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Tom Meyer,MSN,APRN,BC,CCRN,CNS
Clinical Assistant Professor,Adult Health
University ofSouth Alabama,College ofNursing Mobile,Alabama
20.Measures ofOxygenation and Ventilation,21.The Chest X-Ray,33.Oxygen Supplementation,34.Mechanical Ventilatory Support
Diantha D.Miller,MSN,APRN,BC,ACNP,PNP
Adjunct Faculty
University ofSouth Alabama Mobile,Alabama;
Nurse Practitioner
Laser and Skin Care Center ofMobile Mobile,Alabama
70.Eye,Ear,Nose,and Throat Disorders
Sally K.Miller,PhD,APRN,BC,ACNP,ANP,GNP,FAANP
Chair,Department ofPhysiologic Nursing
University ofLas Vegas School ofNursing Las Vegas,Nevada
67.Autoimmune Diseases,85.Managing the Surgical Patient
Charlene M.Myers,MSN,APRN,BC,ACNP,CCRN
Clinical Assistant Professor
Program Coordinator,Adult Acute Care Nurse Practitioner Program
University ofSouth Alabama,College ofNursing Mobile,Alabama
1.Cerebrovascular Accidents: Brain Attack,2.Structural Abnormalities,3.Peripheral Neuropathies,4.Neurologic Trauma,5.Central Nervous System Disorders,6.Seizure Disorders,7.Dementia,23.Pulmonary Function Testing,28.Chest Wall and Secondary Pleural Disorders,35.Peptic Ulcer Disease,36.Liver Disease,37.Biliary Dysfunction,38.Inflammatory Gastrointestinal Disorders,39.Anatomic Intestinal Disorders,40.Gastrointestinal Bleeding,41.Urinary Tract Infections,42.Renal Insufficiency and Failure,43.Benign Prostatic Hyperplasia,44.Renal Artery Stenosis, 45.Nephrolithiasis,75.Management ofthe Patient in Shock
Sandra J.Ogawa,MSN,APRN,BC,ACNP
Acute Care Nurse Practitioner,Thoracic Surgery
Assistant Coordinator,Esophageal Disease Center Heart Institute at St.Joseph’s Medical Center Phoenix,Arizona
84.Hospital Admission Considerations
Marian Elizabeth Peters,MSN,RN,WHNP,CNS
Clinical Assistant Professor
University ofSouth Alabama Mobile,Alabama
69.Ectopic Pregnancy and Sexually Transmitted Infections
Luisa Maria Schulman,MSN,RN,ANP-C,CCRN
Adult Nurse Practitioner,Private Practice Pasadena,California; Lecturer
California State University,Los Angeles School ofNursing Los Angeles,California
66.HIV/AIDS and Opportunistic Infections
Martha N.Surline,MS Director ofStudent Services
University ofSouth Alabama,College ofNursing Mobile,Alabama
76.Nutritional Considerations
Paula K.Vuckovich,PhD,APRN,BC
Assistant Professor,School ofNursing
California State University Los Angeles,California; ReliefSupervisor
Aurora Las Encinas Hospital Pasadena,California
74.Psychosocial Problems in Acute Care
Elizabeth A.Vande Waa,PhD
Associate Professor,Department ofAdult Health
University ofSouth Alabama,College ofNursing Mobile,Alabama
78.Poisoning and Drug Toxicities
John A.Vande Waa,DO,PhD
Associate Professor ofMedicine
Consultant in Infectious Diseases,Immunodeficiencies,Traveler’s Health University ofSouth Alabama Mobile,Alabama
80.Infections
Colleen R.Walsh,RN,MSN,APRN,BC,ACNP,ONC,CS
Faculty,Graduate Nursing
University ofSouthern Indiana,College ofNursing and Health Professions
Evansville,Indiana;
Acute Care Nurse Practitioner
Jenkins Community Hospital
Jenkins,Kentucky
54.Arthritis,55.Subluxations and Dislocations,56.Soft Tissue Injury,57.Fractures, 58.Compartment Syndrome,59.Back Pain Syndromes,65.Other Common Cancers
Gail Washington,DNS,RN
Assistant Professor
California State University,Los Angeles
