reasons for admission
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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 PresentationTRANSCRIPT
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General Care After Stroke, Including
Stroke Units and Prevention and Treatment of
Complications of Stroke
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Reasons for Admission
• Serious illness• Potentially life-threatening disease• Risk for medical or neurological
complications• Neurological deterioration• Observation, evaluation and treatment
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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.
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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.
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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 PneumoniaCongestive heart failure Airway
obstructionCardiac arrhythmias HypertensionDeep vein thrombosis Bladder infectionsPulmonary embolus DepressionGastrointestinal bleeding Electrolyte
disturbance
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• 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
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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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Sinus bradycardia Sinoatrial arrhythmia
Ventricular tachycardia Atrial fibrillation
Ventricular fibrillation PVC Idioventricular rhythms PSVTTorsades de pointes AV block
Heart Disease and Stroke
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• ST-T segment elevation/depression• Pathological Q waves• Negative T waves• Abnormal U waves• QT prolongation
ECG Changes and Stroke
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• 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
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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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• 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
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• 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
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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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• 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
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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 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..
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• 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
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• Drainage of CSF fluid• Evacuation of hematoma• Resection of infarcted tissue• Hemicraniectomy
Surgical Management of Brain Edema and ICP
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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 patient’s needs • Progress in a step-wise progression• Maximize patient’s 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