Documentos de Académico
Documentos de Profesional
Documentos de Cultura
Version 2.10
Page 1 of 22
Consultation Process:
Distribution:
Change Record
Date
Author
Change
Version
Feb 2014
AWB
2.10
Feb 2014
AWB
2.10
Feb 2014
AWB
2.10
Feb 2014
CF/AWB
2.10
Feb 2014
AWB
2.10
Feb 2014
AWB
2.10
Version 2.10
Page 2 of 22
FOREWORD
This guideline is intended to summarize treatment of acute stroke during the initial phases of
diagnosis, investigation and management (i.e. the first few hours to days). They are to support
non-specialist staff prior to the patient being admitted to the Stroke Unit.
More comprehensive guidelines exist and can be accessed online e.g. SIGN guideline 108, NICE.
This guidance is not intended to serve as a standard of medical care or be applicable in every
situation. Decisions regarding the treatment of individual patients must be made by the clinician in
light of that patients presenting clinical condition and with reference to current good medical
practice.
Subarachnoid haemorrhage, subdural and extradural haemorrhage are not dealt with in this
document as they do not fall under the remit of stroke disease.
Version 2.10
Page 3 of 22
Acute Assessment
Airway
Breathing
Circulation
Assess blood pressure and pulse. Avoid wide fluctuations in blood pressure.
Commence IV fluids in hypovolaemic or drowsy patients and in those nil by mouth.
If IV access cannot be obtained and central venous access is inappropriate, then
subcutaneous fluids can be used to maintain plasma osmolality.
Avoid dextrose in the early post-stroke phase to avoid iatrogenic hyperglycaemia.
Disability
D (Dextrose)
Exposure
Cognitive
Function
1.2
Immediate investigations
Obtain blood for FBC, U&E, LFT, CRP, glucose, cholesterol, ESR & clotting screen.
Perform 12 lead ECG, in particular looking for the presence or absence of atrial fibrillation.
Request Chest X-ray
Request a CT brain scan (see section 1.4)
Version 2.10
Page 4 of 22
1.3
Swallow Screen
All patients with suspected stroke should be screened to identify any difficulty in
swallowing. This will be carried out before giving any food, drink or oral
medication and within 6 hours of admission (NICE).
Results will be clearly documented in the unified case notes using the stroke
bundle sticker or water swallow test paperwork. If a patient is not sufficiently alert to
cooperate with screening note this as a Fail and document clearly that screening has
been commenced.
If the patient fails, the screening will be repeated on a 12-hourly basis until 48 hours
post-stroke. If the patient is kept nil-by-mouth
o Commence full oral hygiene
o IV fluids to maintain hydration
o Identify clinically essential medicines and consider alternative routes for
administration (e.g. rectal aspirin, intravenous digoxin).
Patients who fail the water swallow test should be discussed with the Speech and
Language therapist and a dietician.
http://www.nhsforthvalley.com/__documents/qi/ce_guideline_nursing/swallow-screening-foradults-with-suspected-dysphagia-clinical-care-standards.pdf
1.4
CT Brain Imaging
Efforts should be made to scan the patient on the day of the admission if this can be done.
If presenting out-of-hours and no immediate indication (as above), a CT brain should be
requested for the following morning by the admitting doctor.
CT brain scan should be performed within 24 hours of hospital admission.
Confirm in the patients case-notes that a CT scan has been requested. This should help to
avoid duplicate requests and risk of unnecessary ionising radiation exposure.
The result of the scan should be reviewed at the earliest opportunity and recorded in the
patients case notes.
Appropriate action should then be taken as soon as possible (e.g. administering aspirin if
ischaemic stroke, discussion with neurosurgery if appropriate etc.).
It is the responsibility of the person requesting the CT brain scan to ensure the report is
reviewed or that appropriate handover of this responsibility is made to the next shift or
ward to which the patients is transferred in order that the above actions be carried out.
Version 2.10
Page 5 of 22
1.5
If brain imaging has excluded an intracerebral haemorrhage or complicating structural CNS lesion
(e.g. tumour, abscess);
1.6
Organised Stroke Unit care has been shown to improve functional outcome and reduce
mortality in patients with stroke.
The importance of this is recognised by the Scottish Government who set a HEAT
target regarding patients with stroke being treated promptly in a Stroke Unit.