School ofNursing
Los Angeles,California
69.Ectopic Pregnancy and Sexually Transmitted Infections
Carolyn Mathis White,JD,MSN,APRN,BC,FNP,PNP,CCRN
Clinical Assistant Professor
University ofSouth Alabama
Mobile,Alabama;
Nurse Practitioner
Victory Health Partners
Mobile,Alabama
70.Eye,Ear,Nose,and Throat Disorders; 86.Guidelines for Health Promotion and Screening
Kimberly A.Williams,DNSc,APRN,BC,ANP,PMHNP
Assistant Professor
University ofSouth Alabama,College ofNursing Mobile,Alabama;
Adult Health Nurse Practitioner
GulfCoast Medical Center,Biloxi,Mississippi
Garden Park Medical Center,Gulfport,Mississippi
Hancock Medical Center,Bay St.Louis,Mississippi
Memorial Hospital,Gulfport,Mississippi
Ocean Springs Hospital,Ocean Springs,Mississippi
Select Specialty Hospital,Gulfport,Mississippi
88.Immunization Recommendations
Reviewers
Nancy J.Bekken,RN,MSN,CCRN
Spectrum Health Grand Rapids,Michigan
Susan Duhon-Johnston,MSN,FNP-BC
Hospital-based Internal Medicine
Ochsner Health System
New Orleans,Louisiana
Lynn S.Eckhardt,BSN,MSN,NP
Director ofDementia Clinic Neurology Department
Ochsner Health System
New Orleans,Louisiana
Pamela L.Isbell,MSN,CEN
StaffNurse,ReliefCharge Nurse
Orlando Regional Medical Center Orlando,Florida
Suzanne Lazare-Ellis,RN,MSN, CCRN,CNS
Intensive Care Unit StaffNurse
San Francisco VA Medical Center
San Francisco,California
Allyson E.Mobley,MSN,CRNP
Neurology
Alabama Neurological Institute Birmingham,Alabama
Ted Rigney,MS,RNP,CCRN,ACNP Assistant Director Nurse Practitioner Program
University ofArizona College of Nursing Tucson,Arizona
Nancy Evans Stoner,RN,MSN Hospital ofthe University of Pennsylvania Clinical Nutrition Support Service Philadelphia,Pennsylvania
Scott Carter Thigpen,RN,MSN, CCRN,CEN
Assistant Professor ofNursing South Georgia College Douglas,Georgia
Joseph E.Williams,RN,MSN, ACNP-C,ANP-C
Lead Nurse Practitioner Hospitals Division,Department of Internal Medicine
Ochsner Health System New Orleans,Louisiana
Section ONE
Contents
Management of Patients With Neurologic Disorders
1 Cerebrovascular Accidents:Brain Attack, 3
CHARLENE M.MYERS
TIA—Transient Ischemic Attack, 3
Stroke/Brain Attack, 8
Ischemic Stroke, 9
Hemorrhagic Stroke, 14
2 Structural Abnormalities, 23
CHARLENE M.MYERS
Aneurysm, 23
Hydrocephalus, 27
Space-Occupying Lesions (Brain Tumors), 28
3 Peripheral Neuropathies,34
CHARLENE M.MYERS
Guillain-Barré Syndrome, 34
Myasthenia Gravis, 38
4 Neurologic Trauma, 43
CHARLENE M.MYERS
Head Trauma/Traumatic Brain Injury, 43
Spinal Cord Trauma, 51
5 Central Nervous System Disorders, 63
CHARLENE M.MYERS
Meningitis, 63
Cerebral Abscess, 67
Encephalitis, 68
Encephalopathy, 70
6 Seizure Disorders, 72
CHARLENE M.MYERS
Dementia, 82
CHARLENE M.MYERS
Section TWO
Management of Patients With Cardiovascular Disorders
8 Cardiovascular Assessment, 91
THOMAS W.BARKLEY,JR.
9 Hypertension, 95
THOMAS W.BARKLEY,JR.AND JENNIFER RAMOS JAVIER
10 Coronary Artery Disease and Hyperlipidemia, 109
THOMAS W.BARKLEY,JR.AND JENNIFER RAMOS JAVIER
11 Angina and Myocardial Infarction, 121
THOMAS W.BARKLEY,JR.
Fibrinolytic/Thrombolytic Therapy, 135
Percutaneous Transluminal Coronary Angioplasty (PTCA)/Percutaneous
Coronary Intervention (PCI), 138
Coronary Artery Bypass Graft (CABG) Surgery, 139
Cardiac Tamponade, 141
12
Adjunct Equipment/Devices, 144
THOMAS W.BARKLEY,JR.
