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Flashcards

4 - Stroke

lw409 Clinical Masters Inglês 138 flashcards

Flashcards do conjunto (138)

  1. 1what is a stroke?rapidly developing clinical signs of focal disturbance of cerebral function, with symptoms lasting 24hrs+ or leading to death
  2. 2what is a transient ischaemic attack/TIA?same as a stroke, but lasting less than 24hours
  3. 3what sort of symptoms do stroke causelanguage and face affected
  4. 4what causes a stroke?interruption of blood flow to the brain cells
  5. 5do brain cells die?in stroke - yes (maybe cause permanent damage)
    in TIA - no as its short
  6. 6when is rt-PA beneficial?within 3hrs is best
  7. 7what happens if you give rt-PA over 4.5 hours?can cause more damage! DO NOT GIVE
  8. 8what are the 2 types of stroke? how do you tell which one is affecting a patient?infarct
    haemorrhage
    do a CT scan
  9. 9what is an infarctblockage of blood flow to brain which kills cells
  10. 10what is a haemorrhageblood vessel bleeds into brain which squashes cells and kills them by pressure
  11. 11which type of stroke is most commoninfarct
  12. 12what is cerebral infarctionblood to brain cut off - causes swelling and pressure on ventricle
  13. 13what do cerebral infarctions look like on CT scan?symmetrical large grey area where theres no blood
  14. 14what are the two causes of ischaemic stroke- embolic = gunk floating in blood blocks vessels
    - thrombotic = atherosclerotic vessels within the brain
  15. 15what happens in cerebral haemorrhage?sudden increase in volume and no room for expansion = increased pressure which kills brain cells and leaves a big hole
  16. 16what does a cerebral haemorrhage look like on a CT scan?large white area
  17. 17what is the outcome of stroke at 1yr31% dead
    24% disabled
    45% fully recover
  18. 18what is primary preventionprevents stroke happening in the first place
  19. 19what is secondary preventionreduced further strokes after pt has already had a stroke
  20. 20what are examples of primary stroke preventionBP lowered
    stop smoking
    lipids lowered
    diabetes controlled
    AF controlled
    TIA treated
  21. 21what diseases are risk factors for strokediabetes
    high cholesterol
    alcoholic
    sickle cell
    hypertension
    AF/MI
    congestive HF
    previous TIA
  22. 22if you reduce BP by 7.5mmHg, how does that affect stroke risk?reduce stroke by 46%
  23. 23how long do you have to stop smoking before your stroke risk reduces5yrs
  24. 24why do AF pts get strokesflutter of heart rather than squeeze = clot likely to form and could go to brain = stroke
  25. 25what are symptoms of a TIAcollateral weakness/numbness
    sensory loss
    visual disturbances
    sudden onset
    short lived and full recovery within 1hr
  26. 26if theres a problem with the left side of the brain, where do you get symptoms?on the right side
  27. 27what are TIA differential diagnosessyncope
    partial epileptic seizure
    migraine aura
    intoxication
    subarachnoid haemorrhage
    neuroinfection
  28. 28hoe does HRT affect strokeoestrogen - more likely to clot - more likely to get stroke or TIA
    take off HRT if this happens
  29. 29what is the FAST campaign?F - facial weakness - can they smile? has mouth/eye drooped?
    A - arm weakness - can they raise both arms?
    S - speech problems - can they speak clearly and understand you?
