Makindo Medical Notes.com

Related Subjects: |Acute Stroke Assessment (ROSIER&NIHSS) |Atrial Fibrillation |Atrial Myxoma |Causes of Stroke |Ischaemic Stroke |Cancer and Stroke |Cardioembolic stroke |CT Basics for Stroke |Endocarditis and Stroke |Haemorrhagic Stroke |Stroke Thrombolysis |Hyperacute Stroke Care

Physiological Monitoring

• Pulse, BP and oxygen saturation and standard neurological observations should be monitored continuously for the first 24 hours. A BM (glucose) should be checked initially and performed 4 hourly for the first 24 hours if the BM > 11.0 mmol/l or the patient is known to have diabetes.
• Airway management is important in comatose patients and such patients should be managed in the coma/recovery position Occasionally a Nasopharyngeal airway may be needed. Anaesthetic review if GCS low and airway issues anticipated. Intubation is very occasionally required. Observation in HDU/ITU may be appropriate on a case-by-case discussion with the ITU critical care team.
• Escalate airway problems to the Critical outreach team and on-call anaesthetists and discuss with a stroke physician

Seizures

• Seizures are seen in 10% of those post-strokes. Focal seizures which may become secondarily generalised tonic-clonic. Single seizures do not require treatment and often self-terminate and patients should just be kept comfortable with ABCs managed. If seizures recur or a seizure persists then treatment may well be warranted.
• For those who require IV therapy Phenytoin is often used the first line. Once oral therapy possibly Phenytoin or Valproate may be used as first-line agents. The overuse of IV benzodiazepines for simple self-terminating seizures should be avoided as they cause respiratory depression. Patients with status epilepticus is quite uncommon post-stroke but should be managed using standard protocols and liaison with ITU.

Urinary catheters

• These should only be used if a patient has gone into retention which may often not be obvious in the obtunded patient or where urination is exacerbating the care of skin areas and convene or other measures are insufficient to deal with the situation. Urinary catheters to measure output in those with mild derangements of renal function should be discouraged. A urinary catheter should be avoided if at all possible.
• It is best to trial removal of the catheter when patients have improved physically so better able to sit or stand to use a bottle, convene or commode. Catheters should be avoided if possible as they introduce infection. Always consider a catheter induced urinary tract infection in those who deteriorate.

Pyrexia

• Cause is often multifactorial. A raised temperature has been associated with increased infarct volume. Mild pyrexia may be primarily stroke-related or signify infection which is most likely chest or urine. Look also for clues towards biliary or abdominal problems, cellulitis, septic or inflammatory arthritis or conditions such as DVT or Gout. Rarely endocarditis needs to be considered.
• Check Urinalysis, FBC, U&E, LFTs, ESR, CRP, Consider CXR and blood culture. Paracetamol orally/pr or IV up to 6g/day in divided doses may be used to manage pyrexia and should be prescribed on the PRN chart for all patients. Avoid antibiotics unless there is evidence of infection. Discuss difficult cases with the medical registrar or consultant or with microbiology.

Nasogastric tube insertion

• Nasogastric tube insertion can provide much-needed nutrition and hydration. NG tubes, however, are a source of potentially life-threatening complications, especially when misplaced. Please follow the Nasogastric tube insertion policy which is on the intranet.
• If there is any doubt about placement then stop feed and do not use until it has been established that position is safe. If an NG is needed for more than 2 weeks then consider PEG feeding.

Hydration

• All patients unable to take sufficient oral intake and who are not on the Liverpool care pathway or not receiving adequate NG or PEG feeding should receive IV Fluids. Hydration is fundamental and the general policy is to give 2-3 L/day of IV fluids - try to give 0.9% Saline rather than dextrose acutely to minimise cerebral oedema.
• The exact amount will depend on the hydration of the patient, cardiac status, U&E results and urine output. In those who can eat and drink then it is appropriate to stop IV fluids as soon as possible and remove the cannula if not being used. All people with acute stroke should have their hydration assessed on admission, reviewed regularly and managed so that normal hydration is maintained.

Depression and anxiety

• Symptoms of anxiety and depression are seen commonly post-stroke and should be assessed. Some degree of depression is seen normally post-stroke but if it interferes with recovery and therapy then it may be wise to consider an antidepressant.
• A positive attitude and good communication may help to reduce these symptoms and address unexpressed fears and worries. Antidepressants if commenced will need a course usually of at least 6 months. It will be for the GP to wean the patient of the drug at this time

Aspiration pneumonia

• Not uncommon post-stroke where airway protection is poor. There may well be fever and increased respiratory rate and coarse crepitations and /or rhonchi. There may be elevated WCC and raised CRP. and Chest X-ray may show consolidation or patchy shadowing.
• Treatment is usually IV or NG Augmentin or a macrolide if Penicillin allergic according to trust antibiotic guidelines. Do not treat where signs are unconvincing. Inspiratory crepitations are common and not diagnostic of infection. The best method to prevent hypostatic and other pneumonia is to encourage early mobilisation and get the patient out of bed into an upright position to help improve lung function and allow good expectoration. Chest physiotherapy may also be helpful to expectorate secretions.

Stroke and proximal DVT or PE

• Patients with ischaemic stroke and symptomatic proximal deep vein thrombosis or pulmonary embolism should receive anticoagulation treatment (LMWH s/c) in preference to treatment with Aspirin unless there are other contraindications to anticoagulation.
• Patients with haemorrhagic stroke and DVT/PE should initially be discussed with the on-call physician or stroke physician and be considered for a vena caval filter with interventional radiologists.
• In some cases no treatment beyond supportive management is possible as anticoagulation is contraindicated and patient is too unwell to transfer then discuss with on-call consultant.

Palliation

• Stroke has a high mortality and at times it is appropriate to switch the goals from rehabilitation and recovery to palliation and symptom management. If the patient lacks capacity then we should always be aiming to do what the patient would have wanted.
• Close liaison with the family is required. Management plans need to be communicated directly to the family and the goals of nursing and medical care explained. Use of the Liverpool care pathway is encouraged.
• Liaison with the Palliative care team can be useful and can often help support family and improve communication as well as symptomatic care.

Stroke extension and unexplained deterioration post stroke

• Ischaemic and haemorrhagic strokes can both worsen in terms of the volume of the brain affected due to many reasons such as further vessel closure, further bleeding and so on.
• Repeat CT scan may be indicated. Prognosis is usually poor. Exclude other treatable causes of deterioration. Most stroke patients present at their worst and then improve. However, others have a much more variable recovery. Up to 40% of stroke patients deteriorate in the first week and the cause can be single or multifactorial.
• The history of the deterioration should be recorded and the patient examined. Falls and even head injuries are not uncommon. Most patients will need clinical review and basic bloods to look for sepsis, hyponatraemia and other complications. A repeat CT scan may sometimes be needed.
• Causes of deterioration - Aspiration, sepsis, hypoxia, hypoglycaemia or hyperglycaemia, SIADH and hyponatraemia, cardiac arrhythmias, NSTEMI/STEMI, CCF/LVF, DVT/PE, Depression, Recurrent stroke, falls and trauma