Intra-aortic Balloon Pump, 144
Pacemakers, 147
Automatic Internal Cardioverter/Defibrillator (AICD), 154
13 Peripheral Vascular Disease, 157
THOMAS W.BARKLEY,JR.
Peripheral Vascular Disease:Overview, 157
Specific Disorders, 158
Venous Disease, 160
14 Inflammatory Cardiac Diseases, 163
THOMAS W.BARKLEY,JR.
Pericarditis, 163
Endocarditis, 165
15 Heart Failure,169
THOMAS W.BARKLEY,JR.
16 Valvular Disease, 188
THOMAS W.BARKLEY,JR.
17 Cardiomyopathy,193
THOMAS W.BARKLEY,JR.
18 Ectopy and Arrhythmia Emergencies, 198
ROBERT DEMETRIC MARTIN AND THOMAS W.BARKLEY,JR.
Common Cardiac Rhythms/Arrhythmias and Treatment, 198
Algorithms for Cardiac Emergencies, 228
Section THREE
Management of Pulmonary Disorders
19 Diagnostic Concepts ofOxygenation and Ventilation, 231
JUDITH AZOK
Pulmonary Perfusion, 231
Ventilation, 232
Alveolar Diffusion, 233
Oxygen Transport in the Circulation, 234
20 Measures ofOxygenation and Ventilation, 237
TOM MEYER
Oxygenation and Ventilation, 237
Pulse Oximetry, 239
Pulmonary Artery (PA) Catheterization, 240
Fluid Resuscitation, 243
21 The Chest X-Ray, 246
TOM MEYER
General Principles, 246
Reading a Chest X-Ray, 247
Specific Disease Entities, 250
22 Differential Diagnosis ofPulmonary Disorders, 253
THOMAS W.BARKLEY,JR.
Symptom Possibilities and Origins, 253
Risk Factors and Comorbidities, 255
Exposure to Environmental Risks:Work and Medications, 256 Exposure to Infectious Agents, 256
23 Pulmonary Function Testing, 259
THOMAS W.BARKLEY,JR.AND CHARLENE M.MYERS
24 Obstructive (Ventilatory) Lung Diseases, 265
THOMAS W.BARKLEY,JR.,DENISE R.FORTENBERRY,AND GLADYS D.FIELD
Chronic Obstructive Pulmonary Disease (COPD), 265
Emphysema, 270
Chronic Bronchitis, 272
Asthma, 272
Bronchiectasis, 275
Obstructive Airway Lesions, 275
25 Restrictive (Inflammatory) Lung Diseases and Congestive Heart Failure/Pulmonary Edema, 276
THOMAS W.BARKLEY,JR.
Pneumonia, 276
Tuberculosis (TB), 279
Acute Respiratory Distress Syndrome (ARDS)/Acute Lung Injury, 281
Idiopathic Pulmonary Fibrosis (IPF), 284
Sarcoidosis, 286
CHF/ Cardiogenic Pulmonary Edema, 288
26
Pathophysiologically Derived Therapy for Respiratory Dysfunction, 292
THOMAS W.BARKLEY,JR.
Rationale , 292
Good and Bad Medicine for the Lungs, 293
27 Pulmonary Hypertension and Pulmonary Vascular Disorders, 296
THOMAS W.BARKLEY,JR.
Pulmonary Hypertension, 296
Pulmonary Vascular Disorders, 298
28
Chest Wall and Secondary Pleural Disorders, 302
THOMAS W.BARKLEY,JR.AND CHARLENE M.MYERS
Disorders ofthe Chest Wall, 302
Pleural Disorders, 303
29
Respiratory Failure, 307
THOMAS W.BARKLEY,JR.
Definitions and Concepts, 307
Ventilatory Failure, 308
Respiratory Failure, 309
30 Pneumothorax, 310
JUDITH AZOK
31 Lower Respiratory Tract Pathogens, 313
32
THOMAS W.BARKLEY,JR.
Obstructive Sleep Apnea, 323
THOMAS W.BARKLEY,JR.
