ETIOLOGIES UNCOMMONLY ASSOCIATED WITH HYPOGLYCORRHACHIA
Etiologies reported to cause severe hypoglycorrhachia, (CSF glu ≤10 mg/dL)
Frequency of Different Known Diagnoses Seen in Patients with Hypoglycorrhachia
2. HIV-Infected Patients
3. Patients with History of Neurosurgery
4. Patients without HIV or Neurosurgical History
Chow, E., & Troy, S. (2014). The Differential Diagnosis of Hypoglycorrhachia in Adult Patients. The American Journal Of The Medical Sciences, 348(3), 186-190. doi: 10.1097/maj.0000000000000217
Murthy, S., Gomersall, C. and Fowler, R., 2020. Care for Critically Ill Patients With COVID-19. JAMA,.
Half life of TPA is ~5 minutes and only 20% is present and active 10 mins after completion of infusion, but PT and PTT prolongation and fibrinogen levels are decreased x 24 hours or more.
Checklist:
*each bag of cryoprecipitate contains 200-250 mg of fibrinogen, increases fibrinogen levels by 6-8 mg/dL (in a 70 Kg adult)
*half life of fibrinogen is 3-5 days
Gross, H. and Grose, N. (2017). Emergency Neurological Life Support: Acute Ischemic Stroke. Neurocritical Care, 27(S1), pp.102-115.
Modified from MR CLEAN Trial:
A Randomized Trial of Intraarterial Treatment for Acute Ischemic Stroke. (2015). New England Journal of Medicine, 372(4), pp.394-394.
Uptodate: Reperfusion therapy for acute ischemic stroke. Accessed 09/11/2017.
Screening tests
CSF
Specific investigations
Blood/serum
Biopsy
COMA Algorithm (ENLS 2017)
Toxic-Metabolic Etiologies of Coma
“Acute Encephalopathy Work-Up.” Neuroweb.us. http://www.neuroweb.us/Chapters/acute%20encephalopathy/work_up.htm, 2017. Web. 18 Aug. 2017.
Serum studies:
MRI brain w/wo con
CTA head/neck
Lumbar Puncture
*withdraw at least 30 cc of CSF and save extra for additional studies if necessary
From ENLS / ACC/AHA 2013
Algorithm for TIA/AIS:
Eligibility
Absolute exclusion criteria if positive
Relative exclusion criteria if positive—use caution if recommending alteplase if one or more are positive
Some additional considerations
================
Inclusion criteria
Exclusion criteria
<Eligibility criteria for tPA in PDF format>
Written consent is no longer required for tPA as this treatment is considered standard of care for acute ischemic stroke. That being said, the verbiage on this old consent form is a reminder of the information necessary for informed consent for tPA.
I have been clearly and fully informed by Dr._ that I am having a stroke. It has been explained to me that the Intravenous Thrombolytic Therapy using the drug t-PA, administered promptly after the onset of symptoms of a stroke may dissolve the clot and restore blood flow which may lessen the amount of damage to my brain.
I have been made aware that there are common risks and complications of Intravenous Thrombolytic Therapy as well as risks and complications of not having the therapy done. I have been told that the major risks from the use of t-PA are the possibility of internal bleeding including the stomach or intestinal tract and brain. The risk of bleeding in the brain is about 6%. If bleeding into the brain occurs my condition could worsen and may even result in death. I understand that some of the other possible reactions to t-PA include: temporary bruising or bleeding in the mouth, nose, skin, urinary tract or arm. If I refuse therapy my stroke could worsen or not improve.
I have received no guarantees as to results of Intravenous Thrombolytic Therapy. I understand that the alternative is to not receive t-PA and receive only supportive treatment.
In 1996, t-PA was approved by the Food & Drug Administration (FDA) for treatment of stroke within the first 3 hours after onset. In 2009, national guidelines concluded that this treatment could be helpful up to 4.5 hours after the onset of an acute stroke. Currently, the FDA has not approved t-PA for the treatment beyond 3 hours of symptom onset.
The nature and purpose of this therapy and the risks involved have been explained to me by the physician. I have been given an opportunity to ask any questions I may have, and all such questions or inquiries have been answered to my satisfaction. I have read this form and understand it fully.
NOTES:
1. Use actual body weight
2. Alteplase dose is 0.9mg/Kg, max dose not to exceed 90mg.
3. Mix by swirling, rather than shaking
4. 10% of total dose bolused over 1 min, remainder infused over 1 hour
5. Administer 100ml bag of saline after 1 h infusion to flush IV line and ensure entire dose is administered, use same rate to avoid terminal alert please bolus
Comparison of AHA/ASA acute stroke management guidelines (2013) and 2015 FDA prescribing information for alteplase treatment of acute ischemic stroke
Post TPA Orders:
REFERENCES:
Gross, Hartmut, and Noah Grose. 2017. “Emergency Neurological Life Support: Acute Ischemic Stroke”. Neurocritical Care 27 (S1): 102-115. doi:10.1007/s12028-017-0449-9.
SITY work-up:
Singhal, A. B. et al. “Recognition And Management Of Stroke In Young Adults And Adolescents”. Neurology 81.12 (2013): 1089-1097.
If all above questions are answered “Yes” or “N/A,” proceed with early mobilization
Olkowski, Brian F. and Syed Omar Shah. “Early Mobilization In The Neuro-ICU: How Far Can We Go?”. Neurocritical Care (2016): n. pag. Web. 4 Jan. 2017.