After initial work-up in the Emergency Department, Clinical Assessment Unit or Acute
Admissions Unit, patients with stroke or TIA should be transferred to the Stroke Unit.
This should be facilitated early through the Patient Flow Co-ordinators, Stroke Unit and
Stroke Team.
Referral to the Stroke Team should be made. The preferred method of referral may be
updated more frequently than these guidelines. The most up-to-date advice on referral
will be available in CAU/AAU/ED.
Version 2.10
Page 6 of 22
1.7
STROKE BUNDLE
SWALLOW SCREENING
Date:
Time:
:
Initials
Please refer to NHS FV Swallow Screening Procedure and record detailed result on form
Pass
Fail
BRAIN IMAGING
/
Time:
/
:
CT
Scan Performed
Request to Radiology
Date:
Date:
h
Time:
/
h
MRI
Report reviewed
/
Time:
Initials
ASPIRIN
Date:
/
:
Initials
(record time aspirin given)
Date:
Time:
If no haemorrhage on imaging and no other contra-indication, prescribe & administer ASPIRIN 300mg stat
and regular ASPIRIN 300mg daily. DO NOT routinely prescribe prophylactic LMWH.
HEAT Target
Liaise with Flow Co-ordinator and Stroke Nurse or Unit to arrange transfer if clinically stable and appropriate to do so
Admitted to
Stroke Unit
Date:
Time:
Initials
The Stroke Bundle Sticker is available in the acute front door areas the Emergency
Department, the Clinical Assessment Unit and the Acute Admissions Unit in addition to the
Stroke Unit. If a patient is suspected of having a stroke or TIA then place a sticker in their notes
to prompt actions and record times. If the subsequent diagnosis is not stroke or TIA then simply
document this in the notes rather than remove the sticker.
The information above is used for the Scottish Stroke Care Audit to monitor services and
improve patient care (see Section 7).
Version 2.10
Page 7 of 22
Pharmacological Therapy
Patients prescribed aspirin 300mg should continue on this for 14 days then change to
clopidogrel 75mg for long term secondary prevention. (NICE update 2010).
Patients initially prescribed clopidogrel (300mg loading dose then 75mg daily) should
continue on the clopidogrel.
is
evidence
that
If unable to take clopidogrel for long term therapy, aspirin 75mg PLUS dipyridamole
retard 200mg BD is the preferred option.
Anticoagulant therapy should not be used routinely in the acute ischaemic stroke
setting (SIGN, NICE).
Anticoagulation with warfarin can be introduced early in patients with minor stroke or TIA
(SIGN), but should be deferred for two weeks after onset in those with major stroke
(SIGN, NICE). Target INR is 2.0-3.0. Antiplatelet therapy (as in section 2.1.1) should be
used in the interim.
In people with prosthetic heart valves who have disabling cerebral infarction and who
are at significant risk of haemorrhagic transformation, anticoagulation treatment should
be stopped for 1 week and aspirin 300 mg substituted (NICE). Such patients should be
discussed with the cardiologist at the earliest opportunity.
Version 2.10
Page 8 of 22
(continued)
Patients with ischaemic stroke and symptomatic proximal deep vein thrombosis or
pulmonary embolism should receive anticoagulation treatment in preference to
treatment with aspirin unless there are other contraindications to anticoagulation (NICE).
People with haemorrhagic stroke and symptomatic deep vein thrombosis or pulmonary
embolism should have treatment to prevent the development of further pulmonary
emboli. Each patient should be considered on an individual basis. Treatment options
include an inferior vena caval filter or anticoagulation.
Anti-embolic (TED) stockings are not recommended for thromboprophylaxis after stroke
(CLOTS-1 and CLOTS-2 trials).
Intermittent Pneumatic Compression (IPC) has been shown to significantly reduce the
risk of DVT and improve overall survival to 6 months (CLOTS-3 trial). IPC can be used in
patients with ischaemic or haemorrhagic stroke and should be used as soon as is
feasible after admission and definitely within the first three days.
o
After 30 days the responsible clinical team should assess the patient for appropriate DVT
prophylaxis.
Regularly review the need for thromboprophylaxis (both the need to commence therapy
or to discontinue therapy when no longer appropriate).