    T - test all three symptoms
  30. 30is TIA a medical emergencyYES - often underplayed as it gets better
  31. 31what should pts with ongoing TIA symptoms dogo to hospital
    <180 mins = thrombolysis
  32. 32why do we want to assess TIAs?theres a risk that the pt may go onto have a stroke in the next week - need to see these people urgently
  33. 33why is TIA nearly always treated with thrombolysis?its ischaemic - nearly always a clot
  34. 34what score system is used to predict high risk of stroke after TIA?ABCD
    age over 60 = 1
    BP/140/90 = 1
    unilateral weakness = 2
    speech disturbances without weakness =1
    >60min = 2
    10-59min = 1
    <10min = 0
    diabetes = 1
  35. 35after doing ABCD, which pts need treating?over 4 - treat within 24hrs (emergency)
    under 4 - treat within a week (not as urgent)
  36. 36what drugs are used in secondary prevention of stroke and TIAanti platelets
    antihypertensives
    statins
    anticoagulants in AF pts
  37. 37when should aspirin be started for secondary preventionwithin 48hrs
  38. 38which is more effective - aspirin or dipyridamole?both equally effective
    TOGETHER are even more effective
  39. 39what anti platelet is first line in secondary prevention of strokes?clopidogrel
  40. 40what combinations of anti platelets are recommended to reduce stroke riskclopidogrel alone
    OR aspirin and dipyridamole
  41. 41whats the problem with clopidogrelits not licenced in the first 2 weeks after stroke - need to use aspirin 300mg for 2 weeks then clop 75mg OD lifelong
  42. 42should you give people who aren't hypertensive at the start BP reducing meds?YES - proven to reduce stroke risk even if not hypertensive
  43. 43what antihypertensives should be used in secondary prevention of strokeperindopril +/- indapamide
  44. 44what statin is used in primary prevention of strokessimvastatin 40mg
  45. 45what statin is used in secondary prevention of strokes?atorvastatin 40mg
  46. 46what cholesterol level should you consider a statin?>5.2
  47. 47whats the problem with atorvastatin 80mg?prevents strokes better than 40mg BUT increases risks of side effects
  48. 48what is carotid artery stenosis?plaque almost completely blocking blood vessel, but still have blood flow past it
  49. 49why is carotid artery stenosis so bad?if you get a turbulent flow then bits of the plaque can break off = high risk of stroke
  50. 50how is carotid artery stenosis treated?endarterectomy - surgery to remove clot
    OR stenting - blow up a balloon to open vessel (2nd line)
  51. 51how can you detect AFirregular pulse - then do a 12 lead ECG
  52. 52which type of AF has the highest risk of strokeasymptomatic/paroxysmal and permanent have same risk
  53. 53how do you assess stroke risk in AF pts?CHADS-VASC
  54. 54what is the CHADS-VASC scoring systemC - congestive HF/LVD = 1
    H - hypertension = 1
    A - age over 75 = 2
    D - diabetes = 1
    S - stroke or TIA previously = 2
    V - vascular disease (previous MI/plaque)=1
    A - age 65-74yrs = 1
    S - sex category (female) = 1
  55. 55what CHADSVASC score should you consider anticoagulation?score above 1
  56. 56how do you weigh up the risk of stroke and risk of bleeding on anticoagulants?do HASBLED score
  57. 57describe the HASBLED scoring systemH - hypertension = 1
    A - abnormal renal/liver function = max 2
    S - stroke = 1
    B - bleeding = 1
    L - labile INR = 1
    E - elderly over 65yrs = 1
    D - drugs or alcohol = max 2
  58. 58give 4 disadvantages of warfarinnarrow therapeutic window
    administrative burden
    inconvenient testing INR
    dietary/drug interactions
  59. 59give 3 advantages of warfarincheap
    familiarity
    easily reversible with vit k
  60. 60what INR do you want for secondary prevention?between 2 and 3
    over 3 - risk of bleeding
    under 2 - risk of stroke
  61. 61what happens if TTR (time in target range) falls below 70%?efficacy of warfarin to prevent strokes falls dramatically
  62. 62what do you need to monitor when using NOACsrenal and liver function
  63. 63how do you check a pt is taking a NOACcan do APTT
  64. 64what dose of dabigatran should be used? why?150mg then 110mg
    lower dose is just as effective as warfarin in preventing strokes, but lower bleed risk
  65. 65what are disadvantages of dabigatran?- causes dyspepsia
    - large capsule is hard to swallow
    - cant go in rosette box
    - cant go down NG or PEG
    - lack of reversibility
  66. 66which is better in preventing strokes - warfarin or rivaroxaban?both the same
  67. 67give 1 disadvantage and 3 advantages of rivaroxabanx - lack of reversibility
    ✓ - small tab so easy to swallow
    ✓ - can go via NG or PEG
    ✓ can go in dosette box
  68. 68what is apixaban superior than warfarin in?greater at preventing haemorrhagic stroke, not ischaemic
  69. 69give 1 disadvantage and 2 advantages of apixabanx - lack of reversibility
    ✓ - small tab so easy to swallow
    ✓ - can go via NG or PEG
  70. 70which NOAC is best in prevention of stroke in AF?don't know - no head to head trials
  71. 71what is a left atrial appendage closure? why do we do it?close left atrial appendage with inflatable decides to stop clots
    in AF, blood clot arises from left atiral appendage in 90% cases
  72. 72do you need to tell the DVLA after a TIA?yes - cant drive for 1 month
  73. 73how long cant you drive if you have recurrent TIAs?3 months
  74. 74can you fly after a TIA?no contraindications but airlines say leave 1 month due to oxygen pressures in cabins
  75. 75describe the acute treatment of strokehydration
    management of dysphagia
    oxygen therapy
    BP
    VTE prophylaxis
    aspirin
    re-perfusion
    neuroprotection?