Characteristics ofBreathing and Sleep, 323
Obstructive Sleep Apnea (OSA), 323
33 Oxygen Supplementation, 327
TOM MEYER
Basic Principles ofOxygen Supplementation, 327
Facilitation ofVentilation , 329
Devices for Oxygen Supplementation, 332
34 Mechanical Ventilatory Support, 335
TOM MEYER
Indications for Mechanical Ventilation, 335
General Principles ofVentilation, 336
Variables for Mechanical Ventilators, 337
Modes ofMechanical Ventilation, 339
Special Aspects ofVentilator Management, 340
Section FOUR
Management of Patients With Gastrointestinal Disorders
35 Peptic Ulcer Disease, 347
CHARLENE M.MYERS
Peptic Ulcer Disease (PUD), 347
Gastroesophageal Reflux Disease (GERD), 355
36 Liver Disease, 362
CHARLENE M.MYERS
Hepatitis, 362
Hepatic Failure, 368
37 Biliary Dysfunction, 374
CHARLENE M.MYERS
Cholecystitis, 374
Acute Pancreatitis, 377
38 Inflammatory Gastrointestinal Disorders, 382
CHARLENE M.MYERS
Diverticulitis, 382
Ulcerative Colitis, 384
Peritonitis, 387
Appendicitis, 389
39 Anatomic Intestinal Disorders, 392
CHARLENE M.MYERS
Small-Bowel Obstruction, 392
Mesenteric Ischemia, 394
40 Gastrointestinal Bleeding
CHARLENE M.MYERS
Esophageal Varices, 397
Upper Gastrointestinal Bleeding, 400
Lower Gastrointestinal Bleeding, 402
Section FIVE
Management of Patients With Genitourinary Disorders
41 Urinary Tract Infections, 409
CHARLENE M.MYERS
42 Renal Insufficiency and Failure, 415
CHARLENE M.MYERS
Acute Renal Failure, 415
Chronic Renal Failure, 423
Modification ofDrug Dosages, 428
43 Benign Prostatic Hyperplasia, 430
CHARLENE M.MYERS
44
Renal Artery Stenosis, 435
CHARLENE M.MYERS
45 Nephrolithiasis, 439
CHARLENE M.MYERS
Renal Calculi—Nephrolithiasis, 439
Section SIX
Management of
Patients With Endocrine Disorders
46 Diabetes Mellitus, 447
THOMAS W.BARKLEY,JR.AND HECTOR ALVAREZ
Diabetes Mellitus:Overview ofPrinciples, 447
Type 1 Diabetes Mellitus, 451
Type 2 Diabetes Mellitus, 455
47 Diabetic Emergencies, 463
THOMAS W.BARKLEY,JR.AND HECTOR ALVAREZ
Diabetic Ketoacidosis (DKA), 463
Hyperosmolar Hyperglycemic Nonketosis (HHNK), 465
Hypoglycemia, 467
48 Thyroid Disease, 469
THOMAS W.BARKLEY,JR.
Hyperthyroidism (Thyrotoxicosis), 469
Thyroid Storm (Thyrotoxic Crisis), 471
Hypothyroidism (Myxedema Coma), 472
49 Cushing’s Syndrome, 476
THOMAS W.BARKLEY,JR.
50 Primary Adrenocortical Insufficiency (Addison’s Disease) and Adrenal Crisis, 479
THOMAS W.BARKLEY,JR.
51 Pheochromocytoma, 483
THOMAS W.BARKLEY,JR.
52 Syndrome ofInappropriate Antidiuretic Hormone, 487
THOMAS W.BARKLEY,JR.
53 Diabetes Insipidus, 490
THOMAS W.BARKLEY,JR.
