Trust Guideline for the Management of Acute Stroke and Transient Ischaemic Attack in Adults

Transcription

1 Trust Guideline fr the Management f Acute Strke and A clinical guideline recmmended Fr use in: By: Fr: Divisin respnsible fr dcument: Key wrds: Name f dcument authr: Jb title f dcument authr: Name f dcument authr s Line Manager: NNUHFT A&E, AMU and Adult wards Medical and Nursing Staff Adult patients with a suspected strke Medical Divisin (Including Emergency) Acute strke, Transient Ischaemic Attack (TIA), CT scan, ischaemic, haemrrhagic, thrmblysis, antiplatelet, anticagulants, cartid endarterectmy (CEA) Dr Patrick Suttn, Silvia Marrquí Strke Cnsultant, Advanced Clinical Pharmacist - OPM Tim Gilbert and Clive Beech Chief f Medicine Service, Deputy Chief Jb title f authr s Line Manager: Pharmacist/Head f Clinical Pharmacy Dr Kneale Metcalf, Clinical Lead fr Strke Supprted by: Medicine Manjari Mull, Strke Services Manager Clinical Guidelines Assessment Panel (CGAP) Assessed and apprved by the: If apprved by cmmittee r Gvernance Lead Chair s Actin; tick here Date f apprval: 8 February 8 Ratified by r reprted as apprved Clinical Standards Grup and Effectiveness Subt (if applicable): Bard T be reviewed befre: This dcument remains current after this date but 8 February will be under review T be reviewed by: Authrs Reference and / r Trust Dcs ID N: 67 Versin N: Descriptin f changes: Lipid mdificatin, VTE prphylaxis Cmpliance links: (is there any NICE related t guidance) If Yes - des the strategy/plicy deviate frm the recmmendatins f NICE? If s why? Diagnsis and initial management f acute strke and transient ischaemic attack. NICE Clinical Guideline 68, 8. Clpidgrel and mdified-release dipyridamle fr the preventin f cclusive vascular events. NICE technlgy appraisal guidance, N This guideline has been apprved by the Trust's Clinical Guidelines Assessment Panel as an aid t the diagnsis and management f relevant patients and clinical circumstances. Nt every patient r situatin fits neatly int a standard guideline scenari and the guideline must be interpreted and applied in practice in the light f prevailing clinical circumstances, the diagnstic and treatment ptins available and the prfessinal judgement, knwledge and expertise f relevant clinicians. It is advised that the ratinale fr any departure frm relevant guidance shuld be dcumented in the patient's case ntes. The Trust's guidelines are made publicly available as part f the cllective endeavur t cntinuusly imprve the quality f healthcare thrugh sharing medical experience and knwledge. The Trust accepts n respnsibility fr any misunderstanding r misapplicatin f this dcument. Trust Guideline fr the Management f Acute Strke and Authr/s: P. Suttn, S. Marrquí Authr/s title: Strke Cnsultant, Advanced Clinical Pharmacist - OPM Apprved by: CGAP Date apprved: 8//8 Review date: 8// Available via Trust Dcs Versin: Trust Dcs ID: 67 Page f 9

2 Trust Guideline fr the Management f Acute Strke and Cntents Sectin Page Acrnyms and Abbreviatins Acute Strke Pathway 4 TIA Pathway 5 Quick reference guideline: Acute management f strke and TIA 6 Quick reference guideline: Secndary prphylaxis 9 Objective Ratinale Brad recmmendatins ) Diagnsis ) Investigatins ) Acute therapy 4) Physilgical supprt 5 5) Preventin and management f cmplicatins 6 6) Early secndary preventin 4 7) Early rehabilitatin 7 Clinical audit standards 7 Summary f develpment and cnsultatin prcess 7 Distributin list 7 References/Surce dcuments 7 Appendix :ABCD scre 8 Appendix : CT head prtcl 9 Appendix : NIHSS Strke Scale Appendix 4: Labetall IV infusin Appendix 5: GTN IV infusin Appendix 6: Referral fr Rapid Access TIA Clinic/Strke Preventin Clinic Appendix 7: Prescriptin chart fr intravenus unfractinated 5 heparin infusins Trust Guideline fr the Management f Acute Strke and Authr/s: P. Suttn, S. Marrquí Authr/s title: Strke Cnsultant, Advanced Clinical Pharmacist - OPM Apprved by: CGAP Date apprved: 8//8 Review date: 8// Available via Trust Dcs Versin: Trust Dcs ID: 67 Page f 9

