Rationale for Administering Heparin and Labetalol to Mrs. Fenech: A Stroke Case Study

QUESTION

In this case study  could you please answer Why it is rationale to give Mrs. Fenech  Heparin 5000iu IV  and Labetalol with the last 5 year of peer-reviewed reference?

Introduction: Mrs Mary Fenech is a 78-year-old lady with no known allergies (NKA)

Situation: She arrived in the Emergency Department at 09:30 hrs with slurred speech and right sided weakness since 0530 hrs while at home.

Findings from the CT perfusion assessment using Mean Transit Time (MTT) and Time to Peak (TTP) images showed reduced blood flow in the left middle cerebral artery (MCA) vascular territory extending from the medial cerebellum to the deep white matter at the centrum semiovale above the lateral ventricle. A CT angiogram showed an acute left Internal Carotid Artery (ICA) occlusion. Thrombolysis with Alteplase was administered at 11:30hrs

Background: Atrial Fibrillation (AF), Hypertension (HTN), Type 2 Diabetes Mellitus (IDDM), No head trauma, no prior stroke within the previous 3 months

Regular medications–

Atenolol 50mg daily, Aspirin 100mg daily, Lipitor 40mg daily, Magnesium 200mg daily, Amlodipine 5mg daily, Perindopril 5mg daily, NovoRAPID insulin

Assessment: 

• Airway: slight inspiratory stridor
• Breathing: Respiratory rate 24, bilateral air entry, clear sounds. SpO₂ 90% on room air
• Circulation: BP 149/69, irregular rate – 80 bpm
• Disability: GCS 12 (E 4, V 3, M 5) Pupils equal and reacting to light (PEARL). Sluggish eye gaze. Temp 36.9
• Exposure: x2 IVC in Right & Left cubital fossa
• Fluid: IV Compound sodium lactate (Hartman’s) at 20 mL /hr TKVO
• Glucose blood level: 9.5mmol/L 
• Weight approx. 86kg

Stroke Assessment:

F: Face- Right sided facial droop 

A: Arms- Right sided weakness

S: Speech- Aphasia 

T: Time of onset 0530hrs, Time of thrombolysis 1130hrs, time of ECR planned at 1300hrs, Door-to-Needle time 150 minutes, Symptom to needle time 390 minutes 

Results:  A diagnosis of left MCA stroke with totally occluded left Internal Carotid Artery (ICA)

Nursing Interventions: 

• Initiate Stroke Pathway
• Keep in resuscitation bay (Triage category 2)
• Connect to continuous cardiac monitoring
• Record a 12 lead Electrocardiograph (ECG)
• Initiate supplemental oxygen if SpO2 < 93%
• Monitor airway patency
• Record Glasgow Coma Scale hourly
• Prepare for endovascular clot retrieval (ECR) to restore blood flow
• Arrange for a Speech Pathology consult
• Maintain head of the bed elevated to 30 degrees
• Insert a nasogastric tube
• Maintain nil by mouth
• Collect requested pathology
• Monitor for haematemesis, melaena and haematuria

Blood tests:

Coagulation profile and cross match (PT, APTT, INR), FBC, LFT, EUC,

Medications:

• Alteplase (IV)
• Heparin 5000iu (IV)
• Labetalol
• Insulin NovoRAPID (SC)

ANSWER

Rationale for Administering Heparin and Labetalol to Mrs. Fenech: A Stroke Case Study

Introduction

In the context of stroke management, Mrs. Mary Fenech, a 78-year-old woman with atrial fibrillation (AF), hypertension (HTN), and type 2 diabetes mellitus (T2DM), presented to the Emergency Department with acute neurological deficits. A CT perfusion assessment revealed reduced blood flow in the left middle cerebral artery (MCA) vascular territory, with an acute left internal carotid artery (ICA) occlusion. Thrombolysis with Alteplase was initiated. In this case, the rationale for administering Heparin 5000 IU IV and Labetalol to Mrs. Fenech will be discussed based on the presented scenario and recent peer-reviewed references.

Rationale for Heparin 5000 IU IV

Heparin, an anticoagulant, is often used to prevent further thrombus formation and progression in acute ischemic stroke cases. In Mrs. Fenech’s situation, an acute left ICA occlusion was identified, which puts her at an increased risk of developing further thrombi and potential embolic events. The administration of Heparin can prevent the propagation of existing clots, minimize the risk of recurrent stroke, and improve blood flow to ischemic brain tissue (Tsivgoulis et al., 2018). The use of Heparin aligns with guidelines recommending anticoagulation therapy in cases of acute stroke with arterial occlusions to mitigate clot-related complications (Powers et al., 2019).

Rationale for Labetalol

Labetalol, a non-selective beta-blocker, serves as an antihypertensive agent that can stabilize blood pressure in acute stroke scenarios. Mrs. Fenech’s presentation includes hypertension (BP 149/69 mmHg) and a recent Alteplase administration. Elevated blood pressure is a common response to ischemic stroke and thrombolysis, and uncontrolled hypertension can exacerbate the risk of intracranial hemorrhage (ICH). Labetalol’s ability to reduce blood pressure without compromising cerebral perfusion makes it an appropriate choice to manage hypertension post-thrombolysis, contributing to the prevention of potential complications like ICH (Powers et al., 2019; Ahmed et al., 2018).

Conclusion

In Mrs. Fenech’s case, the administration of Heparin 5000 IU IV and Labetalol is well-justified based on her clinical presentation, the risk of further thrombus formation due to an acute ICA occlusion, and the need to manage post-thrombolysis hypertension. These interventions align with established guidelines for stroke management and aim to enhance Mrs. Fenech’s outcome by mitigating the risk of clot propagation and maintaining stable blood pressure levels.