Section SEVEN
Management of Musculoskeletal Disorders
54 Arthritis, 495
COLLEEN R.WALSH
Osteoarthritis, 495
Rheumatoid Arthritis, 498
Gout, 512
55 Subluxations and Dislocations, 515
COLLEEN R.WALSH
Subluxations, 515
Dislocations, 516
56 Soft Tissue Injury, 519
COLLEEN R.WALSH
57 Fractures, 524
COLLEEN R.WALSH
58 Compartment Syndrome, 529
COLLEEN R.WALSH
59 Back Pain Syndromes, 532
COLLEEN R.WALSH
Low Back Pain, 532
Herniated Disk, 535
Section EIGHT
Management of Patients With Hematologic Disorders
60 Anemias, 541
SYLVIA RUSSELL LOVE
Initial Anemia Workup, 541
Pernicious Anemia, 543
Vitamin B12 Deficiency, 545
Iron Deficiency, 546
Folic Acid Deficiency, 549
Anemia ofChronic Disease (ACD), 551
Thalassemia, 553
61 Sickle Cell Disease/Crisis, 557
SYLVIA RUSSELL LOVE
62 Coagulopathies, 562
SYLVIA RUSSELL LOVE
Idiopathic Thrombocytopenic Purpura (ITP), 562
Heparin-Induced Thrombocytopenia (HIT), 564
Disseminated Intravascular Coagulation (DIC), 566
Section NINE
Management of Patients With Oncologic Disorders
63 Leukemias, 573
SYLVIA RUSSELL LOVE
Acute Lymphocytic Leukemia (ALL), 573
Acute Myelogenous Leukemia (AML), 576
Chronic Lymphocytic Leukemia (CLL), 578
Chronic Myelogenous Leukemia (CML), 580
64 Lymphoma, 584
SYLVIA RUSSELL LOVE
Staging, 584
Non-Hodgkin’s Lymphoma (NHL), 588
Hodgkin’s Lymphoma (HL), 590
65 Other Common Cancers, 595
COLLEEN R.WALSH
Lung Cancer, 595
Colorectal Cancer, 599
Breast Cancer, 601
Cervical Cancer, 605
Ovarian Cancer, 607
Prostate Cancer, 610
Bladder Cancer, 613
Endometrial Cancer, 615
Section TEN
Management of Patients With Immunologic Disorders
66 HIV/AIDS and Opportunistic Infections, 621
THOMAS W.BARKLEY,JR.,LUISA MARIA SHULMAN,AND JESSE A.LOPEZ
HIV Infection, 621
Documenting HIV Disease, 622
Clinical Evaluation ofthe Patient at Risk for HIV Infection, 624
Initiation ofHighly Active Antiretroviral Therapy (HAART), 626
Antiretroviral Therapy (HAART), 626
Prophylaxis Against Opportunistic Infections, 628
AIDSIndicator Conditions, 629
67 Autoimmune Diseases,632
SALLY K.MILLER
Giant Cell Arteritis, 632
Systemic Lupus Erythematosus (SLE), 634
SECTION ELEVEN
Management of Patients With Miscellaneous Health Problems
68 Integumentary Disorders, 639
SYLVIA RUSSELL LOVE
General, 639
Dermatitis Medicamentosa (Drug Eruption), 642
Cellulitis, 645
Herpes Zoster (Shingles), 647
Skin Cancer, 650
Melanoma, 652
69 Ectopic Pregnancy and Sexually Transmitted Infections, 655
MARIAN
ELIZABETH PETERS AND GAIL WASHINGTON
Ectopic Pregnancy, 655
Pelvic Inflammatory Disease (PID) Salpingitis, 658
Chlamydia Trachomatis Infection, 661
Gonorrhea, 664
Herpes, 667
Syphilis, 670
70 Eye,Ear,Nose,and Throat Disorders, 674
CAROLYN MATHIS WHITE AND DIANTHA D.MILLER
Conjunctivitis, 674
Corneal Abrasion, 677
Diabetic Retinopathy, 678
Retinal Detachment, 679
Central and Branch Retinal Artery Obstruction, 680
Glaucoma, 681
Bell’s Palsy, 683
Otitis Externa, 684
Otitis Media, 685
Vertigo, 686
Allergic Rhinitis, 688
Epistaxis, 690
Sinusitis, 691
Pharyngitis, 692
Epiglottitis, 694
Temporomandibular Joint Disorder, 695
Trigeminal Neuralgia (TIC Douloureux), 696
71 Headache, 698
SYLVIA RUSSELL LOVE
Section TWELVE
Common Problems in Acute Care
72 Fever, 715
OTTO “JOEY”BONIN,JR.AND LORRIS J.BOUZIGARD
73 Pain, 724
SARA CLARKSON MAJORS
74 Psychosocial Problems in Acute Care, 740
PAULA K.VUCKOVICH
Violence, 740
Depression, 743
Substance Abuse, 746
Anxiety, 750
Crisis Intervention, 751
Grief, 752
Sexuality, 753
Delirium, 754
Acute Agitation (Psychosis Related to Mental Illness), 756
75 Management ofthe Patient in Shock, 760
CHARLENE M.MYERS
Shock, 760
Types ofShock, 770
Prevention, 788
76
Nutritional Considerations, 790
MARTHA N.SURLINE
Nutritional Assessment, 790
Ideal Body Weight (IDBW) Calculations, 791