Version 2.10
Page 9 of 22
Hypertensive encephalopathy
Hypertensive nephropathy
Hypertensive cardiac failure/myocardial infarction
Aortic dissection
Pre-eclampsia or eclampsia
Intracerebral haemorrhage with systolic blood pressure 200 mmHg
or
The patient may be considered for blood pressure lowering medication if a potential
candidate for thrombolysis and BP is >185/110, however, this is at the discretion of the oncall stroke specialist.
2.1.5 Statins
Patients with ischaemic stroke on prior statin therapy should continue treatment, via a
nasogastric tube, if necessary.
SIGN recommends using simvastatin 40mg or atorvastatin 80mg based on the Heart
Protection Study (HPS) and SPARCL trial respectively.
Patients not currently prescribed a statin would usually receive simvastatin 40mg.
Following clinical risk assessment by a stroke consultant atorvastatin 80mg may be
recommended.
Version 2.10
Page 10 of 22
Diabetic patients on insulin who are unable to swallow (or in whom there is concern about
ability to maintain adequate oral intake) should be commenced on an IV sliding scale
insulin regimen.
Care should be taken not to cause hypoglycaemia with such regimes and a glucose
of 7mmol/l is acceptable as the minimum level. The insulin dosing for the sliding
scale may have to be adjusted to avoid glucose levels below this.
Routine use of intravenous insulin regimens to lower blood glucose in patients with
moderate hyperglycaemia after acute stroke is not recommended as there is no trial
evidence yet of benefit and a significant demonstrated risk of inducing hypoglycaemia.
Advice should be sought from the diabetic specialist team if there is continued concern
about glycaemic control.
Hypoglycaemia in stroke
2.2
Further investigation
Clinical deterioration following stroke may be related to intercurrent infection so this must
also be considered.
Further imaging with CT angiogram, MRI brain or MR angiogram may be required and
should be discussed with a consultant.
Request urgent carotid duplex scan for all patients with non-disabling ischaemic stroke
syndrome or TIA in the carotid territory who are potential candidates for carotid surgery
(SIGN).
Version 2.10
Page 11 of 22
2.2.3 Echocardiogram
Echocardiography is not recommended for all patients with ischaemic stroke or TIA (SIGN).
Enter as much information on the request card as possible to allow appropriate vetting of
the request (e.g. ECG findings, presence of murmurs etc).
If a patient has had a recent echocardiogram prior to their stroke, a repeat echo may not be
appropriate.
The routine use of echocardiography with contrast media for further evaluation of patients
following stroke or TIA is not recommended. This should only be requested after discussion
with a cardiologist.
Cardiac rhythm monitoring (24/48/72 hour ECG tapes) may be appropriate to investigate for
paroxysmal atrial fibrillation in patients with sinus rhythm on admission ECG.
This should be requested on discussion with a consultant.
Version 2.10
Page 12 of 22
Initial Management
A baseline full blood count and clotting screen is required (if not already done).
Clotting levels in those receiving anticoagulation treatment (and have an elevated INR)
should be returned to normal as soon as possible. The haematoma seen on the CT is a
snapshot image and will often continue to expand following the CT scan. Discuss with the
on-call haematologist the appropriate treatment to give. This will usually be a combination
of prothrombin complex and intravenous vitamin K. (NICE).
The PT and APTT can be affected by novel oral anticoagulant drugs but these changes do
not reflect the degree of anticoagulant effect of these drugs. If a patient suffers an intracerebral haemorrhage while taking one of these drugs then discuss appropriate treatment
with the on-call haematologist.
While routine surgical evacuation by craniotomy is not recommended for supratentorial primary
intracerebral haematoma, early neurosurgical discussion may still be required in individual
circumstances. This may include younger patients with haemorrhage and subsequent pressure
effects or those with very superficial haemorrhage. If there is doubt about appropriateness, then
discussion should take place in order that patients do not miss out on appropriate intervention.
Blood Pressure Management
Consider acute management of hypertension in intracerebral haemorrhage if systolic blood
pressure >200mmHg. Lowering by no more than 20% in the first 24 hours may be
advisable. Intravenous labetolol or glyceryl tri-nitrate may be options. Clinical trial evidence
in this area is inconclusive.
Clinical Observation
Regular clinical observation should be made including neuro-obs and Glasgow Coma
Scale. This should be done at least hourly for the first 24-48 hours.
