Early management of stroke Flashcards
What is the 3rd common cause of death in the UK?
Stroke
Would the acute weakness of limbs following stroke by ipsilateral or contralateral?
Contralateral
Aswell as contralteral weakness of limbs, what other weakness is experienced as an acute complication of stroke, what 2 symptoms does it lead to?
Weakness and incoordination of oropharyngeal muscles leading to:
1) Dysarthria (slurred, indistinct speech)
2) Incoordination of swallowing
Damage to Broca’s area would lead to what symptoms?
Expressive dysphasia
Flow of speech is stilted with a difficulty finding words but reading, writing and comprehension are relatively intact
What symptoms would damage to Wernicke’s area lead to?
receptive dysphasia
Flow of speech is fluent but use neologisms (made up words) and mistake closely related words, comprehensions, reading and writing are impaired
What 3 physiological variables particularly need to be controlled following stroke?
1) Blood pressure - rises acutely after stroke
2) Oxygenation
3) Capillary blood glucose
In what 4 cases are antihypertensives recommended after acute stroke?
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
What is aortic dissection?
Intima of aorta tears and blood passes between the layers of the aortic wall
How is oxygenation managed following acute stroke?
Supplemental oxygen is only recommended if saturations fall below 95% on air and there are no contra-indications
SMART goals for rehabilitation should be set within how many days of admission?
Within 5 days of admission and should be reviewed regularly
What are SMART goals?
Specific Measurable Achievable Relevant Time limited
How is swallowing assessed (4 steps) - what confirms a safe swallow or unsafe swallow?
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
If a patient has an unsafe swallow what procedure is put in place?
Nil by mouth
Given an NG tube
Refer to speech and language therapist for formal assessment
If a patient still has an unsafe swallow after 6 weeks what should be considered?
A gastrostomy tube
What is the prevention for DVT for hospital inpatients?
Injections of low molecular weight heparin
What is the treatment for DVT?
Warfarin for 6 months
What is the prevelance of pressure ulcers in inpatients?
3-14%
Pressure ulcers are associated with a how many fold increase in mortality in elderly patients?
5 fold
Give 6 risk factors for pressure ulcers?
1) Immobility
2) Malnutrition
3) Diabetes
4) Smoking
5) Terminal illness
6) Sensory impairment
What are the 3 factors in the pathogenesis of pressure ulcers?
1) Sustained pressure, often over a bony prominence
2) Friction and shear forces when moving patient
3) Moisture: incontinence and sweating
What are the 2 contributing factors associated with stroke which can lead to shoulder subluxation?
1) Weakness of rotator cuff muscles on stroke side
2) Neglect of affected limb (in right hemisphere only)
How can other causes of shoulder pain be ruled out in suspected shoulder subluxation?
Ultrasound scan
What is the managment of shoulder subluxation?
Optimise positioning and support shoulder
Why may joint pathologies be a compication following stroke?
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
Why does post stroke pain occur?
Damage to the somatosensory cortex leads to contralateral sensory disturbance
Post stroke can be associated with negative or positive phenomena, give examples of each?
Negative phenomena: decreased sensation in one or more modalities
Positive phenomena: parasthesia, burning or shooting pains or dysaesthesia
What is dysaesthesia?
Abnormal sensations: altered perception (eg. soft touch felt as prickly pain)
Give the 10 common acute complications of stroke?
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
Does post stroke pain tend to respond to paracetamol, opiates or NSAIDs?
No, doesnt tend to respond to any of the 3
Give 2 types of drugs which post stroke pain does tend to respond to?
1) Anti-epileptic drugs: pregabalin or gabapentin
2) Anti-depressant: specifically amitriptyline
Give 5 common contributing factors to incontinence post stroke?
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
Give 3 ways of managing faecal incontinence?
1) Communication strategies - can communicate when need to go
2) Regular toileting
3) Managed bowel regime - use suppositories to open bowels at predictable intervals
What are 3 possible ways of managing urinary incontinence in males?
1) use of bottles if possible
2) Sheath as opposed to an indwelling catheter
3) Long term suprapubic catheter
What percentage of people are affected by depression following stroke?
50%
What are the 5 main contributing factors to the development of depression following stroke?
1) Adjustment to disability
2) Relationship with partner/family
3) Medical condition
4) Financial problems
5) Communication
What important factor must not be forgotten in assessment of depression following stroke?
Suicide risk assessment
In which 2 ways can depression following suicide be managed?
1) Counselling: supported conversation approach
2) Drugs SSRIs - second line
