LA PERTINENCIA DE CANCELAR EL PRESIDENCIALISMO

LIMITACIONES AL PODER DEL PRESIDENTE

CANCELACION DEL PRESIDENCIALISMO MEXICANO 14.1 LA CANCELACION DEL SISTEMA PRESIDENCIAL

14.2 LA PERTINENCIA DE CANCELAR EL PRESIDENCIALISMO

 ABCs: O2, IV, cardiac monitor; consider intubation for severe strokes

 Position: use minimal elevation of head necessary to decrease aspiration (keeping the head of bed flat is the best, if possible)  NPO: until swallowing has been formally

assessed

 Fluids: normal saline only to keep patient euvolemic

 Cardiac monitoring: 24 – 72 hrs of cardiac monitoring to look for atrial fibrillation _{O2: keep O2 saturation at or above 94%}  Antiplatelet therapy: see below

o Do not treat aggressively in first 24 hours due to the concern that immediate lowering of BP may lead to under-perfusion of the brain area around the ischemic segment (penumbra) and further brain ischemia.

o Exceptions:

 BP > 220/120 (if so, consider lowering BP by 15%-20% in first 24 hrs)  BP >185/110 if patient is a candidate to

receive t-PA

 Hypotension: rare, but if present, look for underlying cause (e.g. aortic dissection,) and treat with fluids

 Hyperthermia: treat with cooling and antipyretics and search for cause  Anticoagulation:

o DVT prophylaxis for immobile patients: heparin or low molecular weight heparin (LMWH) subcutaneously

 Hyperglycemia: associated with worse

outcomes, so target glucose levels at 5-10 mmol  Cardiovascular risk factors: should be

evaluated and aggressively managed. Smokers should be advised to quit and provided support to do so.

 Admission: evidence supports admission to dedicated stroke unit if possible

Antiplatelet Therapy

Studies have found antiplatelet therapy after stroke or TIA reduces the risk of further vascular events by about 25%. All of the following agents are acceptable first line choices for secondary stroke prevention and the decision about which agent to use should be determined based on the clinical scenario.

Aspirin

 Loading dose of 160 mg -325 mg as soon as possible after CT excludes hemorrhage  Followed by long term dose of 81 mg per day  Those who have failed on ASA should use

ASA/dipyridamole or clopidogrel

Clopidogrel (Plavix)

 Loading dose of 300mg

 Clopidogrel 75 mg/day alone is as effective as ASA in TIA and stroke

 Use in patients with ASA allergy or patients who have failed on ASA

ASA + Dipyridamole (Aggrenox)

 ASA/dipyridamole is an option for ASA failures

 Warn patients regarding headaches and

consider acetaminophen initially as headache prophylaxis

THROMBOLYTICS

 Use of thrombolytics has become standard of care in many centres. Successful implementation requires great coordination of many services; therefore most large urban centers are developing centralized Stroke Centers.

 Intravenous Tissue Plasminogen Activator (alteplase), the most commonly used

thrombolytic for stroke, is currently approved in Canada if given within 4.5 hours of onset of symptoms, but the benefit is likely better if given sooner ideally within 90 minutes.

 Eligibility determined based on NINDS and ECASS III Stroke Studies

o Consult neurologist and/or Stroke Team o Inclusion Criteria

 Adults with onset of measurable deficit up to 4.5 hours prior to alteplase administration o Exclusion Criteria

 History of intracranial hemorrhage at any time

 Stroke or serious head/spine trauma in past 3 months

 Major surgery in the past 2 weeks  Non-compressible arterial puncture in

past 7 days

 Elevated PTT or INR, or platelets <100,000

 Any other condition that could increase bleeding

 Symptoms suggestive of subarachnoid hemorrhage

 Symptoms due to another nonischemic condition e.g. Todd‘s paralysis  Blood glucose <2.7 or >22.2  Patient on dabigatran (Pradax) and

compliant with medication  Any hemorrhage on brain CT  Persistently elevated BP > 185/110  Evidence of infarction of >33% of the

MCA territory

 Mild or rapidly-improving symptoms  Very severe symptoms (NIHSS >22)  Brain tumour

 Metastatic cancer diagnosis

 Pregnancy (relative contraindication)  Seizure at onset (relative

contraindication)

ABCD2 Score

Age > 60 = 1 point

Blood Pressure > 140/90 = 1 point Clinical Features

Unilateral weakness = 2 points Speech deficit = 1 point Other symptoms = 0 points Duration of symptoms < 10 min = 0 points 10 -59 minutes = 1 point >59 minutes = 2 points Diabetes = 1 point CHA 2 DS 2 Score CHF =1 point HTN = 1 point Age>75= 2 points Age 65-74=1 point Diabetes=1 point

Stroke or TIA previously=2 points Vascular disease (MI, peripheral arterial disease) = 1 point

Sex category (female) =1 point

TREATMENT OF TIA & MINOR STROKE

A TIA is a warning sign of atherosclerotic disease in general and of an impending stroke specifically. Approximately 10% of patients will have a stroke within 1 week after a TIA.

