doyoudig
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history consistent with TIA for 3 hour , focal neurological sign is present , history also suggestive you chest pain , palpitaiton and dyspnea ........what is the next ........
a. EKG
b. CT
c. give aspirin
d. give thrombolytic
e.cardiac enzyme
sorry for not having detail information and ans........: )
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| tongsaa
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D...TIA within 3 hours...thrombolytics shud be initiated..
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| doyoudig
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for full blown stroke, u use Thrombolytics, but not in TIA?
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| wywywy2006
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I think EKG is the next to rule out any lethal cardiac problem.
This TIA may be induced by atrial arrythemia....
Then, we should give anticoagluant
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| dr_arc
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h/o TIA= potential for stroke.
usu bcos of carotid art thrombosis
first do a CTscan , then carotid doplers since most emoli originate form there
also in this pt, examn shows focal neurological deficit so a diagnosis of TIA cannot be made. Diagnose TIA only if all symptoms clear off within 24 hrs.
anyway first do a ct scan, plain.will show ishaemia if present, and will help rule out hemmorhage.
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| dr in trouble
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The next step i guess is to do EKG to rule out MI, u canont give thrombolytics for TIA because they shud resolve within 24 hrs without Rx,CT scan is to rule out bleeding and if u are sure that it is TIA then no need to do CT or MRI, but the point is that if focal neurological signs are there since 3 hrs ,u cannot say that it is TIA until it reolves within 24 hrs, there is no history of headache whih is likely a case in hemorrhagic stroke.
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| doyoudig
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The next step i guess is to do EKG to rule out MI, u canont give thrombolytics for TIA because they shud resolve within 24 hrs without Rx,CT scan is to rule out bleeding and if u are sure that it is TIA then no need to do CT or MRI, but the point is that if focal neurological signs are there since 3 hrs ,u cannot say that it is TIA until it reolves within 24 hrs, there is no history of headache whih is likely a case in hemorrhagic stroke
drintrouble
so if TIA - no need for CT, so u go straight for ECG or Carotid Doppler then give 2ndary prevention w/ antiplatetelts is.s aspririn?
I alwasy thought CT is done regardless of TIA or Full blown Stroke??
Can u pls guide me on workup of a Pt w/ TIA that resolved vs Stroke n pt presents w/ current Focal Neuro probls. You help is appreciated
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| mytime
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HOOOOOOOOO! I was abt to post my answer and went ohhhhhhhhh! I already did! Kept scratching my head as to when I did it?  Then I see.....
DR IN TROUBLE!!!!!!!!!!  Who might seriously be!   
OK my answer was meant to be EKG too. Had a patient who came with evolving stoke and when in the ED he had a heart attack so I guess we as doctors sud rule out that first.
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| doyoudig
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Normally TIA resolves in less that 24 hrs, so here pt has a 3 hr Hx consistent w/ TIA still presenting with focal neuro problems. I guess EKG is correct as arrythmia will kill Pt by the time we do CT Scan
This was areal exam qestion but culd not remember all details
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| njemt369
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The FIRST Step is to GIVE ASPIRIN!!! I gaurantee that... even before the ECG because it is fast easy and not contraindicated for any reason.
After Aspitin I would do ECG
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| doyoudig
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agree w/u njemt369
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| dr in trouble
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I think u cannot give aspirin if there are focal neurological signs without doing CTscan thus rule out hemorrhage. The qs is that if u r sure or the qs is asking u about the management of TIA then it cud be aspirin. i searched on internet and find the following info.
Transient ischemic attacks (TIAs) are warning episodes predicting that such patients are at high risk for stroke which potentially could be life-threatening or leave an individual with substantial disability. TIAs result from large or small vessel disease, cardiogenic embolic events and hematological abnormalities. The patient's past and current medical history provides necessary clues suggesting which investigational tests should be conducted. Every patient presenting with a TIA should have a total blood count, electrocardiogram, and a brain imaging study. Patients with anterior circulation symptoms should undergo noninvasive carotid testing, usually by carotid duplex ultrasonography, to determine if there is a surgically remediable carotid stenosis. Patients with posterior circulation TIAs should undergo magnetic resonance angiography (MRA) or a conventional arteriogram which, if positive, may be an indication for anti-platelet or anticoagulation therapy. Other testing depends on the presumptive etiology of the TIA. In general, a TIA should be considered as a serious warning of impending stroke that requires rapid and efficient investigations to define and remedy the reasons for the cerebral ischemic events.
TIAs by definition may last up to 24 h, but usually are self-terminating after a few minutes. They are a serious warning of possible future strokes that may result in substantial morbidity and mortality. Once TIAs are diagnosed, the major goal is to reduce the risk of future strokes. Patients with TIAs usually present in the Emergency Room or doctor's office. They may seek immediate medical care or relate the history of the TIA during a routine visit. As soon as a diagnosis of a TIA is considered, a careful past and current medical history should be taken to substantiate the diagnosis. Conditions which mimic TIAs need to enter into the differential diagnosis and, if necessary, be ruled out. For example, a Todd's transient paralysis can follow a partial focal seizure. Migraine auras may also mimic TIAs, particularly in the elderly. Any space-occupying lesions and arteriovenous malfunction may first present with a TIA-like complaint. Peripheral nerve disease must be recognized since it can cause transient weakness and/or numbness affecting one limb.
