Here we cover the steps involved in the management of general conditions, any co-morbidity and routine workup which should be done by a general physician on a daily basis in a stroke patient.

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Physiological homeostasis (oxygen, temperature, blood pressure, blood glucose)

1. Supplemental oxygen therapy: Patients should receive supplemental oxygen if their oxygen saturation drops below 95%.
2. Management of body temperature:
   1. Body temperature should be measured:
      1. 4-hourly in ICU or if the patient is non-ambulatory
      2. Twice a day as long as the patient is hospitalised
      3. As and when the patient reports or is reported to have fever
   2. Fever (>99.5ºF) should be treated with paracetamol. The search for possible infection (site and cause) should be made.
   3. Temperature <95ºF can lead to coagulopathies, electrolyte imbalance, infection and cardiac arrhythmias, and therefore should be managed using measures such as:
      1. Removing wet clothing
      2. Covering the person with blankets
      3. Providing warm drinks
      4. Using warm, dry compresses (don't apply direct heat)
      5. Medical treatment depending on the severity of cases: Passive rewarming, blood rewarming, warm intravenous fluids, airway rewarming etc.

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Management of blood pressure

Ischaemic stroke

1. In acute ischaemic stroke, parenteral antihypertensive medication should be recommended only if there is a hypertensive emergency with one or more of the following serious concomitant medical issues:
   1. Hypertensive encephalopathy
   2. Malignant hypertension
   3. Hypertensive cardiac failure/myocardial infarction
   4. Aortic dissection
   5. Pre-eclampsia/eclampsia
2. Antihypertensive medication should be withheld in ischaemic stroke patients unless systolic blood pressure/diastolic blood pressure(SBP/DBP) >220/120 mmHg or the mean arterial blood pressure (MAP) is >120 mmHg. Lowering by 15% during the first 24 hours is recommended.
3. Except in a hypertensive emergency, lowering of blood pressure should be slow and with the use of oral medications.
4. Sublingual use of antihypertensive is not recommended.
5. Blood pressure reduction to 185/110 mmHg or lower should be considered in people who are candidates for thrombolysis.

Pre-thrombolysis

1. If BP is >185/110 mmHg, Inj. labetalol 10-20 mg I.V. should be given over 1 to 2 minutes and may be repeated every 10 minutes to a maximum dose of 300 mg or labetalol infusion can be started at 1 to 8 mg/min.
2. If labetalol is not available, nitroglycerin infusion at 5 μg/min or nicardipine infusion at 5 mg/hour is an alternative to labetalol. Nitroglycerin dose may be increased by 5 μg/min every 3 to 5 minutes to a maximum rate of 200 μg/min. Nicardipine can be increased by 2.5mg/hour every 5min up to a maximum dose of 30 mg/hour.
3. The aim is to continue treatment till target BP <185/110 mmHg is achieved.

During/after thrombolysis

BP should be monitored every 15 minutes for 2 hours, then every 30 minutes for the next 6 hours and finally every hour for the next 16 hours. BP goal is <180/105 mmHg.

Intracerebral haemorrhage (ICH)

1. If systolic blood pressure is >200 mmHg or MAP is >150 mmHg (recorded twice, two or more minutes apart), then blood pressure should be aggressively treated with parenteral antihypertensive (e.g. labetalol, nitroglycerin or nicardipine or sodium nitroprusside).
2. If systolic blood pressure is >180 mmHg or MAP is >130 mmHg (up to 150 mmHg), use of rapidly acting oral or parenteral medication or nitroglycerin patch is advised.
3. Target SBP should be 140 to 150 mmHg for at least 7 days (see secondary prevention guidelines for subsequent days).

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Management of blood glucose

1. Oral hypoglycaemic agents (OHAs) should be discontinued and basal-bolus or sliding scale insulin should be started.
2. The blood glucose level should be maintained between (140-180 mg/dL). Elevated blood glucose >150 mg/dL should be managed with insulin administration using the sliding scale in the first week of stroke onset.
3. Blood glucose should be monitored in case of hypoglycaemia and accordingly, 20% glucose (50 ml bolus) should be administered.

