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General Care After Stroke, Including Stroke Units and Prevention and Treatment of Complications of Stroke. Reasons for Admission. Serious illness Potentially life-threatening disease Risk for medical or neurological complications Neurological deterioration - PowerPoint PPT Presentation
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General Care After Stroke, Including
Stroke Units and Prevention and Treatment of
Complications of Stroke
Reasons for Admission
• Serious illness• Potentially life-threatening disease• Risk for medical or neurological
complications• Neurological deterioration• Observation, evaluation and treatment
Organization of Stroke Care
• Acute Stroke Units– Concentrate admissions to a specialized
facility with skilled care and monitoring.– Shorten hospitalizations and reduce death
and disability.– Reduce complications and promote
rehabilitation.
Organization of Stroke Care
• Stroke Teams– Coordinated teams of health care
professionals to coordinate efficient and effective care for stroke patients.
– Stroke Teams play a part in the hyperacute, the acute and the rehabilitation phases of stroke care.
– Involve the multidisciplinary team.
Stroke Centers
• Primary Stroke Centers – Use the cardiac/trauma model of delivering
care.– Major elements: patient care and support
services.– Define institutions where appropriate care
can be given.
Goals of Treatment After Admission
• Continue care started in emergency department.
• Observe for and prevent or control neurological and medical complications.
• Start rehabilitation and discharge planning.• Evaluate for cause of stroke and start
therapies to prevent recurrent stroke.
Neurological Complications
• Progression of thrombosis• Recurrent embolism• Brain edema• Hydrocephalus• Increased intracranial pressure• Hemorrhagic transformation• Seizures
Medical Complications
Myocardial infarction PneumoniaCongestive heart failure Airway
obstructionCardiac arrhythmias HypertensionDeep vein thrombosis Bladder infectionsPulmonary embolus DepressionGastrointestinal bleeding Electrolyte
disturbance
• Initially treated with bed rest; mobilization begins as soon as the patient’s condition is stable
• Pulse oximetry first 24-48 hours
• Cardiac monitoring first 24 hours
After Admission
After Admission
• Frequent assessments of vital signs and neurological status by nursing staff.
• Protection of airway, especially if depressed consciousness or signs of brain stem dysfunction.
• Supplemental oxygen if patient is hypoxic.
• Assessment for cause of hypoxia.
Heart Disease and Stroke
• Heart disease often is the cause of stroke.• Most patients with stroke have heart
disease.• Stroke, especially intracranial hemorrhage,
can cause myocardial ischemia or cardiac arrhythmias.
• Many persons will have cardiac arrhythmias or electrocardiographic abnormalities after stroke.
Sinus bradycardia Sinoatrial arrhythmia
Ventricular tachycardia Atrial fibrillation
Ventricular fibrillation PVC Idioventricular rhythms PSVTTorsades de pointes AV block
Heart Disease and Stroke
• ST-T segment elevation/depression• Pathological Q waves• Negative T waves• Abnormal U waves• QT prolongation
ECG Changes and Stroke
• Arterial hypertension is common among persons with stroke:– risk factor for stroke– consequence of stroke
• Usually declines spontaneously• Secondary to pain, vomiting, stress,
anxiety• Secondary to increased intracranial
pressure
Hypertension in Stroke
Treatment of Arterial Hypertension
• Oral agents preferred• Continue or re-institute
antihypertensive medications• Goal of lowering pressure by 15%
during first 24 hours
• If parenteral medications are used, prefer short-acting drugs
• Treat fever and search for the cause of fever; suspect pulmonary or urinary tract infections
• Maintain hydration with intravenous fluids
• Treat hyperglycemia and hypoglycemia• Assess swallowing before starting oral
feedings• If necessary, consider enteral feedings
Initial Management of Acute Stroke
• Early mobilization– positive for morale– expedites rehabilitation– lessens risk of pulmonary, skin,
musculoskeletal complications• Watch for hypotension or neurological
worsening• Protect against falls
Mobilization After Stroke
Prevention of DVT and Pulmonary Embolism
• Mobilization• Heparin• LMW heparins/heparinoids• Oral anticoagulants• Aspirin• Alternating pressure stockings
Brain Edema and Increased Intracranial Pressure
• Peaks within one week of stroke• Earlier with hemorrhagic stroke• A leading cause of death• Seen with large multi-lobar strokes• Can be secondary to hydrocephalus
or mass effect of a hematoma
• Common cause of neurological worsening– progression of stroke– secondary brain ischemia– herniation syndromes
• Hallmark is depression of consciousness• Vital signs unstable and arterial
hypertension
Brain Edema and Increased Intracranial Pressure
Management of Brain Edema and Increased Intracranial Pressure
• Restrict fluids moderately• Avoid hypo-osmolar fluids• Control fever, hypoxia, hypercarbia• Elevate head of bed by 30%• Monitor intracranial pressure
Trial of Dexamethasone for Supratentorial Intracerebral Hemorrhage
Dexamethasone Placebo n=46 n=47
Good Recovery 8 5Poor Survivor 17 21Dead 21 21Infectious Complications 13 6
Pougvarin, et al. New England Journal of Medicine 1987;316:1229-1233..
• Hyperventilation to a pCO2 of approximately 28-30 mm Hg
• Corticosteroids are not recommended• Mannitol, 0.25-1 g/kg intravenously
given every 6 h maximum osmolarity 310
• Furosemide 40 mg intravenously
Intracranial Pressure
• Drainage of CSF fluid• Evacuation of hematoma• Resection of infarcted tissue• Hemicraniectomy
Surgical Management of Brain Edema and ICP
Evaluation for Cause of Stroke
• Magnetic resonance imaging of brain• Magnetic resonance angiography• Spiral CT imaging• Carotid duplex• Transcranial Doppler• Transthoracic echocardiography• Transesophageal echocardiography
Prevention of Recurrent Stroke Cardioembolic Stroke
• Oral anticoagulants– prosthetic valves: INR 2.5-3.5– other causes: INR 2.0-3.0
• Stroke despite adequate anticoagulation– add aspirin– add dipyridamole
• Contraindication for anticoagulation– Aspirin
Prevention of Recurrent Stroke
• Carotid endarterectomy if ipsilateral high-grade stenosis, acceptable risk, and skilled surgeon
• Antiplatelet aggregating drugs– Aspirin– Ticlopidine– Aspirin and dipyridamole
Rehabilitation
• Critical part of care after stroke• Begin as soon as patient is stable and
while the patient is still in an acute care bed
• Tailor to individual patient’s needs • Progress in a step-wise progression• Maximize patient’s independence
Decisions About Rehabilitation Influence Discharge Planning
• In-patient rehabilitation unit – attached to acute hospital– free-standing hospital
• Outpatient care• Home care• Skilled nursing facility
Discharge Planning Considerations
• Cognitive and functional status• Family and caregivers’ support• Financial resources• Patient and family education• Follow-up medical care,
rehabilitation• Identify safe place of residence• Community support or resources