Early evaluation and emergency treatment of stroke, ultra-fine summary

*Only for medical professionals to read for reference.
Learning is a habit! Stroke, also known as stroke or cerebrovascular accident, is a group of cerebrovascular diseases characterized by acute onset, focal or diffuse cerebral dysfunction, including ischemic and hemorrhagic strokes .

For a long period of time in the past, stroke was considered to be a local manifestation of the cardiovascular system or overall disease, and was classified as a cardiovascular disease.

Although in recent years, with the in-depth research on the etiology and risk factors of cerebrovascular disease and the development of neuroscience, cerebrovascular disease is classified as a neurological disease in clinical medical institutions with more detailed departments, but it is related to the heart disease.
The vascular system is still inseparable.
Patients with atrial fibrillation and hypertension are more likely to have a stroke than the average person.

1.
Classification of cerebrovascular diseases 1.
Transient ischemic attack (TIA): also known as transient ischemic attack, refers to transient focal brain or retinal dysfunction in the corresponding area caused by vascular ischemia.
The symptoms generally recover completely within 24 hours.

2.
Cerebral infarction: It is a clinical symptom of cerebral dysfunction caused by cerebral tissue ischemia and hypoxia caused by local blood supply disorder.

(1) Embolic cerebral infarction: 20%, emboli can be cardiogenic or arterial.

(2) Thrombotic cerebral infarction: accounts for 60% of ischemic stroke, including large vessel infarction (70%) and small vessel infarction (30%).

(3) Lacunar cerebral infarction: accounts for 20% of ischemic stroke.

It is caused by the occlusion of the perforating blood vessels.

(4) Watershed infarction: also known as marginal zone infarction, it is caused by relatively low perfusion in the terminal area of ​​cerebral arteries and can produce bilateral symptoms.

(5) Other causes of cerebral infarction: especially young patients, other causes need to be considered, including coagulation disorders (such as antiphospholipid antibodies, protein C deficiency, protein S deficiency), sickle cell disease, muscle fiber dysplasia, arterial intimal exfoliation, drugs Abuse etc.

(6) Cerebral infarction of unknown cause: According to current medical knowledge, the cause of the infarction is unknown, or two or more causes are jointly involved.

3.
Cerebral hemorrhage: refers to the non-traumatic rupture of the primary blood vessels in the brain, blood flows into the brain parenchyma or intraventricular hematoma.

4.
Subarachnoid hemorrhage (SAH): Refers to the blood flowing into the subarachnoid space after the intracranial blood vessel ruptures.

5.
Cerebral venous system thrombosis: divided into venous sinus thrombosis and cerebral venous thrombosis.
It is due to inflammatory or non-inflammatory reasons that cause the formation of thrombosis in the venous system and cause occlusion, causing venous return obstacles, causing brain tissue congestion, edema, Increased intracranial pressure, which shows a series of related clinical symptoms.

2.
Early detection, early diagnosis, and early treatment of stroke.
Several pre-hospital treatment principles: 1.
Once a stroke is suspected, transfer to the nearest stroke treatment hospital or stroke center as quickly and safely as possible to minimize delays 2.
It is forbidden to turn the patient's head back and forth, loosen the patient’s clothes and go to the pillow to supine; 3.
Give the first bottle of liquid to the patient who is suspected of stroke with normal saline, and avoid giving sugary solutions (except for suspected hypoglycemia).
The solution is hypotonic, which increases the risk of cerebral edema.
At the same time, attention should be paid to avoid excessive fluid replacement; 4.
If possible, give cerebral protective treatment from the suspected stroke.

Here, I searched for a schematic diagram of a suspicious stroke processing path for your reference: three.
Emergency diagnosis of stroke 1.
Imaging examination The most definite purpose of imaging diagnosis is: ①Differentiation of ischemic and hemorrhagic cerebrovascular disease, cerebrovascular disease and other diseases, such as tumor, subdural effusion, brain Inflammation; ②Judge the degree of ischemia; ③Show occluded arteries and guide treatment.

