Stroke Management

Stroke management is centred on recognising strokes and differentiating between haemorrhagic and ischaemic causes (CT Scanning is useful).

Strokes are usually managed in specialised stroke units. It has been shown that people admitted to a stroke unit have a higher chance of surviving than those admitted elsewhere in hospital, even if they are cared for by doctors with experience in stroke care.

Ischaemic strokes are treated with thrombolytic drugs (to break down any clots) and antiplatelets (such as aspirin or clopidogrel which prevent platelets from aggregating).

Primary treatment: 150-300mg aspirin (after 3 weeks switch to 75mg for secondary prevention) or clopidogrel (an alternative antiplatelet).

For general secondary prevention prescribe 75mg OD aspirin

If Patient in Atrial Fibrillation – consider Warfarin (INR 2.5)

In addition to definitive therapies, management of acute stroke includes the control of blood sugars, oxygenation, hydration and the use of I.V fluids, assessing swallowing, catheterisation, and providing adequate nutrition. Rehabilitation through physiotherapy and early mobilisation is an important part of long term care.

If patient has ipsilateral carotid stenosis (> 80% on Doppler), assess the Patient for common carotid endartectomy.

If a large cerebral haematoma is suspected, neurosurgical evacuation may be required. Anticoagulants and antithrombotics, key in treating ischemic stroke, can make bleeding worse and cannot be used in intracerebral hemorrhage. Patients are monitored and their blood pressure, blood sugar, and oxygenation are kept at optimum levels.

Stroke rehabilitation is the process by which patients with disabling strokes undergo treatment to help them return to normal life as much as possible by regaining and relearning the skills of everyday living.

A rehabilitation team is usually multidisciplinary as it involves staff with different skills working together to help the patient. These include nursing staff, physiotherapy, occupational therapy, speech and language therapy, and usually a physician trained in rehabilitation medicine.

Good nursing care is fundamental in maintaining skin care, feeding, hydration, positioning, and monitoring vital signs such as temperature, pulse, and blood pressure. Stroke rehabilitation begins almost immediately.

For most stroke patients, physical therapy (PT) and occupational therapy (OT) are the cornerstones of the rehabilitation process. Often, assistive technology such as a wheelchair, walkers, canes, and orthotics may be beneficial. PT and OT have overlapping areas of working but their main attention fields are; PT involves re-learning functions as transferring, walking and other gross motor functions. OT focuses on exercises and training to help relearn everyday activities known as the Activities of daily living (ADLs) such as eating, drinking, dressing, bathing, cooking, reading and writing, and toileting. Speech and language therapy is appropriate for patients with problems understanding speech or written words, problems forming speech and problems with swallowing.

Patients may have particular problems, such as complete or partial inability to swallow, which can cause swallowed material to pass into the lungs and cause aspiration pneumonia. The condition may improve with time, but in the interim, a nasogastric tube may be inserted, enabling liquid food to be given directly into the stomach. If swallowing is still unsafe after a week, then a percutaneous endoscopic gastrostomy (PEG) tube is passed and this can remain indefinitely.

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