Patients anticoagulated solely due to atrial fibrillation who have a cerebral haemorrhage
should usually have their anticoagulation fully reversed.
Statin Therapy
Statin therapy after haemorrhagic stroke is not recommended routinely unless the risk of
further ischaemic vascular events outweighs the risk of further haemorrhage (SIGN).
Subarachnoid haemorrhage and subdural and extradural haemorrhage are managed
differently from primary intracerebral haemorrhage and are not covered in this guidance.
Version 2.10
Page 13 of 22
Swallowing Impairment
The presence of dysphagia indicates an increased risk of lower respiratory tract infection.
o Aspiration is a risk of stroke and is associated with poor outcome.
o Risk reduction - sit up and mobilise as soon as possible (NICE, SIGN)
o Treat for aspiration pneumonia as per the local antibiotic guidelines.
The presence of a nasogastric tube does not prevent aspiration of saliva or reflux of NG feed and
aspiration. Attending staff should remain alert to the possibility of aspiration after placement.
4.2
In clinical practice, the screening process is used to identify those patients who should be
referred for full clinical assessment by a professional skilled in the management of
dysphagia (usually a speech and language therapist (SLT).
If the screening procedure does not identify any difficulties, the patient can be allowed to
eat and drink avoiding unnecessary restrictions on oral intake (SIGN 119).
4.3
http://www.nhsforthvalley.com/__documents/qi/ce_guideline_nursing/swallow-screening-foradults-with-suspected-dysphagia-clinical-care-standards.pdf
http://www.nhsforthvalley.com/__documents/qi/ce_guideline_nutrition/clinical-care-standar-forplacement-of-nasogastric-feeding-tubes-in-adults.pdf
http://www.nhsforthvalley.com/__documents/qi/ce_guideline_nutrition/nasogastric-feeding-carebundle.pdf
Version 2.10
Page 14 of 22
Version 2.10
Page 15 of 22
Version 2.10
Page 16 of 22
Section 5:
The symptoms of a TIA usually resolve within minutes or a few hours at most, and anyone with
continuing neurological signs when first assessed should be assumed to have had a stroke.
Was the event of sudden onset? Are the symptoms focal (attributable to a single vascular territory)?
Unilateral weakness and/or sensory disturbance of face, arm, leg or a contiguous combination
Dysphasia
Visual Field Defect Diplopia
Does the patient have vascular risk factors?
Stroke a clinical syndrome of rapidly developing symptoms and/or signs of focal neurological dysfunction lasting
more than 24 hours with no apparent cause other than of vascular origin
TIA - transient episodes of focal cerebral dysfunction or transient monocular dysfunction during which symptoms last
less than 24 hours and are presumed to be of vascular origin.
Score
Risk Group
0 to 3
4 to 5
6 to 7
Low
Medium
High
2 days
90 days
1.0%
4.1%
8.1%
1.2%
5.9%
11.7%
3.1%
9.8%
17.8%
5. Action Plan
Office Hours - 0900h to 1600h Monday to Friday
2
Contact TIA MOBILE 01324 567691
Complete Referral Form
Bloods
Out of Hours - 1600h to 0900h AND all day Saturday & Sunday
ECG
CXR
Bloods
ECG CXR
Complete referral form & leave at ED reception
Start appropriate secondary prevention
Give Driving Advice (see below)
Advise call 999 if further symptoms pending review
If diagnostic doubt, significant abnormality found on basic tests,
or significant co-morbidity, then use clinical judgement &
admission may be appropriate
6. Other Information
Immediate Secondary Prevention Drug Regime
Aspirin 300mg STAT followed by 75mg daily
(If true aspirin intolerance, Clopidogrel 300mg STAT followed by 75mg daily)
Drugs to be dispensed from the Emergency Department or Clinical Assessment Unit
Other drug therapy (other antiplatelets, statins, anti-hypertensives etc.) will be started after clinic review
Patients with stroke, TIA or amaurosis fugax must not drive for at least one month
Document that advice given. If patient drives against advice, will not be covered by insurance company
1. Johnston SC et al. Validation and refinement of scores to predict very early stroke risk after transient ischaemic attack. Lancet 2007;369:283-92
2. SIGN 108.Section 4.5 U&Es, random glucose, random cholesterol, FBC, ESR. Other blood tests as clinically indicated.
3. CXR for all who are admitted, all smokers and all with another clear indication (unless a CXR has recently been performed).
