What is the immediate management for a patient with an acute infarct on a CT (computed tomography) scan?

Immediate Management of Acute Infarct on CT Scan

The immediate management of a patient with an acute infarct on CT scan should include rapid assessment, oxygen supplementation, blood pressure management, and consideration for reperfusion therapy if within the appropriate time window.

Initial Assessment and Stabilization

• Perform rapid evaluation within 10 minutes of arrival to the emergency department, with no more than 20 minutes elapsing before assessment is complete 1
• Immediately initiate cardiac monitoring to identify potential cardiac conditions such as acute myocardial infarction, atrial fibrillation, or heart failure 1
• Provide supplemental oxygen therapy for patients with arterial oxygen saturation <90% 1
• Position the head of the bed at 25-30° to manage potential increased intracranial pressure until large lesions or other causes of increased ICP are ruled out 1
• Obtain vital signs frequently, at least every 30 minutes while in the emergency department 1
• Treat hyperthermia (temperature >99.6°F) with acetaminophen as it is associated with poor outcomes 1

Diagnostic Workup

• Perform a 12-lead ECG to rule out cardiac causes and identify patients with ST-segment elevation or left bundle branch block who may need cardiac reperfusion therapy 1
• Obtain blood samples for cardiac biomarkers, but do not delay reperfusion therapy while waiting for results 2
• Consider emergency echocardiography if the diagnosis is uncertain, but do not delay angiography if indicated 1
• For ischemic stroke patients, determine whether the stroke is an ischemic infarction or intracranial hemorrhage through brain imaging 1

Reperfusion Therapy Decision Making

• For patients with acute myocardial infarction and ST-segment elevation (≥1 mm) in contiguous leads, consider immediate reperfusion therapy with either thrombolysis or primary percutaneous coronary intervention 1
• For patients with ischemic stroke, determine eligibility for intravenous tissue plasminogen activator (tPA) or mechanical thrombectomy 3
• If thrombolytic therapy is indicated for stroke, administer within 4.5 hours of symptom onset 3
• For patients with large vessel occlusion stroke, consider mechanical thrombectomy within 6 hours of symptom onset, or up to 24 hours if they have favorable imaging characteristics 3

Medication Administration

• Administer aspirin 160-325 mg orally immediately for suspected myocardial infarction 1, 2
• Give sublingual nitroglycerin for suspected myocardial infarction (unless systolic BP <90 mmHg or heart rate <50 or >100 bpm) 1
• Provide adequate analgesia with morphine sulfate or meperidine for myocardial infarction 1
• For ischemic stroke patients receiving tPA, monitor neurological status and vital signs every 15 minutes during infusion, every 30 minutes for 6 hours, then hourly until 24 hours after treatment 1, 4

Blood Pressure Management

• For ischemic stroke patients not receiving thrombolysis, notify physician for systolic BP >220 mmHg or <110 mmHg, diastolic BP >120 mmHg or <60 mmHg 1
• For patients receiving thrombolytic therapy, maintain blood pressure below 180/105 mmHg 1
• For myocardial infarction patients, optimal blood pressure targets should be individualized based on the patient's baseline values 1

Follow-up Imaging

• For stroke patients treated with thrombolysis, perform a repeat CT or MRI brain scan 24 hours after the initial stroke event, even if clinically stable 4
• For patients who experience clinical deterioration, obtain emergency CT scanning immediately 4
• The 24-hour follow-up CT scan is required before starting anticoagulants or antiplatelet agents for secondary stroke prevention 4

Special Considerations

• For patients with hyperglycemia (glucose >10 mmol/L or >180 mg/dL), consider glucose-lowering therapy while avoiding hypoglycemia 1
• In patients on metformin and/or SGLT2 inhibitors, carefully monitor renal function for at least 3 days after coronary angiography/PCI 1
• For patients with suspected basilar artery thrombosis who are intubated, CT angiography can help confirm diagnosis and facilitate therapeutic decision-making 5

Common Pitfalls and Caveats

• Relying solely on clinical examination without follow-up imaging may miss asymptomatic hemorrhagic transformation in stroke patients 4
• Delaying antiplatelet therapy in cases of hemorrhagic transformation may be necessary 4
• Delay in obtaining follow-up imaging may postpone initiation of secondary stroke prevention measures 4
• Early signs of ischemia on CT scan such as hyperdense middle cerebral artery sign, reduced contrast attenuation, and loss of insular ribbon may be subtle but are important predictors of infarct progression 6