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Acute Management of Ischaemic Stroke
- Thrombolysis with tissue plasminogen activator for acute ischaemic stroke.
- May be considered for selected patients within 4.5 hours of stroke onset.
- May only be given in consultation with the Acute Neurology Team: call the Acute Neurology Registrar (working hours: pager 8111, other times via hospital operator) or on-call Neurologist. Dr Fink is also available to consult on possible thrombolysis cases during working hours by cellphone via the hospital operator.
- A detailed thrombolysis protocol is available in the Acute Stroke Unit and on ward 28 (search for "stroke guidelines" on the CDHB intranet).
- Aspirin 150-300 mg daily should be started once ICH excluded by CT (withhold 24 hours for patients receiving thrombolysis). After 48 hours, consider changing to clopidogrel 75 mg PO daily. See Secondary Prevention of Ischaemic Stroke for the range of antiplatelet drugs available.
- Maintain patient 'homeostasis':
- Avoid aspiration pneumonia. Document bedside swallowing assessment for all patients.
- Keep nil by mouth (NBM) until formal swallowing assessment: either dysphagia screening tool administered by a stroke unit nurse trained in its use or speech language therapy (SLT) assessment.
- Maintain hydration: subcutaneous, NG or IV fluids if NBM or inadequate intake.
- Subcutaneous route may be a good option if supplementation to poor oral intake is required.
- Maintain euglycaemia.
- Detailed guidelines are available in the ASU (search for "stroke guidelines" on the CDHB intranet). Particular care is needed for insulin-dependent diabetics who are made NBM following stroke.
- It is reasonable to continue usual antihypertensives (Lancet Neurol 2010;9:767-775) but hypotension should also be avoided.
- Consider treating extreme hypertension:
- Ischaemic stroke: >220/120.
- Intracerebral haemorrhage: >180/105.
- Labetalol is the preferred agent to control acute hypertension if this is necessary. Nifedipine should be avoided.
Intravenous Labetalol Protocol
Intravenous Labetalol Protocol
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If systolic BP is 180-230 mm Hg or diastolic BP is 105-120 mm Hg (≥2 recordings, 5-10 minutes apart):
- Give IV labetalol 10 mg over 1-2 minutes.
- The dose may be repeated or doubled every 10-20 minutes up to a total dose of 150 mg.
- Monitor BP every 15 minutes during labetalol treatment and observe for development of hypotension.
- If BP is higher than the above limits, seek Specialist advice.
- Detailed protocols are available in the Acute Stroke Unit. Convert antihypertensive treatment to oral or NGT administration if continued IV boluses are required >24 hours.
- Treat pyrexia >37.5°C with paracetamol (pyrexia is associated with poor outcome after stroke).
- Nutrition: NGT feeding should be considered if NBM/poor intake >48 hours. For some patients, NGT feeding can be delayed safely up to one week from stroke onset. These decisions should be made in conjunction with the multidisciplinary team.
- DVT prophylaxis: see the Thrombosis section - VTE prophylaxis for patients with ischaemic stroke.
- Early mobilization out of bed within 24h should be expected.
- Even short periods are beneficial, e.g., up to commode for toilet or sitting in a chair.
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- Heparin: intravenous unfractionated heparin, subcutaneous unfractionated heparin, LMWH or heparinoids are not routinely recommended for treatment of patients with acute ischaemic stroke.
- IV unfractionated heparin may be considered in carefully selected patients, (e.g., evolving basilar thrombosis, crescendo TIA, carotid or vertebral artery dissection, visible cardiac mural thrombus on echo). However, there is little evidence to support its use. Neurological consultation is recommended.
Topic Code: 1506