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Management of renal function

As the renal clearance of most of the medicines is important, especially when the patient is on thrombolytics, management and monitoring of renal function are important for optimum levels of medicine in the blood. Renal clearance is delayed when KFTs are
abnormal, it may result in general haemorrhage.

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Cerebral oedema and Increased Intracranial Pressure (ICP)

1. Until more data are available, corticosteroids are not recommended for the management of cerebral oedema and increased intracranial pressure following stroke.
2. In patients whose condition is deteriorating secondary to increased ICP, including those with herniation syndromes, various options include: hyperventilation, mannitol, furosemide, CSF drainage and surgery. If a CT scan (first or repeat one after deterioration suggests hydrocephalus as the cause of increased ICP, then CSF diversion procedure can be used.
3. Initial care includes mild restriction of fluids, the elevation of the head end of the bed by 30 degrees and correction of factors that might exacerbate increased ICP (e.g. hypoxia, hypercarbia and hyperthermia).
4. Hyperventilation acts immediately (reduction of the pCO₂ by 5 to 10 mmHg lowers ICP by 25% to 30%) and may be used as a temporary measure to lower ICP but should be followed by another intervention to control brain oedema and ICP. Hyperventilation can cause vasoconstriction that might aggravate ischaemia.
5. An intravenous bolus of 40 mg furosemide may be used in patients whose condition is rapidly deteriorating. If required, furosemide 20 mg (once daily) may be continued for the first week. 3% hypertonic saline or acetazolamide 250 mg (BD) may be added in those not responding to other treatment methods.
6. Strict intake-output chart must be maintained to avoid dehydration.
7. In those with altered consciousness, mannitol (0.5 gm/kg intravenously given over 20 minutes) can be given every 6 to 8 hours. If clinically indicated, dose frequency may be increased to every 4 hours only if the central venous monitoring is possible. Central venous pressure should be kept between 5 and 12 mmHg to prevent hypovolemia. This may be continued for three to five days.

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General early supportive care

Position

1. Patients should be advised to undertake activities like sitting, standing or walking only with caution. An occasional patient, who deteriorates neurologically on assuming sitting or standing posture, should be advised bed rest for at least 24 hours and then the gradual assumption of an upright position.
2. Non-ambulatory patients should be positioned to minimise the risk of complications such as contractures, respiratory complications, and shoulder pain. Unconscious patients should be placed in the recovery position. Change of position every two hours during the day (and also during the night for unconscious patients but for conscious patients every four hours during the night) is recommended to avoid pressure sores.
3. Non-ambulatory patients should preferably be nursed on air mattresses.

Swallowing

1. All conscious patients should have an assessment of the ability to swallow. A water swallow test performed at the bedside is sufficient (e.g. 50 ml water swallow test).
2. Testing the gag reflex is invalid as a test of swallowing.
3. Patients with normal swallow should be assessed for the most suitable posture and equipment to facilitate feeding. Any patient with abnormal swallow should be fed using a nasogastric tube.
4. Patients who require nasogastric tube feeding for more than three weeks may be referred for gastrostomy.
5. Patients with altered sensorium should be given only intravenous fluids (dextrose saline or normal saline) for at least 2 to 3 days, followed by nasogastric tube feeding.

Oral care

1. All stroke patients should have an oral/dental assessment including dentures, signs of dental disease etc. upon or soon after admission.
2. For patients wearing a full or partial denture, it should be determined if they have the neuromotor skills to safely wear and use the appliance(s). If not, the denture should be removed.
3. The oral care protocol should address areas including frequency of oral care (twice per day or more), types of oral care products  (toothpaste and mouthwash) and specific management for patients with dysphagia.
4. If concerns are identified with oral health and/or appliances, patients should be referred to a dentist for consultation and management as soon as possible.

