Ischemic Stroke

Airway, Breathing, Circulation

  • Decreased resp drive in hemorrhage, vertebrobasilar ischemia, bihemispheric ischemia
  • Hypoventilation => vasodilation => Increased ICP
  • Maintain sats > 94% if hypoxic

H&P

  • Establish time
  • NIHSS scores (>= 20 indicate severe stroke

Vitals

  • Fever
    • Contributes to brain injury, increased mortality
    • Differential
      • Meningitis
      • Subdural Empyema
      • Brain Abscess
      • Infective Endocarditis

Labs

  • Noncontrast head CT
  • Serum glucose/POCT glucose
  • O2 sat
  • ECG
  • CBC
  • Troponin
  • BMP
  • Coags
  • Consider
    • LFTs
    • Tox screen
    • Blood ETOH
    • Pregnancy test
    • ABG
    • CXR (consider aspiration)
    • LP if subarachnoid suspected
    • EEG if seizures suspected
    • Thrombin time or ecarin clotting time if patient taking direct thrombin inhibitor/direct factor Xa inhibitor
    • Type and cross in case FFP needed to reverse coagulopathy for ICH

Nursing/Monitoring

  • Cardiac monitoring for at least 24 hours to monitor for afib, longer monitoring = more chance to detect afib
  • IVF for dehydration
  • Patient Positioning
    • Ischemic stroke: Supine position 24 hours to increase cerebral perfusion (if tolerated)
    • Hemorrhagic, clinical deterioration > 24h, large infarction, or inc. ICP: HOB 30 degrees
  • Activity
    • Early mobilization (within 24h) reduces 3 month outcomes
  • Reduce Fevers (APAP for normothermia)

Procedures

  • Echocardiogram
  • NPO until swallow eval

Glucose Control

  • Hyperglycemia is associated with worsening outcomes
  • treatment for hyperglycemia to achieve serum glucose concentrations in the range of 140 to 180 mg/dL

Blood Pressure Control

  • First 24 Hours
    • Elevated systolic blood pressure was associated with an increased risk of recurrent ischemic stroke (50 percent greater risk of recurrence with a systolic blood pressure of >200 mmHg versus 130 mmHg), while low blood pressure (particularly <120 mmHg) was associated with an excess number of deaths from coronary heart disease.
    • TPA
      • Before lytic therapy is started, treatment is recommended so that systolic blood pressure is ≤185 mmHg and diastolic blood pressure is ≤110 mmHg
      • The blood pressure should be stabilized and maintained at or below 180/105 mmHg for at least 24 hours after thrombolytic treatment. This issue is discussed in detail separately
    • Non-TPA
      • blood pressure not be treated acutely unless the hypertension is extreme (systolic blood pressure >220 mmHg or diastolic blood pressure >120 mmHg), or the patient has active ischemic coronary disease, heart failure, aortic dissection, hypertensive encephalopathy, acute renal failure, or pre-eclampsia/eclampsia
  • After 24 Hours
    • Current guidelines suggest that antihypertensive medications should be restarted at approximately 24 hours after stroke onset in patients with preexisting hypertension who are neurologically stable, unless a specific contraindication to restarting treatment is known
    • However, patients with extracranial or intracranial large artery stenoses may require a slower reduction in blood pressure (eg, over 7 to 10 days after ischemic stroke), as some degree of blood pressure elevation may be necessary to maintain cerebral blood flow to ischemic brain regions
  • Agents for BP Control
    • Consensus guidelines suggest intravenous labetalol and nicardipine as first-line antihypertensive agents if pharmacologic therapy is necessary in the acute phase, since they allow rapid and safe titration to the goal blood pressure

Lytics

  • Alteplase for treatment of acute ischemic stroke within 3 hours

Meds

  • Antithrombotic therapy initiated within 48hours of stroke onset
  • PPX for DVT
  • Antithrombotic therapy at discharge
  • Lipid lowering therapy
  • Smoking cessation

 

The Mandatory Disclaimer: All information on this website is purely for educational and training purposes. Use best clinical judgement, the most current reference articles, medical standards of care, and specialist consultations when making clinical decisions for your patients.

Last Updated August 26, 2015