WBR0895

Author	[[PageAuthor::Ayokunle Olubaniyi, M.B,B.S [1]]]
Exam Type	ExamType::USMLE Step 3
Main Category	MainCategory::Emergency Room
Sub Category	SubCategory::Neurology
Prompt	[[Prompt::A 64-year-old woman with a past medical history of hypertension, osteoarthritis, and diabetes is brought to the ED with an acute onset of impaired speech, right-sided hemiplegia, and right-sided facial palsy. She also complains of headache and dizziness. She suddenly noticed that she was unable to use her right arm and leg 2 hours ago. No history of trauma. She is on hydrochlorothiazide, lisinopril and pravastatin. Her vitals reveals a temperature of 38.5 degrees Celsius, blood pressure of 192/115 mmHg, heart rate of 105 beats per minute, respiratory rate of 12 breaths per minute, and she is saturating at 92%, while breathing room air. Examination reveals an elderly woman, conscious and alert, not in any obvious painful distress. Lungs and cardiac were auscultations are unremarkable. Abdomen was non-tender, non-distended and without any hepatosplenomegaly. Neurological examination confirms the presenting complaints above. An immediate non-contrast CT of the brain done ruled out hemorrhage in the brain. There is no contraindication to the use of thrombolytics in this patient, and intravenous recombinant TPA (alteplase) is being strongly considered. What is the next best step to take in the management of this patient?]]
Answer A	AnswerA::Proceed with the administration of IV thrombolytics
Answer A Explanation	AnswerAExp::IV thrombolytics must only be administered after ensuring a blood pressure ≤180/110 mmHg. IV thrombolytics are generally administered within 4.5 hours of onset of symptom ONLY in patients without contraindicationS (i.e., eligible patients).
Answer B	AnswerB::Order carotid duplex USS, echocardiography and venous doppler USS to investigate the etiology
Answer B Explanation	AnswerBExp::These investigations are not indicated in the first 24 hours of onset of stroke. They are done to investigate the etiology when the patient is stable.
Answer C	AnswerC::Administer IV antihypertensives
Answer C Explanation	AnswerCExp::The blood pressure must be controlled before IV thrombolytics can be administered.
Answer D	AnswerD::Administer oral acetaminophen to treat fever
Answer D Explanation	AnswerDExp::IV acetaminophen may be indicated in treating fever in thrombolysis-ineligible patients. Furthermore, in stroke patients, nothing is given by mouth until speech and swallow evaluation is done in order to reduce the risk of aspiration.
Answer E	AnswerE::Admit ICU for close monitoring of vitals and bleeding complications
Answer E Explanation	AnswerEExp::All patients must be managed in the ICU post-IV TPA for close monitoring of blood pressure and bleeding complications.
Right Answer	RightAnswer::C
Explanation	[[Explanation::This is a case of acute ischemic stroke presenting after two hours of symptom onset. She is a good candidate for thrombolysis, but her blood pressure is elevated. An elevated blood pressure is not uncommon in cases of stroke, and great caution has to be taken in the management of blood pressure because the perfusion of the ischemic areas in the brain is largely dependent on the systemic blood pressure. Elevated blood pressure increases the risk of hemorrhage following administration of thrombolytics. The blood pressure of a candidate for thrombolysis must be ≤180/110 mmHg, and must be maintained below 180/105 mmHg for the first 24 hours post thrombolysis. Commonly used agents include labetalol, nicardipine, and in extreme cases, sodium nitroprusside. In patients with contraindication to thrombolysis, elevated blood pressure is generally not treated until it is >220/120 mmHg, or when BP is <220/120 mmHg with evidence of end organ damage (e.g., myocardial infarction, aortic dissection, pulmonary edema, and hypertensive encephalopathy) Educational Objective: The blood pressure must be controlled before IV thrombolytics can be administered. The following are the don’ts of acute ischemic stroke: Do not treat hypertension except the blood pressure is >220/120 mmHg, and not until CT/MRI have been performed. Do not initiate anticoagulation treatment within the first 24 hours. Do not commence oral administration of medications before speech and swallow evaluation. Do not delay sending the patient to CT for any reason. Reference: http://www.wikidoc.org/index.php/Stroke_resident_survival_guide Educational Objective: References: ]]
Approved	Approved::No
Keyword	WBRKeyword::Stroke, WBRKeyword::acute ischemic stroke, WBRKeyword::management of blood pressure in stroke
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