Rosen & Barkin's 5-Minute Emergency Medicine Consult (611 page)

• Alteplase (tPA): 0.9 mg/kg IV, max. 90 mg, over 1 hr:
  
  • Give 10% of dose as a bolus over 1 min.
    
  • Immediately follow with the remainder, infused over the subsequent 59 min
    
• Labetalol: 10 mg IV over 1–2 min; then, if needed:
  
  • Repeat or double dose q10–20min up to a max. of 300 mg, or
    
  • Start a drip at 2–8 mg/min
    
• Nicardipine: 5 mg/h as a drip; titrate upward in 2.5 mg/h increments every 5 min, up to a max. of 15 mg/h
  

• Nitroprusside: 0.5–1 μg/kg/min, continuous IV drip, titrated to BP parameters
  
• Cryoprecipitate and fibrinogen: 6–8 U IV
  
• Platelets: 6–8 U IV
  

FOLLOW-UP

All patients given reperfusion therapy for a CVA should be admitted to an intensive care setting for frequent neurologic checks and vital sign assessments.

Not applicable

• Be specific in eliciting time of onset; patient or family may note “time of onset” as the time the stroke was 1st recognized (e.g., upon awakening from sleep)
  
• tPA has a plasma half-life of <5 min; a delay between bolus and infusion, or pause in the infusion, may result in a decrease in plasma levels and effectiveness
  
• “Time is brain” (and hemorrhage); initiate treatment as quickly as possible, even if the patient presents early
  

• Jauch EC, Cucchiara B, Adeoye O, et al. Part 11: Adult stroke: 2010 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care.
  Circulation.
  2010;122:S818–S828.
  
• Lansberg MG, O’Donnell MJ, Khatri P, et al. Antithrombotic and thrombolytic therapy for ischemic stroke: Antithrombotic Therapy and Prevention of Thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines.
  Chest.
  2012;141:e601S–e636S.
  
• Lees KR, Bluhmki E, von Kummer R, et al. Time to treatment with intravenous alteplase and outcome in stroke: An updated pooled analysis of ECASS, ATLANTIS, NINDS, and EPITHET trials.
  Lancet.
  2010;375:1695–1703.
  

See Also (Topic, Algorithm, Electronic Media Element)

• Cerebral Vascular Accident
  
• Transient Ischemic Attack
  

CODES

• 434.01 Cerebral thrombosis with cerebral infarction
  
• 434.11 Cerebral embolism with cerebral infarction
  
• 434.91 Cerebral artery occlusion, unspecified with cerebral infarction
  

BASICS

Respiratory distress, shortness of breath, or dyspnea is a common complaint for patients presenting to the ED.

• Upper airway obstruction:
  
  • Epiglottitis
    
  • Croup syndromes
    
  • Laryngotracheobronchitis
    
  • Foreign body
    
  • Angioedema
    
  • Retropharyngeal abscess
    
• Cardiovascular:
  
  • Pulmonary edema/CHF
    
  • Dysrhythmias
    
  • Cardiac ischemia
    
  • Pulmonary embolus
    
  • Pericarditis
    
  • Tamponade
    
  • Air embolism
    
• Pulmonary:
  
  • Asthma
    
  • Chronic obstructive pulmonary disease (COPD)/emphysema
    
  • Pneumonia
    
  • Influenza
    
  • Bronchiolitis
    
  • Aspiration
    
  • Adult respiratory distress syndrome (ARDS)
    
  • Pulmonary edema
    
  • Pleural effusion
    
  • Toxic inhalation injury
    
• Trauma:
  
  • Pneumothorax
    
  • Tension pneumothorax
    
  • Rib fractures
    
  • Pulmonary contusion
    
  • Fat embolism with long-bone fractures
    
• Neuromuscular:
  
  • Guillain–Barré syndrome
    
  • Myasthenia gravis
    
• Metabolic/systemic/toxic:
  
  • Anaphylaxis
    
  • Anemia
    
  • Acidosis
    
  • Hyperthyroidism
    
  • Sepsis
    
  • Septic emboli from IV drug use or infected indwelling lines
    
  • Salicylate intoxication
    
  • Drug overdose
    
  • Amphetamines
    
  • Cocaine
    
  • Sympathomimetic
    
  • Obesity
    
• Psychogenic:
  
  • Anxiety disorder
    
  • Hyperventilation syndrome
    
• Bioterrorist threats:
  
  • Anthrax
    
  • Pneumonic plague
    
  • Tularemia
    
  • Viral hemorrhagic fevers
    

• Respiratory failure is the most common cause of cardiac arrest in infants.
  
• Croup syndromes include:
  
  • Viral
    
  • Spasmodic
    
  • Bacterial
    
  • Congenital defects
    
  • Noninflammatory causes (foreign body, gastroesophageal reflux, trauma, tumors)
    
• Most common cause of upper airway obstruction:
  
  • <6 mo: Congenital laryngomalacia
    
  • >6 mo: Viral croup
    
• Epiglottitis:
  
  • Highest incidence at ages 2–4 yr
    
  • Abrupt onset
    
  • Fever
    
  • Respiratory distress and stridor
    
  • Difficulty swallowing oral secretions
    
  • Restlessness and anxiety
    

• Amniotic fluid embolism during or after delivery
  
• Septic embolism from septic abortion or postpartum uterine infection
  

DIAGNOSIS

• Tachypnea
  
• Dyspnea
  
• Tachycardia
  
• Anxiety
  
• Diaphoresis
  
• Cough (“barking,” productive)
  
• Stridor
  
• Hoarse voice
  
• Difficulty swallowing or handling oral secretions
  
• Upper airway rhonchi (wheezes)
  
• Lower airway crackles (rales)
  
• Increased work of breathing
  
• Accessory and intercostal muscle use
  
• Hypoxemia
  
• Hypocapnia or hypercapnia if severe
  
• Respiratory acidosis
  
• Cyanosis
  
• Lethargy, then obtundation
  

• Previous history of asthma, COPD, cardiac disease, or dysrhythmia, CHF, foreign-body aspiration, or toxic exposure
  
• Recent fever or upper respiratory tract infection, cough, sputum production, sore throat, systemic disease, anxiety disorder
  
• Recent chest or long-bone trauma
  
• IV drug use or indwelling catheters
  
• Recurrent fevers, night sweats, weight loss
  

• Observe: Mental status, level of distress, work of breathing, jugular venous pressure, skin color
  
• Feel/palpate: Distal pulses, heart perioperative MI, chest wall, peripheral edema
  
• Percuss: Lungs for dullness or resonance, abdominal distention, or hepatomegaly
  
• Auscultate: Heart sounds, murmurs, lung wheezes or crackles, neck for upper airway stridor, abdomen bowel sounds