(1) Electronic computed tomography (CT) recommendations: CT scans should be used as a routine and most important diagnostic examination method.

Significance: CT can detect cerebral hemorrhage or hemorrhagic infarction immediately, distinguish cerebral hemorrhage and cerebral infarction, only exclude cerebral hemorrhage before performing thrombolysis, antiplatelet or anticoagulant therapy; it can exclude some easily treatable causes, such as subdural hematoma ; Can rule out diseases similar to cerebrovascular diseases, such as tumors or SAH; can rule out cerebellar hemorrhage, especially when there are cerebellar symptoms and signs considering infarction or hemorrhage; if the diagnosis is in doubt, such as asymptomatic carotid artery stenosis, determine whether there is stillness Sexual infarction.

CT time: small intracranial hemorrhage can get better quickly, so it is difficult to distinguish small cerebral infarction on CT scan after a few days.

Fresh cerebral hemorrhage showed high density on CT.

SAH can be lighter in density and can be a thin, white layer.

Early signs of acute ischemia on CT include: decreased contrast between gray matter and white matter, decreased brain tissue density (low density); space-occupying effects include compression of the brain sulcus, subarachnoid cistern, and even ventricular deformation and midline displacement.

The worse the collateral circulation in the area of ​​vascular occlusion, the more severe the ischemia, and the earlier the abnormal changes on CT.

And CT angiography (CTA) can detect intracranial and extracranial vascular abnormalities.

(2) Functional MRI technical recommendations: MRI diffusion and perfusion imaging (DWI, PWI) should be performed for patients with acute ischemia for 3 to 6 hours.

Significance: MRI perfusion image is similar to CT perfusion image.
After injection of enhancer, it can immediately show changes in cerebral perfusion; MRI diffusion image is the most sensitive to the examination of cerebral ischemia, less than 1 minute, can be detected just a few minutes before occlusion The abnormal changes produced by the blood vessels can help find the location of blood vessel blockage or brain damage.

The comprehensive application of PWI and DWI is helpful to find the ischemic penumbra and provide imaging basis for thrombolytic therapy.

2.
Lumbar puncture (LP) recommendations: SAH is suspected clinically, but the CT scan is normal; patients with fever, headache, and neck stiffness are suspected of meningitis.

Significance: About 5% of SAH CT scans are normal.
Such patients often have less bleeding and no focal neurological defects (Hunt and Hess grade D); if SAH is clinically suspected, lumbar puncture should be performed even if the CT scan is normal. 4.
Emergency treatment 1.
General emergency treatment: Recommendations: routinely establish intravenous access; give normal saline for the first bottle of liquid, avoid giving sugary solutions; correct hyperglycemia and high fever; temporarily fast water until it is confirmed that the swallowing function is normal, and if necessary Nasal feeding tube; catheterization can be done if necessary.

Significance: After the patient arrives at the hospital, routinely establish a venous channel, and open a second venous channel if necessary.

For most patients, normal saline is given to maintain normal volume.

Unless the patient has low blood pressure, avoid rapid intravenous drip because it increases the risk of cerebral edema.

Avoid giving sugar solutions (except for suspected hypoglycemia).
Such solutions are hypotonic and increase the risk of cerebral edema.

2.
Control blood sugar unless the patient's blood sugar level is known, sugary solutions should not be given.

Many patients with cerebroemia have a history of diabetes, some of which are discovered for the first time after cerebral infarction.

The acute phase of cerebrovascular disease can worsen the original diabetes, and high glucose levels are not good for stroke, so short-term insulin therapy is necessary.

If the blood sugar is higher than 11.
1mmol/L, give insulin.

Hypoglycemia rarely occurs in patients with acute cerebral infarction.
If it occurs, it is best to give 10%-20% glucose intravenous infusion to correct it.

3.
Airway and ventilation recommendations: It is necessary to ensure that the patient's airway is unobstructed, provide oxygen to the hypoxic, and if necessary, tracheal intubation or tracheotomy.

Significance: Airway obstruction may be the main problem of acute cerebrovascular disease, especially in patients with impaired consciousness.