Determining Nutritional Needs, 791
Food Guide Pyramid, 793
Nutritional Support, 794
77 Fluid,Electrolyte,and Acid-Base Imbalances, 799
R.MICHAEL CULPEPPER
Hyponatremia, 799
Hypernatremia, 803
Hypokalemia, 805
Hyperkalemia, 806
Hypocalcemia, 808
Hypercalcemia, 810
Hypomagnesemia, 812
Hypermagnesemia, 813
Hypophosphatemia, 814
Hyperphosphatemia, 815
Acid-Base Disorders, 816
Metabolic Acidosis, 817
Metabolic Alkalosis, 819
Respiratory Acidosis, 820
Respiratory Alkalosis, 822
Intravenous Fluid Management, 823
78 Poisoning and Drug Toxicities, 828
ELIZABETH A.VANDE WAA
Acetaminophen Toxicity, 828
Alcohol (Ethanol) Toxicity, 829
Antiarrhythmic Drug Overdose, 830
Barbiturate Overdose, 830
Benzodiazepine Overdose, 831
Beta Blocker Overdose, 831
Calcium Channel Blocker Overdose, 832
Carbon Monoxide Poisoning, 832
Digoxin Toxicity, 833
Lithium Toxicity, 833
Salicylate Toxicity, 834
Narcotic Toxicity, 834
Organophosphate (Insecticide) Poisoning, 835
Antipsychotic Toxicity, 835
Antidepressant Toxicity, 836
Stimulant Toxicity, 836
Theophylline Toxicity, 837
Anticoagulant Overdose, 837
Methanol Toxicity, 838
Ethylene Glycol Toxicity, 838
Bites and Stings, 839
79 Wound Management, 842
CATHERINE BLACHE
Types ofWounds—Definitions, 842
Key Factors in Delayed Healing, 842
Subjective Findings, 843
General Physical Examination Guidelines for Wound Assessment, 843
Wound-Specific Physical Examination Findings, 844
Laboratory/Diagnostic Findings, 845
Management, 846
Selected Treatment Options, 847
80 Infections, 851
JOHN A.VANDE WAA
Hospital-Acquired Infections, 851
Community-Acquired Infections, 858
81 Chest,Abdominal,and Eye Trauma, 863
THOMAS W.BARKLEY,JR.
Chest Trauma, 863
Abdominal Trauma, 867
Penetrating Eye Trauma, 870
82 Solid Organ Transplantation, 871
KIMBERLY RILEY BRYAN
Solid Organ Transplantation, 871
Immunosuppression and Organ Rejection, 872
Common Medical Complications in Solid Organ Transplantation, 875
Common Infections, 876
Kidney Transplantation, 878
Liver Transplantation, 879
Lung Transplantation, 880
Heart Transplantation, 881
Pancreas Transplantation, 882
Intestinal Transplantation, 883
83 Burns, 886
THOMAS W.BARKLEY,JR.
84
Hospital Admission Considerations, 890
SANDRA J.OGAWA AND THOMAS W.BARKLEY,JR.
History and Physical Examination (H&P), 890
Admission Orders, 895
Progress Note, 896
Presentation ofPatient, 897
Procedure Note, 897
Discharge Summary, 898
Prescriptions, 899
General Guidelines for Admission to an Intensive Care Unit (ICU), 899
General Guidelines for Discharge From an ICU, 901
85 Managing the Surgical Patient, 902
SALLY K.MILLER
Preoperative Assessment, 902
Postoperative Care, 907
Section THIRTEEN
Health Promotion
86 Guidelines for Health Promotion and Screening, 913
CAROLYN MATHIS WHITE
Visionary Plan for Health, 913
Prevention, 916
Prevention and Health Promotion in Clinical Practice, 917
87 Major Causes ofMortality in the United States, 931
BARBARA ANN SHELTON BROOME
Leading Causes ofDeath in the U.S., 931
Risk Assessment, 931
88 Immunization Recommendations, 939
KIMBERLY A.WILLIAMS
Immunization, 939
APPENDIX
2007 Asthma Guidelines,National Heart,Lung,and Blood Institute, 957
Cerebrovascular Accidents: Brain Attack
CHARLENE M.MYERS
Hemorrhagic stroke, 431
Ischemic stroke, 434.91
Stroke/brain attack, 434.91
Transient ischemic attack, 436
TIA—TRANSIENT ISCHEMIC ATTACK
I.Definition
A. Classic definition:sudden or rapid onset ofneurologic deficit caused by focal ischemia that lasts for a few minutes and resolves completely within 24 hours
B. Recently proposed revision ofclassic definition:briefepisode ofneurologic dysfunction caused by focal brain or retinal ischemia,with clinical symptoms typically lasting less than 1 hour and no evidence ofacute infarction