ABCD2 Score:

A patient with TIA who has a higher score may have a higher risk for a stroke; however, a recent study has failed to validate this score. Nonetheless, consider admission to hospital for patients with an ABCD2 score of 5 or 6

.

Anticoagulation in the Presence of Atrial Fibrillation

Primary Stroke Prevention

 Patients diagnosed with atrial fibrillation should be risk-stratified for risk of stroke using a standardized tool such as CHA 2 DS 2 - VASc o If score 0, patients should receive daily ASA o If score 1, patients may receive either warfarin

or dabigatran or ASA

o If score 2 or greater, patients should receive either warfarin or dabigatran

 Warfarin: Target INR of 2.5 (range 2.0-3.0)  Dabigatran: 150 mg twice daily for most

individuals; 110 mg twice daily for patients aged 80 or more years and for patients at risk of bleeding; contra-indicated in renal failure Secondary Stroke Prevention

 Atrial fibrillation + TIA or minor stroke: start oral anticoagulation (warfarin or dabigatran)

immediately

 Atrial fibrillation + acute ischemic stroke o Should be on oral anticoagulation but timing

for starting is unclear. It is common to wait 2- 14 days to repeat CT to exclude intracranial hemorrhage.

o Heparin or LMWH not recommended  Consult your neurologist

SUMMARY

 A TIA is a brief episode of neurological dysfunction caused by brain or retinal ischemia with symptoms typically lasting < 1 hour and without evidence of acute infarction on brain imaging, whereas a stroke has symptoms that last for >24 hours or radiologic evidence of infarction

 Be careful to rule out common ‗stroke mimics‘ in the emergency department

 Patients with TIAs or stroke require workup with CBC, glucose, ECG, CT head and early Doppler ultrasound of the carotid arteries at minimum.  Patients should be rapidly evaluated with a

careful history and physical examination at a Stroke Centre ideally if they are potential candidates for thrombolytics

 Thrombolytics should be considered if they can be administered within 4.5 hours of the onset of stroke

 Careful attention should be paid to patient position, fluid balance, blood pressure, glucose, fever and oxygenation in those requiring admission to hospital for stroke

 Secondary stroke prevention for most patients should include an antiplatelet agent such as

 Anticoagulation should be initiated in most patients with atrial fibrillation who have had a stroke for secondary stroke prevention and in selected patients with atrial fibrillation who have not yet had a stroke for primary stroke

prevention

REFERENCES

1. Johnston SC et al. National Stroke

Association guidelines for the management of transient ischemic attacks. Ann Neurol 2006; 60:301-313.

2. Sacco RL et al. Guidelines for prevention of stroke in patients with ischemic stroke or transient ischemic attack. Circulation 2006;113:e409-449.

3. The Canadian Stroke Strategy. www.canadianstrokestrategy.ca 4. Adams H et al. Guidelines for the early

management of adults with ischemic stroke. Stroke 2007; 38:1655-1711Wardlow C, van Gijn J, Dennis M et al. Stroke

Practical Management. ThirdEdition.

Massachusetts USA. Blackwell Publishing, 2008. 5. Perry J et al. Prospective validation of the

ABCD2 score for patients in the emergency department with transient ischemic attack. CMAJ 2011 Jul 12; 183(10):1137-45.

6. The Heart and Stroke Foundation. www.heartandstroke.com 2012. 7. Up to Date. www.uptodate.com 2012.

Title Responses and Scores 1.A) Level of consciousness 0—alert

1—drowsy 2—obtunded 3—coma/unresponsive 1.B) Orientation questions 0—answers both correctly

1—answers one correctly 2—answers neither correctly 1.C) Response to commands 0—performs both tasks correctly

1—performs one task correctly 2—performs neither

2. Gaze 0—normal horizontal movements 1—partial gaze palsy

2—complete gaze palsy 3. Visual fields 0—no visual field defect

1—partial hemianopia 2—complete hemianopia 3—bilateral hemianopia 4. Facial movement 0—normal

1—minor facial weakness 2—partial facial weakness 3—complete unilateral palsy 5. Motor function (arm) 0—no drift

a. Left 1—drift before 5 seconds b. Right 2—falls before 10 seconds

3—no effort against gravity 4—no movement

Title Responses and Scores 6. Motor function (leg) 0—no drift

a. Left 1—drift before 5 seconds b. Right 2—falls before 5 seconds 3—no effort against gravity 4—no movement 7. Limb ataxia 0—no ataxia

1—ataxia in 1 limb 2—ataxia in 2 limbs

8. Sensory 0—no sensory loss

1—mild sensory loss 2—severe sensory loss

9. Language 0—normal

1—mild aphasia 2—severe aphasia 3—mute or global aphasia 10. Articulation 0—normal

1—mild dysarthria 2—severe dysarthria 11. Extinction or inattention 0—absent

1—mild (loss 1 sensory modality) 2—severe (loss 2 modalities)

19: STATUS EPILEPTICUS

In document UNIVERSIDAD AUTONOMA DE NUEVO LEON TEMA (página 113-117)