Stabilizing Stroke Patients: Quick And Effective Strategies

Stabilizing a stroke patient is a complex process that requires prompt recognition and timely intervention to prevent further brain damage and reduce the risk of death or long-term disability. The first few hours after a stroke are crucial, as healthcare professionals work to manage the patient's breathing, heart function, blood pressure, bleeding, and swallowing, among other symptoms. A brain scan, typically a CT scan, is often performed to determine the type and location of the stroke, which guides treatment options. For ischemic strokes caused by a clot, clot-busting drugs may be administered to reopen blocked arteries, while hemorrhagic strokes may require surgery to control bleeding. During this acute stage, the patient's condition is stabilized, and they are closely monitored for any changes. This early intervention is critical to improving patient outcomes and preventing further complications.

Monitor and manage blood pressure

Blood pressure control is a critical aspect of stabilising a stroke patient. The optimal blood pressure targets are yet to be determined, but it is generally agreed that aggressive efforts to lower blood pressure may be detrimental as they can decrease perfusion pressure and prolong or worsen ischemia. Both elevated and low blood pressures are associated with poor outcomes in stroke patients.

In the acute management of stroke, the consensus recommendation is to lower blood pressure only if the systolic pressure exceeds 220 mm Hg or if the diastolic pressure is greater than 120 mm Hg. However, a systolic blood pressure greater than 185 mm Hg or a diastolic pressure greater than 110 mm Hg is a contraindication for thrombolytics, a common treatment for acute ischaemic stroke. Therefore, blood pressure management may vary depending on whether thrombolytic therapy is being considered.

For patients who are not candidates for thrombolysis and have a systolic blood pressure below 220 mm Hg and a diastolic blood pressure below 120 mm Hg, blood pressure should be monitored without acute intervention. However, if there is evidence of end-organ involvement, such as pulmonary edema, aortic dissection, or hypertensive encephalopathy, antihypertensive therapy may be indicated. For patients with higher blood pressures, labetalol or nicardipine are typically the initial drugs of choice, with nitroprusside as another option in the setting of continuous blood pressure monitoring. The goal of intervention is to achieve a reduction in blood pressure of 10-15%.

For patients receiving thrombolytics, such as those with acute ischaemic stroke, blood pressure management is vital as uncontrolled hypertension is associated with hemorrhagic complications. The initial drug of choice is typically labetalol, with nitroglycerin topical or nicardipine as alternatives. Monitoring of blood pressure is crucial, especially during the first 24 hours. The goal of therapy should be to reduce blood pressure by 15-25% in the first day, with continued blood pressure control during hospitalisation.

In the case of hypotension, aggressive fluid resuscitation, a search for the underlying cause, and vasopressor support if necessary, are recommended. Baseline systolic blood pressure below 100 mm Hg and diastolic blood pressure below 70 mm Hg are associated with worse outcomes.

Control blood sugar levels

High blood sugar levels, or hyperglycemia, are common in patients with acute ischemic stroke and are associated with worse outcomes compared to normal blood sugar levels. If a stroke patient also has diabetes, their medical team will work with them to manage it.

Aggressive methods for reducing high blood sugar immediately following a stroke are not more effective than standard, lower-risk treatments. This was the conclusion of the Stroke Hyperglycemia Insulin Network Effort (SHINE) study, a large, multi-site clinical study. The study compared two commonly used strategies for glucose control in ischemic stroke patients: intensive glucose management, which required the use of intravenous delivery of insulin to bring blood sugar levels down to 80-130 mg/dL, and standard glucose control, which used insulin shots to get glucose below 180 mg/dL. Both treatments were equally effective at helping patients recover from their strokes. However, intensive glucose therapy increased the risk of very low blood glucose (hypoglycemia) and required a higher level of care, such as increased supervision from nursing staff.

Therefore, the recommended approach to controlling blood sugar levels after a stroke is to use standard glucose control methods, such as insulin shots, rather than more aggressive methods. This approach has been validated by research and is recommended in clinical guidelines.