Other patients will be assessed at clinic and a chest x-ray performed if necessary.
4. DVLA guidelines can be found online at https://www.gov.uk/government/publications/at-a-glance
Version 2.10
Page 17 of 22
Section 6:
6.1
Special Circumstances
Following proximal middle cerebral artery (MCA) occlusion, subsequent massive oedema of
infarcted tissue can result in a progressive increase in intracranial pressure, coning and
death.
For individuals aged up to 60 years who suffer an acute MCA territory ischaemic stroke
complicated by massive cerebral oedema, surgical decompression by hemicraniectomy
can significantly reduce mortality if performed within 48 hours of stroke onset (SIGN).
Intravenous mannitol and/or corticosteroids have no effect on outcome and are not
recommended.
6.2
Local oedema within the posterior fossa following significant cerebellar infarction with local
mass effect or mass effect from haemorrhage can result in occlusion of the 4th ventricle and
obstructive hydrocephalus with coning.
Events can proceed rapidly with rapid and catastrophic deterioration. Close observation of
such patients is required including neuro-observation (including Glasgow Coma Scale) at
least hourly for the first 48 hours.
Basilar artery occlusion can also cause significant morbidity and mortality.
Version 2.10
Page 18 of 22
6.3
Cerebral venous thrombosis is a rare cause of stroke, accounting for 0.5% of all strokes per
annum. Diagnosing cerebral venous thrombosis is difficult and CVT are often assumed to
be ischaemic infarcts. Clinical symptoms are very variable and non-specific. CT
appearances can be subtly different and other imaging such as MR or CT venography may
be required. The aetiology is often multifactorial and underlying thrombophilias are found in
22% of patients (SIGN).
Patients with CVT should be discussed with a stroke specialist either locally or at the
Western General Hospital, Edinburgh.
6.4
The most likely cause of stroke in cervical artery dissection is embolism from the
dissection flap.
In patients with extracranial cervical arterial dissection consider treatment with either
anticoagulation for three to six months or antiplatelet agents (SIGN, NICE).
Version 2.10
Page 19 of 22
Section 7:
The Scottish Stroke Care Audit (SSCA) has been collecting information about stroke care
since 2002 and includes all hospitals managing acute stroke in Scotland. Its function is to
improve stroke care and outcomes using evidence-based medicine and audit standards. It
lies within the structure of NHS Quality Improvement Scotland (NHS QIS).
Data is collected on all patients admitted to hospital with stroke or TIA and all patients
attending outpatient cerebrovascular/TIA clinics.
The Scottish Government recognises stroke as a key health issue for the people of
Scotland and the Scottish NHS. HEAT targets have been used to emphasise the
importance of access to specialist stroke services.
Further information on the Scottish Stroke Care Audit including annual reports can be
accessed on their website.
http://www.strokeaudit.scot.nhs.uk
Swallow Screen
o 90% of stroke patients should have a swallow screening assessment on the day of
hospital admission (day 0.
Brain Imaging
o 90% of stroke patients should have a brain scan within 24 hours of hospital
admission.
Administration of Aspirin
o 100% of patients with acute ischaemic stroke (where there is no contra-indication to
aspirin therapy) should receive aspirin within one day of admission (day 0 or day 1).
It is anticipated that the above four standards will be accepted as a Stroke Bundle and that there
will be a future standard set for the percentage of stroke patients who achieve the full stroke
bundle standards.
Use of the Stroke Bundle Sticker (Section 1.7) in case notes will help prompt tasks being carried
out and recording of the time achieved.
Thrombolytic Therapy
o 80% of patients receiving thrombolytic therapy for acute ischaemic stroke should
receive the initial bolus dose of Actilyse within 60 minutes of arrival at hospital).
Out-patient Clinics
o 80% of patients with a definite cerebrovascular diagnosis (stroke, TIA, transient
monocular blindness or retinal artery occlusion) should be assessed at a
neurovascular clinic with 4 calendar days of receipt of referral.
Carotid Surgery
o 80% of patients undergoing carotid intervention for symptomatic carotid artery
disease should have the intervention within 14 days of the event that led to the
patient first seeking medical assistance.
Version 2.10
Page 20 of 22
Include
Version 2.10
Page 21 of 22
Version 2.10
Page 22 of 22