II.Etiology/incidence/prevalence
A. Incidence is 160/100,000;prevalence is 135/100,000.
B. Carotid or vertebral artery disease
C. Cardiac emboli as seen in arrhythmia (atrial fibrillation),myocardial infarction,congestive cardiomyopathy,and valvular disease
D. Hematologic causes
1. Red blood cell (RBC) disorders
a. Increased sludging
b. Decreased cerebral oxygenation such as in severe anemia
c. Polycythemia,sickle cell anemia
2. Platelet disorders
a. Thrombocytosis
b. Thrombocytopenia
3. Myeloproliferative disorders,leukemia with white blood cell (WBC) count greater than 150,000
4. Increased viscosity/hypercoagulable conditions
a. Antiphospholipid antibody syndrome (e.g.,lupus anticoagulant, anticardiolipin antibody)
b. Oral contraceptive use
c. Antithrombin III deficiency
d. Protein S and C deficiency
e. Tissue-type plasminogen activator (t-PA) and plasminogen deficiencies
f. Patients particularly at risk for a hypercoagulable state
i. Older than age 45
ii. History ofthrombolytic event
iii. History ofspontaneous abortion
iv. Related autoimmune conditions (e.g.,lupus)
v. Stroke ofunknown cause
vi. Family history ofthrombotic events
E. Intracranial causes
1. Brain tumor
2. Focal seizure
3. Hemorrhage
a. Subdural hematoma (SDH)
b. Subarachnoid hemorrhage (SAH)
c. Intracerebral hemorrhage (ICH),which may cause cerebrovascular dysfunction due to leakage ofblood outside the normal vessels
F. Subclavian steal syndrome
1. Localized stenosis or occlusion ofa subclavian artery proximal to the source ofthe vertebral artery,so that blood is stolen from that artery
2. Blood pressure is significantly lower in the affected arm than in the opposite arm.
G. Others
1. Transient hypotension
2. Osteophytes that cause compression ofneck vessels
3. Kinking ofneck vessels during rotation ofthe head
4. Cocaine abuse
5. Hypoglycemia
III.Risk factors
A. TIA:Individuals are at risk for stroke in the months,as well as the years, immediately after the initial TIA;therefore,proper treatment ofattacks is important.Approximately one third ofstroke patients have a history ofTIA.
