Early management of stroke

Question 1

What is the 3rd common cause of death in the UK?

Answer 1

Stroke

Question 2

Would the acute weakness of limbs following stroke by ipsilateral or contralateral?

Answer 2

Contralateral

Question 3

Aswell as contralteral weakness of limbs, what other weakness is experienced as an acute complication of stroke, what 2 symptoms does it lead to?

Answer 3

Weakness and incoordination of oropharyngeal muscles leading to:

1) Dysarthria (slurred, indistinct speech)
2) Incoordination of swallowing

Question 4

Damage to Broca’s area would lead to what symptoms?

Answer 4

Expressive dysphasia

Flow of speech is stilted with a difficulty finding words but reading, writing and comprehension are relatively intact

Question 5

What symptoms would damage to Wernicke’s area lead to?

Answer 5

receptive dysphasia
Flow of speech is fluent but use neologisms (made up words) and mistake closely related words, comprehensions, reading and writing are impaired

Question 6

What 3 physiological variables particularly need to be controlled following stroke?

Answer 6

1) Blood pressure - rises acutely after stroke
2) Oxygenation
3) Capillary blood glucose

Question 7

In what 4 cases are antihypertensives recommended after acute stroke?

Answer 7

Get a rise and may settle within a few days, antihypertensives are not recommended unless:

1) intracerebral haemorrhage with a BP >200
2) Hypertensive encephalopathy/nephropathy/cardiomyopathy
3) Aortic dissection
4) Eclampsia/pre-eclampsia

Question 8

What is aortic dissection?

Answer 8

Intima of aorta tears and blood passes between the layers of the aortic wall

Question 9

How is oxygenation managed following acute stroke?

Answer 9

Supplemental oxygen is only recommended if saturations fall below 95% on air and there are no contra-indications

Question 10

SMART goals for rehabilitation should be set within how many days of admission?

Answer 10

Within 5 days of admission and should be reviewed regularly

Question 11

What are SMART goals?

Answer 11

Specific
Measurable
Achievable
Relevant
Time limited

Question 12

How is swallowing assessed (4 steps) - what confirms a safe swallow or unsafe swallow?

Answer 12

1) Position patient correctly and make sure they are alert
2) Give a single teaspoon of water
3) Give 2 further teaspoons of water
4) Give 50 ml of water
If at any stage the pateint is drooling from the mouth, coughing, choking or has a wet voice or cough this confirms and unsafe swallow. If not then patient has a safe swallow

Question 13

If a patient has an unsafe swallow what procedure is put in place?

Answer 13

Nil by mouth
Given an NG tube
Refer to speech and language therapist for formal assessment

Question 14

If a patient still has an unsafe swallow after 6 weeks what should be considered?

Answer 14

A gastrostomy tube

Question 15

What is the prevention for DVT for hospital inpatients?

Answer 15

Injections of low molecular weight heparin

Question 16

What is the treatment for DVT?

Answer 16

Warfarin for 6 months

Question 17

What is the prevelance of pressure ulcers in inpatients?

Answer 17

3-14%

Question 18

Pressure ulcers are associated with a how many fold increase in mortality in elderly patients?

Answer 18

5 fold

Question 19

Give 6 risk factors for pressure ulcers?

Answer 19

1) Immobility
2) Malnutrition
3) Diabetes
4) Smoking
5) Terminal illness
6) Sensory impairment

Question 20

What are the 3 factors in the pathogenesis of pressure ulcers?

Answer 20

1) Sustained pressure, often over a bony prominence
2) Friction and shear forces when moving patient
3) Moisture: incontinence and sweating

Question 21

What are the 2 contributing factors associated with stroke which can lead to shoulder subluxation?

Answer 21

1) Weakness of rotator cuff muscles on stroke side

2) Neglect of affected limb (in right hemisphere only)

Question 22

How can other causes of shoulder pain be ruled out in suspected shoulder subluxation?

Answer 22

Ultrasound scan

Question 23

What is the managment of shoulder subluxation?

Answer 23

Optimise positioning and support shoulder

Question 24

Why may joint pathologies be a compication following stroke?

Answer 24

Patient may compensate for weakness on the affected side by increased use of unaffected side which may unmask or exacerbate pre-existing musculo-skeletal conditions eg chronic back pain, OA, RA

Question 25

Why does post stroke pain occur?

Answer 25

Damage to the somatosensory cortex leads to contralateral sensory disturbance

Question 26

Post stroke can be associated with negative or positive phenomena, give examples of each?

Answer 26

Negative phenomena: decreased sensation in one or more modalities
Positive phenomena: parasthesia, burning or shooting pains or dysaesthesia

Question 27

What is dysaesthesia?

Answer 27

Abnormal sensations: altered perception (eg. soft touch felt as prickly pain)

Question 28

Give the 10 common acute complications of stroke?

Answer 28

1) weakness - contralateral limbs and speech and swallowing problems
2) Language problems
3) DVT
4) Aspiration pneumonia associated with dysphagia
5) Pressure ulcers
6) Shoulder subluxation
7) Joint pathologies
8) Post stroke pain
9) Incontinence
10) Depression

Question 29

Does post stroke pain tend to respond to paracetamol, opiates or NSAIDs?

Answer 29

No, doesnt tend to respond to any of the 3

Question 30

Give 2 types of drugs which post stroke pain does tend to respond to?

Answer 30

1) Anti-epileptic drugs: pregabalin or gabapentin

2) Anti-depressant: specifically amitriptyline

Question 31

Give 5 common contributing factors to incontinence post stroke?

Answer 31

1) Communication - cant communicate he needs the toilet
2) Immobility - cant reach the toilet in time
3) Constipation with overflow
4) Medication - laxatives, diuretics
5) Other medical problems: DM (polyuria), UTI, prostatic hypertrophy

Question 32

Give 3 ways of managing faecal incontinence?

Answer 32

1) Communication strategies - can communicate when need to go
2) Regular toileting
3) Managed bowel regime - use suppositories to open bowels at predictable intervals

Question 33

What are 3 possible ways of managing urinary incontinence in males?

Answer 33

1) use of bottles if possible
2) Sheath as opposed to an indwelling catheter
3) Long term suprapubic catheter

Question 34

What percentage of people are affected by depression following stroke?

Answer 34

50%

Question 35

What are the 5 main contributing factors to the development of depression following stroke?

Answer 35

1) Adjustment to disability
2) Relationship with partner/family
3) Medical condition
4) Financial problems
5) Communication

Question 36

What important factor must not be forgotten in assessment of depression following stroke?

Answer 36

Suicide risk assessment

Question 37

In which 2 ways can depression following suicide be managed?

Answer 37

1) Counselling: supported conversation approach

2) Drugs SSRIs - second line