Transcript GENERAL CARE AFTER STROKE

General Care
After Stroke, Including
Stroke Units and Prevention
and Treatment of
Complications of Stroke
Reasons for Admission
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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
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Progression of thrombosis
Recurrent embolism
Brain edema
Hydrocephalus
Increased intracranial pressure
Hemorrhagic transformation
Seizures
Medical Complications
Myocardial infarction
Congestive heart failure
obstruction
Cardiac arrhythmias
Deep vein thrombosis
Pulmonary embolus
Gastrointestinal bleeding
disturbance
Pneumonia
Airway
Hypertension
Bladder infections
Depression
Electrolyte
After Admission
• 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
• 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.
Heart Disease and Stroke
Sinus bradycardia
arrhythmia
Ventricular tachycardia
Ventricular fibrillation
Idioventricular rhythms
Torsades de pointes
Sinoatrial
Atrial fibrillation
PVC
PSVT
AV block
ECG Changes and Stroke
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ST-T segment elevation/depression
Pathological Q waves
Negative T waves
Abnormal U waves
QT prolongation
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
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
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
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
Prevention of DVT and
Pulmonary Embolism
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Mobilization
Heparin
LMW heparins/heparinoids
Oral anticoagulants
Aspirin
Alternating pressure stockings
Brain Edema and
Increased Intracranial Pressure
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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
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
Management of Brain Edema and Increased
Intracranial Pressure
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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
Poor Survivor
Dead
Infectious Complications
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Pougvarin, et al. New England Journal of Medicine 1987;316:1229-1233..
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
Surgical Management of
Brain Edema and ICP
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Drainage of CSF fluid
Evacuation of hematoma
Resection of infarcted tissue
Hemicraniectomy
Evaluation for Cause of Stroke
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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
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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