Early mobilisation

1. All patients should be referred to a physiotherapist/rehabilitation as soon as possible, preferably within 24 to 48 hours of admission.
2. Passive full-range-of-motion exercises for paralyzed limbs can be started during the first 24 hours.
3. The patient’s need in relation to moving and handling should be assessed within 48 hours of admission.

Nutrition

Physician/nurse/dietician should do nutrition assessment at the bedside and nutritional support should be considered in any malnourished patient.

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Management of Seizures

Patients with seizures, even single, should be treated with a loading and maintenance dose of a suitable anti-convulsant. Status epilepticus should be treated as per its guidelines. At present, there is insufficient data to comment on the prophylactic administration of anticonvulsants to patients with recent strokes.

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Deep venous thrombosis (DVT)

Prophylaxis against DVT

1. Patients with paralysed legs (due to ischaemic stroke) should be given standard heparin (5000 units subcutaneous twice daily) or low-molecular-weight heparin (with appropriate prophylactic doses as per agent once a day) to prevent DVT.
2. In patients with paralysed legs (due to ICH), DVT pump, routine physiotherapy and early mobilisation should be carried out to prevent leg vein thrombosis.
3. Early mobilisation and optimal hydration should be maintained for all acute stroke patients.
4. CLOTS (Clots in Legs OrsTockings after Stroke) trial data do not support the routine use of thigh-length graduated compression stockings for the prevention of deep vein thrombosis.

Treatment of DVT

1. Standard heparin (5000 U IV) or low molecular weight heparin (with appropriate therapeutic doses as per agent) should be started initially. When standard heparin is used, a prior baseline complete blood count and aPTT (activated partial thromboplastin time) should be done and a rebolus (80 U/kg/h) and maintenance infusion (18 U/kg/h) should be given (target aPTT of 1.5 times the control value). For using low molecular weight heparin, aPTT monitoring is not required.
2. Anticoagulation (warfarin 5 mg once daily or acenocoumarol 2 mg) should be started simultaneously unless contraindicated and the dose should be adjusted subsequently to achieve a target INR of 2.5 (range 2.0-3.0), when heparin should be stopped.
3. Baseline INR must be done before starting anticoagulation with warfarin or acenocoumarol.

Bladder care

1. An indwelling catheter should be avoided as far as possible and if used, indwelling catheters should be assessed daily and removed as soon as possible.
2. Intermittent catheterisation should be used for urinary retention or incontinence.

Bowel care

1. Patients with bowel incontinence should be assessed for other causes of incontinence including impacted faeces with spurious diarrhoea. Appropriate management with diapers may be considered.
2. Patients with severe constipation should have a drug review to minimise the use of constipating drugs, be given advice on diet, fluid intake and exercise (as much as possible), be offered oral laxatives and be offered rectal laxatives only if severe problems remain.

Infections

1. Development of fever after stroke should prompt a search for pneumonia, urinary tract infection or deep venous thrombosis.
2. Prophylactic administration of antibiotics is not recommended.
3. Appropriate antibiotic therapy as per national guidelines on antibiotic use should be administered early (after taking relevant culture specimens).

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Eye care

Eye complications in patients with stroke are common especially in patients who are unconscious or sedated. Eye complications can range from mild conjunctival infection to serious corneal injury. Permanent ocular damage may result from ulceration, perforation, vascularisation, and scarring of the cornea. Eye care should be part of the care provided to all people upon admission to stroke unit. To prevent dry eye, polyethylene film, methylcellulose drops, or methylcellulose ointment may be used. Polyethylene film covers are more effective at reducing the incidence of corneal abrasions than are ointments and drops.

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Click here to see references

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To read the first part on acute management, click here.

Disclaimer- The views and opinions expressed in this article are those of the author's and do not necessarily reflect the official policy or position of M3 India.

The author is a practising super specialist from New Delhi.