3 Trust Guideline fr the Management f Acute Strke and Acrnyms and Abbreviatins ABCD AF CEA CRP CT CTA DBP D/NOAC ECG ESR FAST FBC GTN (H)ASU ICH IHD INR IPC LDL-C LFT LMWH MCA MRA MRI MUST NBM NG NASCET NIHSS PCC PEG PVD SAN SBP TC TIA U&E VRIII VTE Scring system t predict risk f strke after TIA Atrial Fibrillatin Cartid Endarterectmy C-Reactive Prtein Cmputed Tmgraphy Cmputed Tmgraphy Angigraphy Diastlic Bld Pressure Direct/Nn-Vitamin K Oral AntiCagulant Electrcardigram Erythrcyte Sedimentatin Rate Face Arm Speech Time test fr diagnsis f strke Full Bld Cunt Glyceryl Trinitrate (Hyper) Acute Strke Unit Intracerebral Haemrrhage Ischaemic Heart Disease Internatinal Nrmalised Rati Intermittent Pneumatic Cmpressin sleeves Lw-Density-Lipprtein Chlesterl Liver Functin Test Lw Mlecular Weight Heparin Middle Cerebral Artery Magnetic Resnance Angigraphy Magnetic Resnance Imaging Malnutritin Universal Screening Tl Nil By Muth Nasgastric feeding tube Nrth American Symptmatic Cartid Endarterectmy Trial Natinal Institutes f Health Strke Scale (t measure severity f a strke) Prthrmbin Cmplex Cncentrate Percutaneus Endscpic Gastrstmy feeding tube Peripheral Vascular Disease Strke Alert Nurse Systlic Bld Pressure Ttal Chlesterl Transient Ischaemic Attack Urea & Electrlytes Variable Rate Intravenus Insulin Infusin Venus Thrmbemblism Trust Guideline fr the Management f Acute Strke and Authr/s: P. Suttn, S. Marrquí Authr/s title: Strke Cnsultant, Advanced Clinical Pharmacist - OPM Apprved by: CGAP Date apprved: 8//8 Review date: 8// Available via Trust Dcs Versin: Trust Dcs ID: 67 Page f 9

4 Trust Guideline fr the Management f Acute Strke and Acute Strke Pathway Trust Guideline fr the Management f Acute Strke and Authr/s: P. Suttn, S. Marrquí Authr/s title: Strke Cnsultant, Advanced Clinical Pharmacist - OPM Apprved by: CGAP Date apprved: 8//8 Review date: 8// Available via Trust Dcs Versin: Trust Dcs ID: 67 Page 4 f 9

5 TIA Pathway Trust Guideline fr the Management f Acute Strke and Trust Guideline fr the Management f Acute Strke and Authr/s: P. Suttn, S. Marrquí Authr/s title: Strke Cnsultant, Advanced Clinical Pharmacist - OPM Apprved by: CGAP Date apprved: 8//8 Review date: 8// Available via Trust Dcs Versin: Trust Dcs ID: 67 Page 5 f 9

6 Trust Guideline fr the Management f Acute Strke and Quick reference guideline: Acute Management f strke and TIA Trust Guideline fr the Management f Acute Strke and Authr/s: P. Suttn, S. Marrquí Authr/s title: Strke Cnsultant, Advanced Clinical Pharmacist - OPM Apprved by: CGAP Date apprved: 8//8 Review date: 8// Available via Trust Dcs Versin: Trust Dcs ID: 67 Page 6 f 9

7 Trust Guideline fr the Management f Acute Strke and Trust Guideline fr the Management f Acute Strke and Authr/s: P. Suttn, S. Marrquí Authr/s title: Strke Cnsultant, Advanced Clinical Pharmacist - OPM Apprved by: CGAP Date apprved: 8//8 Review date: 8// Available via Trust Dcs Versin: Trust Dcs ID: 67 Page 7 f 9

