Makindo Medical Notes

Related Subjects: |Acute Stroke Assessment (ROSIER&NIHSS) |Atrial Fibrillation |Atrial Myxoma |Causes of Stroke |Ischaemic Stroke |Cancer and Stroke |Cardioembolic stroke |CT Basics for Stroke |Endocarditis and Stroke |Haemorrhagic Stroke |Stroke Thrombolysis |Hyperacute Stroke Care

Physiological Monitoring

• Continuous monitoring of pulse, BP, oxygen saturation, and standard neurological observations is essential for the first 24 hours. Check blood glucose (BM) initially, and if BM > 11.0 mmol/l or if the patient is diabetic, continue 4-hourly checks for the first 24 hours.
• Airway management is critical for comatose patients; position in coma/recovery stance, and consider nasopharyngeal airway if needed. Low GCS and anticipated airway issues may warrant anaesthetic review and potential intubation, often requiring observation in HDU/ITU in consultation with the ITU critical care team.
• Escalate airway issues to the Critical Outreach Team and on-call anaesthetists, and consult with a stroke physician as necessary.

Seizures

• Seizures occur in 10% of stroke patients, often presenting as focal seizures that may progress to generalized tonic-clonic. Single seizures typically do not require treatment and usually self-terminate; manage airway, breathing, and comfort.
• If seizures recur or persist, treatment may be warranted. Phenytoin is often used first-line for IV therapy, with oral Phenytoin or Valproate as possible maintenance options. Avoid excessive IV benzodiazepines for simple, self-limiting seizures due to respiratory depression risk. Manage status epilepticus with standard protocols, coordinating with ITU.

Urinary Catheters

• Catheters should only be used for retention or significant skin care needs that cannot be managed otherwise. Avoid routine catheterization to measure output in mild renal function derangements, as it increases infection risk. Trial catheter removal when physical recovery permits.
• Consider catheter-related UTI as a cause of deterioration in post-stroke patients.

Pyrexia

• Pyrexia can increase infarct volume and is often multifactorial, potentially stroke-related or secondary to infection. Consider sources like chest, urine, biliary, cellulitis, or less commonly endocarditis.
• Investigate with urinalysis, FBC, U&E, LFTs, ESR, CRP, and possibly CXR and blood culture. Use paracetamol up to 6g/day PRN to manage fever; reserve antibiotics for confirmed infection. Consult difficult cases with a senior or microbiology.

Nasogastric Tube Insertion

• NG tube insertion is beneficial for nutrition and hydration but carries risks if misplaced. Follow the NG tube insertion policy strictly. Stop feeds if there is any doubt about tube placement until confirmation is obtained. If an NG tube is needed beyond two weeks, consider PEG feeding.

Hydration

• Patients unable to maintain oral intake should receive IV fluids, typically 2-3 L/day of 0.9% saline to avoid cerebral oedema. Adjust fluids based on hydration, cardiac status, U&E, and urine output. Cease IV fluids as soon as oral intake is sufficient.

Depression and Anxiety

• Post-stroke anxiety and depression are common and should be assessed. Mild symptoms are typical, but significant distress interfering with recovery may require an antidepressant. Positive communication and reassurance are also beneficial. Antidepressant treatment generally lasts at least six months, with GP follow-up for discontinuation.

Aspiration Pneumonia

• Aspiration pneumonia is common post-stroke with poor airway protection. Symptoms include fever, increased respiratory rate, coarse crepitations, and elevated WCC and CRP. CXR may show consolidation.
• Treat with IV or NG Augmentin or a macrolide for penicillin-allergic patients per antibiotic guidelines. Avoid unnecessary antibiotics for unconfirmed cases. Encourage early mobilization and upright positioning to prevent pneumonia, supplemented with chest physiotherapy if needed.

Stroke and Proximal DVT or PE

• Ischaemic stroke patients with symptomatic DVT or PE should receive LMWH s/c over Aspirin unless contraindicated. Hemorrhagic stroke cases require consultation with a stroke physician or on-call consultant, and may involve vena caval filter placement with interventional radiology input.

Palliation

• High stroke mortality may necessitate shifting from rehabilitation to palliative care. Respect patient wishes, involve family, and communicate care goals clearly. Use the Liverpool Care Pathway and engage the Palliative Care Team for support in symptom management and family communication.

Stroke Extension and Unexplained Deterioration

• Both ischaemic and haemorrhagic strokes may worsen due to additional vessel closure, further bleeding, or other factors. Consider a repeat CT scan if warranted, as prognosis is often poor. Evaluate other deterioration causes, including sepsis, hypoxia, hypoglycaemia, hyponatraemia, cardiac events, DVT/PE, recurrent stroke, or trauma.