stroke is a medical emergency. face arm speech test helps public recognise symptoms of stroke; can...
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Stroke is a Medical Emergency
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Face Arm Speech Test
Helps public recognise symptoms of stroke;
• Can they smile? Does one side droop? • Can they lift both arms? Does one drop? • Is their speech slurred or muddled? • Test all three symptoms
Of course, there can be other focal neurological symptomstoo (and not all of the above symptoms are due to a stroke)
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Acute Management (1)
• Ischaemic stroke– Aspirin (within 48 hours of onset) – Clot busting drugs (only within 4.5 hours of symptom
onset)– Decompressive craniectomy (lifting a flap of the skull
to relieve pressure) in a tiny proportion of patients
• Haemorrhagic stroke– Neurosurgery (only occasionally) to remove blood– Reverse blood clotting defects
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Acute management (2)
• General supportive– Intravenous fluids (for patients who can’t swallow)– Nutrition (nasogastric tube, modified diet, normal diet)– Oxygen (if oxygen levels low)– Bowel and bladder care – Prevention of pressure sores (? Pressure relieving
mattress, regular turns)
• Best outcomes if patient is admitted to a stroke unit
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What is a stroke unit?
• Organised stroke unit care is provided by multidisciplinary teams that exclusively manage stroke patients in; – a dedicated ward (stroke, acute, rehabilitation,
comprehensive)– with a mobile stroke team or – within a generic disability service (mixed rehabilitation
ward).
Stroke Unit Trialists' Collaboration. Organised inpatient (stroke unit) care for stroke Cochrane Database of Systematic Reviews. 2007.
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Stroke Unit, Royal Infirmary, Edinburgh 2000
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Cochrane Systematic Review of Stroke Units
• 31 trials, 6936 patients, compared stroke unit care with an alternative service
• 26 trials (5592 participants) compared stroke unit care with general wards
• Stroke unit care reduced the odds of death, institutionalised care and dependency
• Outcomes independent of patient age, sex or stroke severity
• Better when stroke units based in a discrete ward
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Why do stroke units improve outcomes? • Care co-ordinated by a multidisciplinary team
• Team meets to discuss patients at least weekly
• Nurses have expertise in rehabilitation
• Team consists of professionals interested or specialising in stroke
• Regular in-service training for staff and involvement of carers in patient care
• ? Early mobilisation, rapid treatment of complications of stroke
Langhorne1995.
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Rehabilitation Aims to Minimise Functional Effects
of Stroke
• Core team– Physician– Nurses– Physiotherapist– Occupational therapist– Speech and language
therapist– Social worker– Dietician
• Others who may be consulted– Psychologist– Psychiatrist– Vascular surgeon– Radiologist– Rheumatologist– Optometrist – Orthotist
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Scottish Stroke Care Audit
• National Audit allows each health board to evaluate care against published standards– Brain imaging– Aspirin– Stroke Unit access– Swallowing
assessments– Neurovascular clinic
access
http://www.strokeaudit.scot.nhs.uk/
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Complications from stroke during hospital admission
0
10
20
30
40
50
60
recurrentstroke
seizures urine infections chest infections other infections falls pain anxiety depression emotionalism confusion
frequency %
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Patterns of recovery are variable
time
function
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A 58 year old man• A shop keeper, drives a car
• Sudden onset of left arm and leg weakness, and slurred speech
• Presented at 6 hours, given aspirin
• Admitted to a stroke unit
• 2 days later weakness was improving
• 3 weeks later: slightly weak finger grip and reduced power left leg, ready for hospital discharge
• Long-term issues….driving, returning to work, secondary stroke prevention
• • He would like to know whether he will make a full recovery
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A 70 year old lady
• Sudden onset of severe right sided weakness and dysphasia, drowsy; found lying on floor by husband
• Unable to swallow, so required nasogastric feeding
• Over the next few weeks, developed pneumonia, requiring antibiotics and oxygen
• Recovered from pneumonia but still had severe dysphasia and no movement in her right side
• No real neurological recovery at 2 months, required PEG tube feeding
• Decision made in consultation with family that nursing home care required
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Patterns of Recovery
• Rate of recovery generally most rapid in the first few weeks
• If a patient deteriorates, consider medical complications, recurrent stroke
• 95% have completed functional recovery by 3 months
• But some patients continue to recover for several years
• Recovery related to – Restoration of blood flow (and so neurones not
irreversibly damaged may recovery) – Neuroplasticity– Functional adaptations
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Summary• Stroke is a medical emergency: Act FAST!
• Acute treatments can improve outcome
• Stroke Unit care improves outcomes
• Medical complications are common after stroke
• Pattern and rate of recovery is highly variable