ppt

1. Management of acute
stroke
Presenter :- Dr Henok miheret (intern)
Moderator :- Dr. Guadie . (consultant neurologist)
:- Dr Birhanu ( NR2)

2. General considerations
• Time is the essence in the hyper acute evaluation of stroke patients
• The history, physical examination , serum glucose, oxygen saturation ,
and a non contrast CT scan are sufficient in most cases to guide acute
therapy
• “Time is brain”

3. General care for all stroke patients
• ABC of life and feeding test
• Protect the ischemic penumbra and Avoid secondary ischemia
• Prevent complication
• Standard nursing care
• Rehabilitative strategies

4. Airway protection
• For every stroke patient assessing vital signs and ensuring stabilization of
airway, breathing, and circulation is part of the initial evaluation of all
patients
• Patients with decreased consciousness or bulbar dysfunction may be
unable protect their airway and those with increased intracranial pressure
due to hemorrhage, vertebrobasilar ischemia or bihemispheric ischemia
• can present with vomiting, decreased respiratory drive or muscular airway
obstruction which results in hypoventilation with a resulting increase in
CO2 may lead to cerebral vasodilation and increase ICP
• in these case intubation may be necessary to restore adequate ventilation
and to protect the airway from aspiration

5. • Stroke patient should be positioned appropriately: Flat or 30o - 45o up depending
on the condition of the patient
• Oro-tracheal secretions should be removed
• If saturation Is below 95%, put on 100% intranasal or face mask
oxygen

6. Circulation
• When a stoke patients present with hypotension a prompt cardiac
evaluation is necessary
• Hypotension should be treated with maintenance fluid
• Hypertension depending on the type of stroke can be treated with
short acting antihypertensive

7. Dysphagia
• It is a common complication of stroke and a major risk factor
for developing aspirational pneumonia
• Dysphagia related to stroke is more precisely characterized as
oropharyngeal dysphagia, defined by swallowing impairment of
the upper digestive tract
• Independent predictors of dysphagia on initial presentation
include male gender, age greater than 70, disabling stroke, and
impaired pharyngeal response
• Dysphasia usually improves spontaneously with return of safe
swallowing function by two weeks In approximately 90 percent
of patients

8. Swallow test
Swallow test for
30 ml of liquid
meal
Swallow test for
30 ml of semi
solid meal
Swallow test for
30 ml of solid
meal
failed
Ng tube
feeding
pass
pass
failed
Ng tube
feeding
failed
Oral liquid
feeding
pass
Oral solid
feeding
FAILED SWALLOW TEST
Content stays in the
mouth for more than 10
to 15 sec
Content visible after
swallow completed
Content leak from mouth
Chocking episodes after
test
Wet voice with
conversation

9. Protect the ischemic penumbra and avoid
secondary damage
• our management goal is to optimize cerebral perfusion in the
ischemic penumbra
• Hypertension management :- for ischemic stroke it is only
recommended to decrease the blood pressure if it is above 220/ 120
or if there is concomitant mi, malignant hypertension, or if rtPA is
about to be give
• Fever :- it is detrimental and should be treated with antipyretics and
surface cooling

10. • Glucose :- it should be kept below 180mg/dl and above at least 60mg/dl, a
more intensive glucose control strategy doesn’t improve outcome
• Cerebral edema :- it peaks at the 2nd and 3rd day but couses mass effect up
to 10 days, which can be treated with water restriction and IV mannitol but
hypovolemia should be avoided.
• craniotomy and temporary removal of the cranium reduces mortality by
50%, the benefit for older patients ( age > 60) is less but still significant

11. • Usually patients with cerebral edema present with a
deteriorating mental status and at least one of the
following signs

12. Cerebral edema

13. Infections
• Fever after a stroke should prompt evaluation for common sources, including pneumonia
and urinary tract infection.
• Pneumonia is the commonest cause of fever in the first 48 hrs. of stroke with risk factors
including aspiration; atelectasis; intubation…
• Early mobilization, airway care and dysphagia assessment prevent pneumonia
• Urinary tract infections are often seen during the first 5 days of the hospitalization.
• Prolonged catheter use and poor catheter care are risks.

14. DVT and PTE prophylaxis
• The development of DVT may take place as early as day 2 after stroke
onset, with a peak incidence between days 2 & 7.
• The incidence of DVT in immobile patients with stroke was b/n 11%
and 15% of patients within the first month of stroke.
• PTE occurs in 1-3% of stroke with mortality rate of 13-25%
• Risk factors of DVT Severe disability; old age and dehydration

15. If there are no contraindications,
• low-dose subcutaneous UFH at a dosage of 5000 units twice a day or
LMWH is used.
• The Prevention of VTE after Acute Ischemic Stroke with LMWH study
showed that enoxaparin (40 mg once daily) was superior to UFH in
preventing VTE in patients with acute ischemic stroke but was
associated with a small increase in extra cranial hemorrhage rates
• If heparin is contraindicated, intermittent pneumatic compression
(IPC) of the lower extremities is recommended.

16. Standard nursing care
• Bed side care for clothing and feeding
• Frequent positioning to prevent pressure sore
• Routine care of ng tube , eye and mouth
• Monitoring the swallow test daily

17. Rehabilitation
• Physiotherapy
• Speech therapy
• Occupational therapy

19. We can classify acute ischemic stroke management principles to six categories
1.Medical support
2.IV thrombolytics
3.Endovascular revascularization
4.Antithrombotic treatment
5.Neuroprotection
6.Stroke care and rehabilitation

20. Intravenous thrombolysis
• The NINDS study on rtPA shows
that there is a clear benefit
selected patients with acute
stroke
• Iv rtPA ( 0.9mg/kg not to exceed
90mg ) 10% bolus and the rest
infused over 1 hr.

21. Management gaps
• Stoke management set up in our hospital has yet to improve
• We don’t have emergency CT scan
• We don’t have fibrinolytic agents
• The patient hypertension is managed with nefidipine
• We don’t have stroke care centers
• Patients initial RBS was not registered

22. Thank you

23. reference