Additionally, it is important to monitor blood sugar levels regularly and manage them effectively to prevent further complications.

Administer tissue plasminogen activator (t-PA)

Tissue plasminogen activator (t-PA) is a critical anti-thrombotic drug that can be used to stabilise stroke patients. It is a thrombolytic protease that converts the inactive plasminogen protein into its active form, plasmin. Plasmin is the major enzyme responsible for breaking down blood clots. t-PA is a serine protease (EC 3.4.21.68) found on endothelial cells lining the blood vessels.

T-PA can be administered intravenously, intraosseously, or via a catheter, depending on the severity and accessibility of the stroke. The faster t-PA is administered after the onset of stroke symptoms, the better. Ideally, it should be given within 4.5 hours of symptoms starting. It is important to note that t-PA is contraindicated and dangerous in cases of hemorrhagic stroke and head trauma.

There are several different types of t-PA, including alteplase, reteplase, and tenecteplase, which are produced using recombinant biotechnology techniques. These types of t-PA are used in clinical medicine to treat embolic or thrombotic strokes. The use of t-PA has been shown to significantly increase the odds of patients being alive and independent at the final follow-up, particularly when treated within 3 hours.

The benefits of t-PA administration in stroke patients include reducing the severity of the stroke and reversing some of its effects by reopening blocked arteries. However, there is a risk of hemorrhage with its use, and a significant mortality rate has been noted, mostly from intracranial haemorrhage.

Manage airway and breathing

Stabilizing a stroke patient involves managing their airway and breathing, as well as their heart function, blood pressure, bleeding, and swallowing. Here are some detailed instructions on how to manage the airway and breathing of a stroke patient:

• If the patient's Glasgow Coma Scale score is 8 or less, rapidly decreasing, or if they have inadequate airway protection or ventilation, they require immediate airway control through rapid sequence intubation.
• In cases where increased intracranial pressure (ICP) is suspected, rapid sequence induction should be administered to minimize the adverse effects of intubation.
• If brain herniation is imminent, the goal of mechanical ventilation is to hyperventilate and decrease ICP by reducing cerebral blood flow. In such cases, the recommended endpoint is an arterial pCO2 of 32-36 mm Hg, and IV mannitol can be considered.
• Supplemental oxygen should be provided if the patient's pulse oximetry reading or arterial blood gas measurement indicates hypoxia (SaO2 < 94%). Hypoxia in stroke patients is often caused by partial airway obstruction, hypoventilation, atelectasis, or aspiration of stomach or oropharyngeal contents.
• Supplemental oxygen use should be guided by pulse oximetry to ensure the patient's oxygen levels are within the desired range.
• Patients should be placed in a sitting position with their head elevated to at least 30 degrees for the first 24 hours, as this position may improve blood flow velocity in acute ischemic stroke. However, they should not be kept in this position for longer than 24 hours to avoid complications such as deep vein thrombosis, pressure ulcers, aspiration, and pneumonia.

Cardiac monitoring

The duration of cardiac monitoring is essential for effective detection. While a 24-hour Holter ECG monitoring may be standard in some places, studies have shown that longer monitoring periods significantly improve detection rates. For example, extending the recording time from 24 to 72 hours increases the frequency of detecting paroxysmal atrial fibrillation from 1.2% to 6.1%.

One study found that continuous cardiac monitoring in a stroke unit for at least 48 hours after admission was useful for detecting atrial fibrillation and optimising treatment. Another study compared 14-day patch-based monitoring with 24-hour Holter monitoring and found that the longer, patch-based monitoring was superior in detecting paroxysmal atrial fibrillation, with an associated greater use of anticoagulation for secondary stroke prevention.

In conclusion, cardiac monitoring plays a vital role in stabilising stroke patients by helping to identify atrial fibrillation, which can be a cause or complication of stroke. Longer monitoring periods, such as those exceeding 24 hours, have been shown to improve the detection of atrial fibrillation and lead to better treatment outcomes.

Frequently asked questions