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| khorshid
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So is it aspirin, ECG, CT?
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| dr in trouble
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i will go for ECG first, but the qs is inco.mplete, not reaching on any final decision
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| Justice
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EKG
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| njemt369
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Aspirin has no contraindications... not even Hemorrhagic stroke... I scored 256/99 on Step 2 CK...
I may be wrong, but I believe I am right... please correct me if I am wrong. thanks
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| salo
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i would 1st chk his BP sounds like malignant htn ...whatever !! with given info ekg of course !!
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| starcraftbw
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Do CT-scan next.
>why not EKG or cardiac enzymes? cuz if pt had emboli stroke --> focal deficit would not go away
>NO ASA, thrombolytic: you don't know if pt has intracranial bleeding or not
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| elitoki
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I think Answer is C. ASA.
Any type of Chest Pain should give ASA as first treatment.
So, if this Q. tells you chest pain as a Symptom, then ASA would be the answer, then do EKG to rule out angina or MI. The cardiac enzyme will not elevated until after 4 hr.
Also, this pte has other dx, that is TIA, and the first approach that we have to do is give ASA as first tx.
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| peraspera
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Emergency Department Care:
Supporting the airway and restoring perfusion or a stable rhythm are tenets of emergency care. By definition, patients with TIA are hemodynamically stable and able to support their own airways. Rapid assessment excludes those conditions that mimic a TIA such as hypoglycemia or an intracranial hemorrhage.
Vital signs must be obtained promptly and addressed as indicated.
Place the patient on a cardiac monitor and a pulse oximeter and establish an IV line (if one has not already been established by EMS).
Obtain a fingerstick glucose level and treat accordingly.
#1.Obtain an ECG and initiate treatment for symptomatic rhythms or evidence of ischemia.
#2.Rapid pharmacologic intervention in patients with TIAs caused by atherosclerosis is limited to antiplatelet or anticoagulation therapy. Treatment for TIA caused by dysrhythmias, extracranial embolisms, or metabolic disorders can require a specific treatment dictated by the cause.
Emergency physicians may be in the unique position to limit the progression of the TIA. Emergency physicians must know when to initiate single-agent antiplatelet therapy, adjust existing antiplatelet therapy, initiate anticoagulant therapy, or advance other pharmacologic treatment. Recent therapeutic intervention and outcome studies have advanced the understanding of TIA. Patient outcomes are no longer clumped with "all stroke patients." We appreciate unique TIA therapy is available. Emergency physicians must closely examine the therapeutic options for patients who experience a TIA.
If the patient is already taking aspirin, he or she may be a candidate to take aspirin plus extended-release dipyridamole. Recent reports suggest that this combination is more effective than aspirin alone at preventing stroke, particularly in patients at high risk for stroke. Although dual therapy carries the increased risk of GI bleeding.
A possible benefit may exist by administering antiplatelet therapy with aspirin and clopidogrel to patients who are showering the cerebral circulation with microemboli.
Several new oral anticoagulant medications, including ximelagatran, are in the final stages of clinical trials for use in the prophylaxis of ischemic thromboembolic stroke. Once approved for use, the potential of such drugs in the arena of stroke treatment is significant. Emergency physicians interested in keeping abreast of the challenging field of post-TIA therapy must closely follow the results of the PRoFESS (the Prevention Regimen for Effectively Avoiding Second Strokes) study. This is a randomized, double blind interventional study designed to compare 25 mg aspirin/200 mg extended-release dipyridamole with clopidogrel monotherapy and to compare telmisartan with placebo in the prevention of recurrent stroke.
Drug Category: Antiplatelet agents -- These agents inhibit platelet function by blocking cyclooxygenase and subsequent aggregation. Antiplatelet therapy is demonstrated to be superior to placebo in reducing rates of subsequent infarction and death in patients who have experienced multiple TIAs. Compared to control groups, patients with a history of TIAs who take antiplatelet therapy have significant reductions in rates of fatal stroke, fatal myocardial infarction, and vascular death. Patients presenting with thromboembolic complications are to be anticoagulated promptly if they do not have a therapeutic international normalized ratio (INR) of 2.5-3.5.Drug Name
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| usmle-china
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The UW says all TIA, especially recurrent TIA should give Aspirin
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| Dr.D
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Aspirin, There are no contraindication in this patient as according to the information provided. Next I will go for EKG.
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| doyoudig
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thx guys for all the great input, just as star decribed it I also have come to the conslusion that
next Step --> CT to r/o bleed from ichemia -- alsways 1st
then decide what to give.....depending on results of CT
then --> Investigate the cause such as Heart related......
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| Justice
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njemt369 wrote:
I scored 256/99 on Step 2 CK...
Very strong argument... Lot's of Ppl have quite the same result, so...
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| dr.roh
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step 2 secrets...says to order CT-scan first before giving ASA
*because according to the book....ASA is contraindicated in hemorrhagic stroke....
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