Insufficient ventilation can cause hypoxemia and hypercapnia, leading to instability of cardiopulmonary function.

Inhalation of secretions and stomach contents is a serious complication, which can cause obstruction of the airway and death.

It is necessary to ensure that the patient's airway is unobstructed and the breathing cycle is stable.

Normal respiratory function and adequate oxygen supply are necessary for the treatment of acute cerebrovascular disease.

Adequate oxygen supply and hyperventilation may be important for the protection of the penumbra.

For patients with mild to moderate cerebrovascular disease, if there is no hypoxia (blood oxygen saturation>90%), oxygen is not routinely given; pulse oximetry measurement, such as SO2<90%, oxygen supply, 2~4L/min , High concentration oxygen is contraindicated.

If there is no pathological respiration and blood gas analysis indicates moderate hypoxia, oxygen inhalation is sufficient.

For patients with pathological respiration, severe hypoxemia or hypercapnia, and coma patients with a higher risk of aspiration, early endotracheal intubation is recommended.

Indications for intubation are PO2<60mmHg or PCO2>50mmHg or obvious dyspnea.

Oral intubation should be done carefully.
To avoid reflex arrhythmia and/or blood pressure disturbances, atropine, thiopental, succinate, propofol, and succinylcholine should be used.

Prevent inhalation of stomach contents.

All patients undergoing nasogastric or oral endotracheal intubation should prevent inhalation and have their blood pressure measured every 6 hours.

The soft tube is generally maintained for no more than 2 weeks.

Patients with prolonged coma or pulmonary complications should undergo a tracheotomy after 2 weeks.

4.
Suggestions for vital signs: pay close attention to vital signs (pulse, respiration, blood pressure, body temperature) to find abnormalities and changes.

Significance: Abnormal breathing is particularly common in patients with lethargic cerebrovascular disease, and often reflects severe brain dysfunction.

Hypertension often occurs after a stroke.
This condition can result from underlying hypertension, a strong response to nervous system emergencies, and a physiological response to brain hypoperfusion.

Without antihypertensive treatment, blood pressure often returns to normal.

A variety of cardiovascular problems can occur in stroke patients, and arrhythmia can lead to cerebral thromboembolism.

Paroxysmal atrial fibrillation, severe symptomatic bradycardia, and high-grade atrioventricular block can be the cause or result of cerebrovascular disease events.

In the acute stage of cerebrovascular disease, ST-T changes and increased myocardial enzymes may appear similar to myocardial ischemia.

Atypical or asymptomatic myocardial infarction can occur in elderly or diabetic patients.

If acute or recent myocardial infarction is suspected, a 12-lead electrocardiogram (ECG) should be performed and left ventricular wall thrombosis should be excluded as much as possible.

Life-threatening arrhythmia is a potential early complication of stroke, especially in patients with intracerebral hemorrhage.

For severe stroke and hemodynamic instability, continuous ECG and systemic circulation should be monitored.

A.
Recommendations for blood pressure management: If blood pressure rises after ischemia or hemorrhagic stroke, more urgent treatment is generally not needed unless there are other medical diseases (myocardial infarction, heart failure, aortic dissection).

The indications for ischemic stroke requiring immediate antihypertensive treatment are systolic blood pressure> 220mmHg, diastolic blood pressure> 120mmHg or mean arterial pressure (MAP)> 130mmHg.

For those who need thrombolytic therapy, blood pressure should be strictly controlled at systolic blood pressure <180mmHg and diastolic blood pressure <100mmHg.

For hemorrhagic stroke, it is generally recommended to actively control blood pressure.

In patients with a history of hypertension, the blood pressure level should be controlled to an average artery below 130mmHg.

Patients just after surgery should avoid MAP greater than 110mmHg.

If the systolic blood pressure is 180mmHg and the diastolic blood pressure is 105mmHg, the blood pressure will not be lowered temporarily.

If the systolic blood pressure is less than 90mmHg, vasopressors should be given.

Blood pressure management for ischemic stroke: Antihypertensive therapy can be harmful.

