Therapeutic Handbook - GGC Prescribing

Management of Acute Stroke 2The first 24 hoursAssessment / Monitoring• Potential Thrombolysis case:- If the patient presents within 4.5 hours of onset of focal symptoms, thrombolysis referralmay be appropriate – see Acute Stroke Guideline 1.- If patient presents > 4.5 hours, follow local protocol for stroke admissions.• Request ECG, U&Es, glucose (non-fasting), LFTs, cholesterol, FBC and ESR• Swallow test: check before prescribing and administering oral medication, oral fluids or diet.• Check BP:- If < 100/60 mmHg seek cause and consider commencing IV fluids (see Generalmanagement and drug therapy section on next page for details).- If > 200/130 mmHg seek evidence of malignant hypertension and consider treatment onlyafter discussion with consultant.Otherwise, document blood pressure but do not intervene.• Temperature: if > 37.5 O C look for evidence of infection and send blood / urine / sputum cultureas appropriate and give paracetamol (orally or per rectum). If aspiration is probable, commenceappropriate therapy (see General management and drug therapy on next page).• Check oxygen saturation and treat hypoxaemia if necessary (see General management anddrug therapy on next page).• Withhold antiplatelet / antithrombotic medication until CT scan excludes haemorrhage.CT brain scans should be requested as soon as possible after admission, and immediate scanningshould be carried out in the following instances:- Deteriorating consciousness level or coma.- On anticoagulants (ensure INR / coagulation is checked and discuss with consultant whetherreversal of anticoagulation is appropriate for patient).- Brain stem symptoms plus bilateral limb signs or progression of signs or ‘locked in’.- Cerebellar stroke with headache or features of raised intracranial pressure.- Severe headache.- ‘Stuttering’ onset.- Immunocompromised patients- Unexplained fever- Clinical signs of raised intracranial pressure• Rhythm check – atrial fibrillation may be present (see page 105 for management).Cardiovascular SystemContinues on next pagePage 119