B. Hypertension
C. Cardiac disease,such as the following:
1. Mitral valve disease
2. Anterior wall myocardial infarction
3. Congestive myopathy
4. Arrhythmia (e.g.,atrial fibrillation)
D. Smoking
E. Obesity
F. Hyperlipidemia
G. Elevated homocysteine levels in the elderly
H. Advanced age
I. Diabetes
J. Alcohol and recreational drug abuse
IV.Clinical manifestations
A. Carotid artery syndrome
1. Ipsilateral monocular blindness (amaurosis fugax) described as similar to a shade coming down over one eye
2. Paresthesia/weakness ofcontralateral arm,leg,and face (may be episodic)
3. Dysarthria,transient aphasia
4. Ipsilateral,vascular-type headache
5. Carotid bruit may be present.
6. Microemboli,hemorrhage,and exudate may be visualized in the ipsilateral retina.
B. Vertebrobasilar artery syndrome
1. Visual disturbance bilaterally (blurred vision,diplopia,complete blindness)
2. Vertigo,ataxia,tinnitus
3. Nausea and/or vomiting
4. Sudden loss ofpostural tone in all extremities while consciousness remains intact (drop attacks)
5. Dysarthria
6. Perioral or facial paresthesia
7. Acute confusional state
V.Diagnostics/laboratory findings
A. Laboratory evaluation should include the following:
1. Complete blood count (CBC),platelet count,prothrombin time (PT), partial thromboplastin time (PTT),and international normalized ratio (INR) to detect these conditions:
a. Anemia
b. Polycythemia
c. Leukemia
d. Thrombocytopenia
e. Hypercoagulopathy
2. Anticardiolipin antibodies (immunoglobulin [Ig]G,IgM,IgA) and assay for lupus anticoagulant for suspected antiphospholipid antibody syndromes
3. Assays for antithrombin III,proteins S and C,plasminogen, and t-PA
4. Electrolytes,glucose to detect the following:
a. Hyponatremia
b. Hypokalemia
c. Hypoglycemia
d. Hyperglycemia
5. Sedimentation rate,to detect these conditions:
a. Vasculitis
b. Infective endocarditis
c. Hyperviscosity
d. Giant cell arteritis
6. Lipid profile
a. Detects hyperlipidemia
7. In selected patients,antinuclear antibody (ANA),Venereal Disease Research Laboratory test (VDRL),and toxicology screen
8. Homocysteine level
a. An amino acid
b. Elevated plasma level associated with increased risk ofvascular events
B. Computed tomography (CT) scan ofthe head
1. May reveal “silent”ischemia or ischemic images,as well as hemorrhage or infarct and SDH
2. 10% to 20% ofpatients with TIAs have an infarct in the territory relevant to their symptoms.
C. Magnetic resonance imaging (MRI),particularly diffusion-weighted imaging (DWI) and perfusion-weighted imaging (PWI)
1. More sensitive than CT scan to early pathologic changes ofischemic infarction because ofits excellent detection ofbrain edema
2. MRI is also preferred for the detection oflacunar or vertebrobasilar TIAs,or when vascular territory is not well defined.
D. Single photon emission computed tomography (SPECT)
1. Injection with 99mTc-labeled agent
2. Multiple views ofemission projection data
3. Essentially,a VQ (ventilation/quantification) scan ofthe brain
E. Duplex ultrasonography
1. 85% sensitivity and 90% specificity
2. Useful in identifying hemodynamically significant carotid stenosis
F. Magnetic resonance angiography (MRA)
1. Alternative to ultrasound studies
2. No contrast medium is needed.
3. Can be obtained at the same time as an MRI scan
4. Good means for assessment ofextracranial and intracranial vessels
G. Carotid Doppler ultrasound has limited usefulness.
H. Echocardiography and a 24-hour Holter monitor are used to evaluate for a cardiac source ofemboli.
I. Transesophageal echocardiography (TEE) to detect vascular tree abnormalities and stenosis
J. Cerebral angiography for patients whose symptoms suggest involvement of the carotid circulation and who are candidates for carotid endarterectomy (CEA)
K. Chest x-ray for enlarged heart
L. Blood cultures to monitor for infective endocarditis
M. Temporal artery biopsy to detect giant cell arteritis
N. Cardiac enzymes to detect an acute myocardial infarction
O. Electroencephalography (EEG) indicated in patients suspected ofhaving a seizure disorder associated with stroke,as well as an underlying toxic-metabolic disorder that may cause seizure activity
VI.Management
A. Address the following underlying risk factors:
1. Hypertension (HTN)
2. Diabetes mellitus (DM)
3. Obesity
4. Hyperlipidemia
5. Smoking
B. Carotid TIAs
1. Greater than 70% obstruction:CEA is indicated for those who are a good surgical risk.
2. Less than 30% obstruction:Surgery is not indicated.
3. Recently,carotid angioplasty and stenting (CAS) has emerged as an alternative in high-risk surgical patients,or when CEA is contraindicated for technical or medical reasons.
C. Anticoagulation ifcaused by a cardioembolic event
1. May prevent recurrent cardioembolic events
2. Begin with heparin (loading dose of5000-10,000 units for those not at risk for hemorrhagic transformation and maintenance infusion of 1000-2000 units/hour).
3. Target PTT should be 1.5 times control.
4. Follow with warfarin (Coumadin),5-15 mg PO (per os;by mouth), which is indicated for the following:
a. TIA caused by embolism arising from a mural thrombus after a myocardial infarction (MI)
b. TIA caused by embolus in patients with mitral stenosis or prosthetic heart valves
c. Recurrent TIAs despite platelet antiaggregant agents
d. INR of2 to 3 is considered therapeutic.
D. Antiplatelet therapy is useful for patients who are not candidates for surgery or warfarin therapy (those with gastrointestinal [GI] bleeding, bleeding tendencies,or severe hypertension,elderly patients who fall frequently,or uncooperative patients).
