Tasty Morsels of EM 089 – #FRCEM Stroke

28 Jul

(Featured image, Allan Ajifo on Flickr, CC license)

I’m entering a few months prep for the UK and Ireland exit exam in Emergency Medicine: the FRCEM. I’ll be adding lots of little notes on pearls I’ve learned along the way. A lot of my revision is based around the Handbook of EM as a curriculum guide and review of contemporary, mainly UK guidelines. I also focus on the areas that I’m a bit sketchy on. With that in mind I hope they’re useful.

You can find more things on the FRCEM on this site here.

We see strokes all the time so this isn’t meant to be comprehensive and focusses on the NICE 2017 Guidance and doesn’t touch on the veracity of the statements contained theirin

What does NICE say to do in assessing TIA and what investigations should be done?

  • FAST pre hospital
  • ROSIER in ED
  • TIA
    • ABCD2 recommended (4 or more the cut off for higher risk
      • Age >60
      • BP >140/90
      • Clinical Features
        • unilateral weakness (+2); isolated speech (+1)
      • Duration
        • 10-59 (+1)
        • >60 (+2)
      • Diabetes
    • Note two or more in a week is automatic high risk as per NICE no matter what the score
  • The risk levels in NICE correspond to the urgency of follow up but all should get 300mg of aspirin (not 75)
  • Investigations in TIA
    • MRI preferred
    • image the carotids (nil preference stated)

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Indications for imaging in acute stroke?

  • indications for imaging
    • reperfusion candidate
    • on anticoagulation/bleeding tendency
    • GCS<13
    • progressive or fluctuating symptoms
    • severe headache
    • papilloedema, neck stiffness
When should tPA be given?
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  • up to 4.5 hrs
  • they have a good section on resources required to do this
  • BP should be lowered below 185/110

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Discuss venous thrombosis, dissection and decompressive craniectomy in stroke

  • Stroke from venous sinus thrombosis
    • full anticoagulation recommended
  • Stroke from dissection
    • anti platelet or anticoagulant
    • NICE states preferably as part of a trial because we honestly don’t know which is better
  • Decompressive craniectomy in stroke
    • referral should be within 24 hrs of onset
    • age<60
    • MCA with NIHSS>15
    • reduced LOC
    • CT signs of >50% MCA terriory infarct

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What is the ROSIER score?

(0 or less implies stroke unlikely)

  • Asymmetric facial weakness +1
  • Asymmetrical arm weakness +1
  • Assymetrical leg weakness +1
  • Speech disturbance +1
  • Visual field deficit +1
  • LOC/Syncope -1
  • Seizure -1

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