  76. 76why do we need acute treatment with aspirin?anti platelets beneficial within 48hrs
  77. 77why do we need acute treatment with heparin?we DONT - low and medium dose has no benefit - increases bleeds
  78. 78how should we treat BP in acute stroke?beta blockers have no benefit
    BUT may benefit in intracerebral haemorrhage
  79. 79what is an ischaemic penumbra? how is it treated?not completely blocked - give rt-PA within 3hrs to prevent disability
  80. 80how do you treat a heamorrhagic stroke?very difficult - cant treat a bleed!
    antihypertensives
    surgical removal
  81. 81which sex are more likely to get stroke?men, but women more likely to die from it
  82. 82what drugs should you give if you suspect a stroke?NOT ASPIRIN
    it might be a bleed and you'll make it worse
    (give aspirin if they have chest pain)
  83. 83should you treat a woman with a CHADSVASC score of 1?no -only scores because she's female
  84. 84should you withhold oral anticoagulant if a pt is at risk of falls?NO
  85. 85should you anti coagulate pts with uncontrolled hypertensionNO
  86. 86why don't old people like taking warfarin?they think its rat poison
  87. 87what is primary prevention of stroke in AFcontrol modifiable risk factors
    treat/control AF where possible
  88. 88what are symptoms of AFlight headed, fatigue, palpitations, dyspnoea, chest pain
  89. 89what biochemical markers should you monitor in pts with AF?TFT
    FBC
    U+E
    BG
    BP
  90. 90what do you use to treat permanent AF?rate control
  91. 91what do you use to treat persistent AFrhythm control if under 65yrs
  92. 92what do you use to treat paroxysmal AFrhythm control (pill in the pocket)
  93. 93which AF pts need anticoagulation?ALL OF THEM
  94. 94what is 1st 2nd and 3rd line in AF1 - b blocker or RL-CCB e.g. diltiazem/verap
    2 - dual therapy with beta blocker, diltiazem or digoxin
    3 - rhythm strategy - pharmacological or electrical cardioversion
  95. 95name 3 rate control drugs and 4 rhythm control drugsRATE - B blocker/RL-CCB/digoxin
    RHYTHM - B blocker/amiodarone/flecanide /drodenarone
  96. 96if you stop warfarin and want to swap to a NOAC, when should the NOAC be started?when INR <2
  97. 97which pts is digoxin ok in?sedentary patients
  98. 98name 2 non-pharmacological treatments of AFelectrical cardioversion to shock heart back into normal rhythm
    ablation to stop electrical impulses that cause AF
  99. 99when should you consider anti coagulating men with AFCHADSVASC over 1
  100. 100when should you reassess the efficacy of an anticoagulant<65% TTR
    2 INR values over 5
    1 INR value over 8
    2 INR values less than 1.5
  101. 101what factors could contribute to poor anticoagulant control?cognitive function
    adherence
    illness
    interactions
    lifestyle (diet/alcohol)
  102. 102should you give aspirin to pts with AF?NO - not used in primary prevention
  103. 103when should you review AF pts NOT taking an anticoagulant?when theyre 65yrs old or develop a disease e.g. diabetes or hypertension
  104. 104how often should the need for anticoagulants be reassessed?annually
  105. 105what is first line in AFrate control e.g. beta blocker (NOT sotalol, use bisoprolol) or RL-CCB e.g. diltiazem/verapamil
  106. 106what drug should NOT be used for long term rate controlamiodarone
  107. 107when should you carry out emergency electrical cardioversion? (without delaying to achieve anticoagulation)in pts with life-theratening haemodynamic instability caused by new onset AF
  108. 108what is pharmacological cardioversion for new onset AFflecainide or amiodarone
  109. 109who is suitable for pill in the pocketpst with infrequent paroxysms and few symptoms
    OR where symptoms are induced precipitants e.g. alcohol or caffeine
