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Classified as :
and mortality
Complications of Immobility :
Deep Vein Thrombosis / Pulmonary Embolism
Falls Pressure sores / ulceration
Infections :
Chest Infection Urinary Tract Infection Other Infections
Malnutrition :
Dysphagia
Dehydration
Pain :
Shoulder pain ( subluxation in the paretic limb ) Miscellaneous pain ( headache, musculoskeletal )
Neuropsychiatric Disturbances :
Depression Acute Confusional States ( Delirium )
Miscellaneous :
Cardiac Complications ( Arrhythmias, Myocardial Infarction ) Gastrointestinal Bleed Constipation
DVT.
Proximal DVT is more associated with Fatal Pulmonary
Embolism
patients with fluctuating symptoms patients treated with thrombolytics - in first 24 hrs.
contraindications for antithrombotic therapy in first 24 hrs post thrombolysis hemorrhagic infarcts
Caution : patients with Peripheral arterial disease
Peripheral Neuropathy
mobilization Patients with stroke during hospitalization : high risk for falls Incidence of second falls is almost twice that of first falls Risk factors : Heart disease Pre stroke cognitive impairment Urinary incontinence Most happen during day ( 45 % ) patients room ( 51 % ) during visits to bath room ( 20 % )
stroke :
Use adult assistive walking devices Motion detectors
Bed alarms
Use of convex mirrors to enable nursing staff to view
hallways from nursing stations Continuing staff education Minimal use of sedative medications
In dependent areas ( sacrum , greater trochanter ) Measures to reduce the incidence : Early mobilization of neurologically stable patients Those who cannot be mobilized, routine assessment of skin
breakdown is to be made Frequent Turning Keep skin dry and free of moisture Use oscillating mattresses to minimize the pressure on susceptible areas ( sacrum , greater trochanter ) Antibiotics and debridement
admission
Fever : Heralding sign of infection High risk factors : Age > 65 yrs
Patients with dysphagia Patients with dysarthria Failure of bedside water swallow test
especially in patients with reduced level of consciousness Incentive Spirometry : to facilitate air movement and prevent ateclectasis at lung bases Mobilization and Frequent changes in position
A study of Prophylatic antibiotics to prevent infection after stroke
( Chamorro et al 2005 )
radiographically confirmed chest infecion and in those where clinical suspicion is high
Empiric coverage for both aerobic and anaerobic pathogens should
patient with stroke Associated with use of indwelling bladder catheter Preventive measures : Intermittent catheterization Anticholinergic drugs Peform Urine analysis on routine basis Prompt antibiotic therapy : helps to prevent bacteremia, sepsis
videofluroscopy
A diverse array of stroke localizations may result in dysphagia
Hemispheric lesions : motor impairment of face, lips, tongue
attention deficit Brain stem lesions : impair normal pharyngeal swallow laryngeal elevation glottic closure cricopharyngeal relaxation
Brain stem stroke Impaired consciouness Difficulty / Inability to sit upright Shortness of breath Slurred speech Facial weakness Wet cough Weak cough Hoarse voice
3-oz water swallow test For those who fail in swallow test : to keep NPO
in approximately 25 % of patients
Discomfort involving cervical and lumbar spine, hip, knee
Treatment
onset Severity of depression : lesion volume functional impairment Degree of overall cognitive impairment
Systematic review of nine prevention trials provided little
Emotional lability
Anxiety Fatigue Differential diagnosis of delirium is broad. Causative factor must be aggressively searched Predisposing factors : advanced age
Prophylaxis But practically use of H2 antagonists / PPI is useful to prevent episodes of GI bleed
Cerebral edema Mass effect and herniation Hemorrhagic transformation Seizures Progressing ischemia Recurrent stroke
neurological function occurred in 13 % of patients within 48 72 hrs of hospitalization for acute ischemic stroke
Deterioration : Progressive stroke ( 33 % ) Increased intracranial pressure ( 27 % ) ( mc in 1st wk ) Recurrent cerebral ischemia ( 11 % ) ( mc in 1st wk ) Secondary parenchymal hemorrhage ( 11 % )
tissue shifts compress anterior cerebral artery against ipsilateral falx posterior cerebral artery against incisura
Cerebellar infarction can result in Brainstem compression &
Drowsiness ( earliest )
Progressive decline in level of consciouness Worsening neurological deficit Headache Nausea & Vomiting Life threatening cerebral edema associated with massive
MCA infarction becomes evident b/w 2 and 5 days after stroke onset
herniation high : young female absence of prior h/o stroke carotid artery occlusion
Hypodensity > 50 % of MCA Territory
maintainence : 0.25 0.5 g/kg every 4-6 hrs target s.osmolality : 310-320 mosm/L Hypertonic Saline : 3 % NaCl target : S.Na+ : 145 mmol/L Barbiturates Hyperventilation : target Pa Co2 : 30 mm Hg Elevated Head Position : head of bed kept at 30 degrees
%
Accompanied by neurological deterioration or frank hematoma
formation
Risk factors : Patients treated with antithrombotic and thrombolytic therapy Large infarct with mass effect Advanced age ( > 70 yrs ) Low platelet count Elevated Blood Pressure
transfusion of Fresh Frozen Plasma ( 5-10 ml/kg ) and Cryoprecipitate ( 0.1bag/kg ) is recommended.
range from 2 23 %
injury
Early onset seizures ( < 14 days post stroke ) are at lower risk of seizure
Cost effective
Reduce mortality
Improve functional outcomes