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General Management of

Acute Stroke
Moch Syahrial P, dr, Sp.S
Dept of Neurology, Gambiran General Hosptal

Stroke

A syndrome characterized by rapidly


developing clinical signs of focal (or global)
disturbance lasting 24 hours or longer, or
leading to death/disability with no apparent
cause other than of vascular origin

National Institute of Neurological Disorders and Stroke, 2002.

Six mainstays
to the management of acute stroke

Diagnosis procedures to confirm diagnosis and provide the


opportunity to make therapeutic decision

Treatment of general conditions that influence long-term


functional outcome (BP, body temp, glucose level)

Specific therapy directed against particular aspects of stroke


pathogenesis, either recanalisation of a vessel occlusion or
prevention of mechanisms leading to neuronal death
(neuroprotection)

Prevention and treatment of complication, either medical or


neurological

Early secondary prevention, to reduce the incidence of early


stroke recurrence

Early rehabilitation

EUSI 2003

Emergent Dx and Assessment

Emergent Care: Evaluation, Diagnosis, and Triage


(Hour 0)
In addition to stabilizing the patient (supporting the ABCs -- airway,
breathing, circulation), the aims of emergent care are 4-fold:
To confirm the presence of acute stroke vs other systemic or
neurologic disorder(s)
To identify patients eligible (or ineligible) for acute IVT;
To screen for medical or neurologic complications; and
To provide baseline historical data to help determine the vascular
distribution, pathophysiology, and etiology of stroke
Emergent evaluation includes the medical history and physical (H&P)
examination, neurologic examination, and brain imaging studies.

Immediate General Assessment: <10 Minutes


From Arrival
Assess ABCs, vital signs
Provide oxygen by nasal cannula
Obtain IV access; obtain blood samples
(CBC, electrolytes, coagulation studies)
Check blood sugar; treat if indicated
Perform general neurological screening
assessment

Immediate Neurological Assessment:


<25 Minutes From Arrival
Review patient history
Establish onset (<3 hours required for thrombolytics)
Perform physical examination
Perform neurological examination:
Determine level of consciousness (Glasgow Coma Scale)
Determine level of stroke severity (NIH Stroke Scale or Hunt and Hess Scale)
Order urgent noncontrast CT scan
(door-toCT scan performed: goal <25 min from arrival)
Perform lateral cervical spine x-ray (if patient comatose/history of trauma)

Immediate Diagnostic Studies: Evaluation of a


Patient With Suspected Acute Stroke
All patients:
Brain CT (brain MRI could be considered at qualified centers)
Electrocardiogram
Blood glucose
Serum electrolytes
Renal function tests
Complete blood count, including platelet count
Prothrombin time/international normalized ratio [INR]
Activated partial thromboplastin time [aPTT]

Selected patients:

Hepatic function tests


Toxicology screen
Blood alcohol determination
Pregnancy test
Oxygen saturation or arterial blood gas tests (if hypoxia is suspected)
Chest radiography (if lung disease is suspected)
Lumbar puncture (if subarachnoid hemorrhage is suspected and CT is negative for blood)
Electroencephalogram (if seizures are suspected)

TERAPI UMUM: 6B
BREATH

BOWEL

Pernafasan
Oksigenasi

BLOOD
Tekanan darah
Gula darah

Konstipasi
Nutrisi
Perdarahan GIT

BLADDER
Retensi/inkontinensia urine
Keseimbangan cairan &
elektrolit

BRAIN
Penurunan kesadaran
Kejang
Peningkatan TIK

BONE & BODY SKIN

Imobilitas dekubitus

PENYULIT NEUROLOGIK
EDEMA SEREBRAL &
PENINGKATAN TIK
KEJANG
TRANSFORMASI PERDARAHAN

TANDA PENINGKATAN TIK

Nyeri kepala
Muntah proyektil
Hiccup
Penglihatan kabur

Penurunan kesadaran
Cushing reflex
Kejang
Pupil unisocor
Dilated pupil, nonreactive
pupil
Papil edema
Cranial nerve VI palsy
uni/bilateral
Decerebrate/decorticate
posture

TERAPI PENINGKATAN TIK


Tinggikan posisi kepala 300
Posisi kepala hendaklah menghindari penekanan vena
jugular
Hindari pemberian cairan glukosa atau cairan hipotonik
Hindari hipertermia, hipoglikemia, hiperglikemia
Jaga normovolemia
Osmoterapi atas indikasi
Intubasi untuk menjaga normoventilasi (pCO2 35-40
mmHg)

KEJANG
STATUS EPILEPTIKUS
Bangkitan kejang yg berlangsung lebih dari 30 mnt, atau
adanya dua bangkitan kejang atau lebih dimana diantara
bangkitan kejang tadi tdk terdapat pemulihan kesadaran

KLASIFIKASI
SE Konvulsi
SE non-konvulsif

PENANGANAN SE
Stad I (0-10 mnt)

Memperbaiki fungsi
kardiorespirasi
Memperbaiki jalan nafas,
pemberian oksigen, resusitasi
Px status neurologis

Stad II (1-60 mnt)

Pengukuran TD, N, t
EKG
IV Line, sample darah
Diazepam 10-20 mg i.v

PENANGANAN SE
Stad III (0-60 mnt)

Menentukan etiologi
Bila kejang berlangsung terus
selama 30 mnt setelah
pemberian diazepam pertama,
beri Phenytoin
Terapi vasopresor bila diperlukan
Koreksi komplikasi

Stad IV (30-900 mnt)


Bila kejang tdk teratasi, trasfer ke
ICU, berikan propofol, midazolam
atau thiopentone