  110. 110what drug is used for pill in the pocketflecianide or propafenone
  111. 111should you anti coagulate AF pts at risk of stroke with a HASBLED score over 3?YES - but need closer monitoring
  112. 112what should be considered if anticoagulation is contraindicated or not toleratedleft atrial appendage closure
  113. 113list 5 non modifiable risk factors for strokeage
    gender (men more likely)
    family history
    ethnicity (afro-caribbean higher)
    genetic conditions (Fabry's disease)
  114. 114list 7 modifiable risk factors for strokeBP
    AF
    diabetes
    high cholesterol
    smoking
    ischaemic heart disease/peripheral artery disease
    poor diet and obesity
  115. 115why do we want to treat stroke quickly?to reduce damage done
  116. 116what does the ABCD score tell you?identifies which pt are at highest risk of recurrent stroke yo allow very rapid investigation and treatment
  117. 117list the medicines used in the treatment of ischaemic stroke1 - thrombolysis with rt-PA
    2- aspirin 300mg OD within 48hrs, continued for at least 14 days
    3- anticoagulants (not in acute phase) e.g. UFH/LMWH/warf/NAOC
  118. 118how can you reduce intracranial pressure?mannitol
    hypertonic saline
    glycerol
    or corticosteroids
  119. 119what is the treatment for intracerebral haemorrhage?heamatoma evacuation
    reduce pressure using corticosteroids/mannitol
  120. 120what other management needs do you need to think about in stroke?fluid replacement
    BG and BP management
    feeding
    oxygen therapy
    manage pyrexia
    early mobilisation
  121. 121what drug should be given to people who have had a TIA and the ABCD score is over 4aspirin 300mg OD started immediately - seen within 24hrs
  122. 122what drug may need to be given alongside aspirinPPI
  123. 123what BG target is needed during stroke treatment4-11 (use iV insulin and glucose if needed)
  124. 124when should cardioversion be used to treat AFnew onset (<48hrs) as we know there no clots in the bottom of the heart that will fly about
  125. 125how can we tell if theres clots in the heart before we cardiovert?TTE and TTO tests
  126. 126what do you need to do before cardioverting if AF is long-standinganti coagulate with warfarin for 3-4 weeks, check there no clots THEN convert
  127. 127why shouldn't you give a b blocker and diltiazem togethercan cause complete heart block
  128. 128what check should be done after a TIA?ECG to rule out AF
  129. 129what is SALTspeech and language therapy - test to see if you should give meds orally or rectally if you cant swallow
  130. 130if you give rt-PT, how soon after should you start aspirin?24hrs after (continue for 2 weeks)
  131. 131whats the problem with rt-PT and diabetics?alteplase cant be given if theyre hyperglycaemic - need to treat with insulin first before thrombolysing
  132. 132what dose atorvastatin should be used if a pt has ACS80mg (unlicensed)
  133. 133how long are dual platelets used for after ACS?12 months
  134. 134what do you have to worry about with metforminRENAL FUNCTION
    get lactic acidosis if eGFR is less than 45
  135. 135after a stroke, when should medicines be changed/added/removed?after 48hrs
  136. 136do you need to give VTE prophylaxis to pts who have been thrombolysed?no - would increase haemorrhagic risk
  137. 137can you use TEDS stockings in a stroke?NO
  138. 138what VTE prophylaxis could you give to a thrombolysed patient?hydration
    mobility
    foot pump

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Masters Clinical FlashCards sobre 4 - Stroke, criado por lw409 em 25-04-2015.
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lw409
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