Avoid excessive use of antihypertensive drugs.
Excessive antihypertensive treatment can reduce cerebral perfusion pressure and cause stroke to worsen.
In addition, stroke patients may overreact to antihypertensive drugs.

It is forbidden to use short-acting diarrhea because it is most important for patients with blocked arteries to maintain adequate collateral blood flow.

For those who need thrombolytic therapy, blood pressure should be strictly controlled to reduce the risk of potential bleeding.

Such as systolic blood pressure> 180mmHg or diastolic blood pressure> 110mmHg.

Blood pressure management for hemorrhagic stroke: The patient's ideal blood pressure needs to be individualized, referring to the presence or absence of chronic hypertension, intracranial pressure (ICP), age, cause of bleeding, and time of onset before the illness.
It is generally recommended to actively control blood pressure. In theory, lowering blood pressure can reduce the risk of rebleeding in small arteries; however, excessive blood pressure can decrease cerebral perfusion pressure, which theoretically makes the brain injury more serious, especially when intracranial pressure increases.

B.
Recommendations for controlling body temperature: For patients with body temperature> 38.
5°C and those with bacterial infections, give antipyretic drugs (acetaminophen, etc.
) and early use of antibiotics to reduce body temperature to below 37.
5°C as soon as possible.

Significance: Fever affects the prognosis of stroke.

Many patients develop infection after stroke, and infection is not good for stroke.

Experimental studies have found that fever increases the volume of infarcts.

It is reasonable and necessary to control the body temperature of stroke patients.

Appropriate cultures and smears (sputum, blood, and urine) are given to patients with fever or at risk of infection, and antibiotics are given.

If the ventricular tube is used, it should be analyzed by cerebrospinal fluid (CSF) to check for signs of meningitis, and if present, receive appropriate antibiotic treatment.

Patients with> 38.
5℃ were treated with acetaminophen or cooling blanket.

It is generally believed that the body temperature should be lowered to below 37.
5℃ as soon as possible.

5.
To maintain the balance of water and electrolytes: to maintain the balance of fluids and electrolytes to prevent blood concentration, increased hematocrit and changes in hemodynamic characteristics.

Fluid balance should be calculated for daily urine output and hidden water loss (urine volume plus 500ml, 300ml fluid volume for every 1°C increase in fever patients).

When the intracranial pressure increases, it is recommended to maintain a slight negative balance of body fluids (about 300ml/d~500ml/d).

Daily monitoring of electrolytes and correcting their disorders to maintain them at normal levels, blood gas analysis can correct the imbalance of acid-base balance.

Significance: If the fluid is excessive, it will cause pulmonary edema, cardiogenic dyspnea, and aggravate cerebral edema.

The optimal central venous pressure (CVP) or pulmonary artery wedge pressure may vary from person to person.

If considering hypotension caused by hypovolemia, CVP should be maintained at 5mmHg~12mmHg or pulmonary artery wedge pressure should be maintained at ≈10mmHg14mmHg.

Severe electrolyte abnormalities are rare in stroke.

As the disease progresses, insufficient secretion of antidiuretic hormone can cause hyponatremia.
At this time, fluid intake can be restricted or high sodium fluid can be given.

Maintain normal plasma osmolality between 300mOsm/L~320mOsm/L.

If insulin is given, the need for potassium should be increased.

6.
Other medications (sedation, pain relief, antiemetics) Many patients have emotional manifestations, which can cause suffering to patients, caregivers and families, and may lead to self-injury.

Common causes of restlessness are fever and insufficient capacity.

Sedatives and antipsychotics should be considered after removing the cause.

It is recommended to use weak to strong antipsychotics carefully, and benzodiazepines that act quickly may be the best.

If necessary, add other drugs, such as analgesics and neuroleptics for symptomatic treatment of severe headaches, and antiemetics for the treatment of vomiting.
The dosage and time of administration should be based on clinical needs.

Text starters: the medical profession Neurology Channel author: silence reviewed article: Li Tu Ming, deputy director of Physicians Editor: Mr.
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