General Care After Stroke, Including Stroke Units and Prevention and Treatment of Complications of S

1
General Care After Stroke, Including Stroke
Units and Prevention and Treatment of
Complications of Stroke
2
Reasons for Admission

• Serious illness
• Potentially life-threatening disease
• Risk for medical or neurological complications
• Neurological deterioration
• Observation, evaluation and treatment

3
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.

4
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.

5
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.

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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.

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Neurological Complications

• Progression of thrombosis
• Recurrent embolism
• Brain edema
• Hydrocephalus
• Increased intracranial pressure
• Hemorrhagic transformation
• Seizures

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Medical Complications

• Myocardial infarction Pneumonia
• Congestive heart failure Airway obstruction
• Cardiac arrhythmias Hypertension
• Deep vein thrombosis Bladder infections
• Pulmonary embolus Depression
• Gastrointestinal bleeding Electrolyte
  disturbance

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After Admission

• Initially treated with bed rest mobilization
  begins as soon as the patients condition is
  stable
• Pulse oximetry first 24-48 hours
• Cardiac monitoring first 24 hours

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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.

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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.

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Heart Disease and Stroke

• Sinus bradycardia Sinoatrial arrhythmia
• Ventricular tachycardia Atrial fibrillation
• Ventricular fibrillation PVC
• Idioventricular rhythms PSVT
• Torsades de pointes AV block

13
ECG Changes and Stroke

• ST-T segment elevation/depression
• Pathological Q waves
• Negative T waves
• Abnormal U waves
• QT prolongation

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Hypertension in 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

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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

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Initial Management of Acute Stroke

• 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

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Mobilization After Stroke

• Early mobilization
• positive for morale
• expedites rehabilitation
• lessens risk of pulmonary, skin, musculoskeletal
  complications
• Watch for hypotension or neurological worsening
• Protect against falls

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Prevention of DVT and Pulmonary Embolism

• Mobilization
• Heparin
• LMW heparins/heparinoids
• Oral anticoagulants
• Aspirin
• Alternating pressure stockings

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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

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Brain Edema and Increased Intracranial Pressure

• Common cause of neurological worsening
• progression of stroke
• secondary brain ischemia
• herniation syndromes
• Hallmark is depression of consciousness
• Vital signs unstable and arterial hypertension

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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

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Trial of Dexamethasone for Supratentorial
Intracerebral Hemorrhage

• Dexamethasone Placebo
• n46 n47
• Good Recovery 8 5
• Poor Survivor 17 21
• Dead 21 21
• Infectious Complications 13 6
• Pougvarin, et al. New England Journal of
  Medicine 19873161229-1233..

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Intracranial Pressure

• 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

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Surgical Management of Brain Edema and ICP

• Drainage of CSF fluid
• Evacuation of hematoma
• Resection of infarcted tissue
• Hemicraniectomy

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Evaluation for Cause of Stroke

• Magnetic resonance imaging of brain
• Magnetic resonance angiography
• Spiral CT imaging
• Carotid duplex
• Transcranial Doppler
• Transthoracic echocardiography
• Transesophageal echocardiography

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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

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Prevention of Recurrent Stroke

• Carotid endarterectomy if ipsilateral high-grade
  stenosis, acceptable risk, and skilled surgeon
• Antiplatelet aggregating drugs
• Aspirin
• Ticlopidine
• Aspirin and dipyridamole

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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 patients needs
• Progress in a step-wise progression
• Maximize patients independence

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Decisions About Rehabilitation Influence
Discharge Planning

• In-patient rehabilitation unit
• attached to acute hospital
• free-standing hospital
• Outpatient care
• Home care
• Skilled nursing facility

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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