8 Trust Guideline fr the Management f Acute Strke and Trust Guideline fr the Management f Acute Strke and Authr/s: P. Suttn, S. Marrquí Authr/s title: Strke Cnsultant, Advanced Clinical Pharmacist - OPM Apprved by: CGAP Date apprved: 8//8 Review date: 8// Available via Trust Dcs Versin: Trust Dcs ID: 67 Page 8 f 9

9 Trust Guideline fr the Management f Acute Strke and Quick reference guideline: Secndary prphylaxis Trust Guideline fr the Management f Acute Strke and Authr/s: P. Suttn, S. Marrquí Authr/s title: Strke Cnsultant, Advanced Clinical Pharmacist - OPM Apprved by: CGAP Date apprved: 8//8 Review date: 8// Available via Trust Dcs Versin: Trust Dcs ID: 67 Page 9 f 9

10 Trust Guideline fr the Management f Acute Strke and Objective T prvide high quality evidence-based care t patients wh have suffered an acute strke r TIA. Ratinale This guideline has been prduced as a summary f all relevant clinical guidelines available in the management f acute strke and TIA, in rder t standardise care f this grup f patients. Brad recmmendatins Strke is the UK s third biggest killer and a leading cause f adult disability. Treating strke as a medical emergency will imprve the utcme. All patients with a suspected strke shuld be admitted directly t a specialist acute strke unit fllwing initial assessment (see NNUH Internal Strke Pathway). The management f acute strke is divided int the fllwing areas: ) Diagnsis ) Investigatins ) Acute therapy 4) Physilgical supprt in the first 4-48 hurs 5) Preventin and management f cmplicatins (medical and neurlgical) 6) Early secndary preventin 7) Early rehabilitatin ) Diagnsis In peple with sudden nset f neurlgical symptms a validated tl, such as FAST (Face Arms Speech Time), shuld be used utside hspital t screen fr a diagnsis f strke r TIA. Peple with a suspected TIA shuld be assessed as sn as pssible fr their risk f subsequent strke using the ABCD scre (Appendix ) and referred t the TIA Clinic if apprpriate using the Referral fr Rapid Access TIA Clinic frm (Appendix 6). All patients needing t be admitted shuld be clerked using the Rapid Strke Assessment Prfrma (unless already clerked n an equivalent dcument). Patients shuld be transferred directly t the Hyperacute Strke Unit as sn as pssible and shuld remain in the specialist strke unit (HASU r ASU) fr the duratin f their inpatient stay. ) Investigatins Brain Imaging (see Appendix ) Brain imaging (CT) shuld be perfrmed immediately (ideally the next imaging slt and definitely within an hur f arrival t NNUH) fr the fllwing: candidate fr thrmblysis Trust Guideline fr the Management f Acute Strke and Authr/s: P. Suttn, S. Marrquí Authr/s title: Strke Cnsultant, Advanced Clinical Pharmacist - OPM Apprved by: CGAP Date apprved: 8//8 Review date: 8// Available via Trust Dcs Versin: Trust Dcs ID: 67 Page f 9

11 Trust Guideline fr the Management f Acute Strke and n anticagulant treatment a knwn bleeding tendency a depressed level f cnsciusness (Glasgw Cma Scre belw ) unexplained prgressive r fluctuating symptms papilledema, neck stiffness r fever severe headache at nset f strke symptms Fr the rest f patients, brain imaging shuld be perfrmed as sn as pssible and within hurs frm admissin. Mde f imaging: CT brain This shuld be sufficient in mst cases and shuld be cnsidered as the first line unless there are specific indicatins fr ther imaging mdalities (MRI, CT perfusin). MRI brain Nt used as a rutine investigatin. Hwever, it will be useful in the fllwing situatins: Lcatin f the strke in the brain nt clear with CT scan Suspected psterir circulatin strke but CT scan is negative r equivcal, if psitive imaging will influence treatment Diagnsis ther than strke is suspected frm CT scan Cnsider first line in psterir (nn thrmblysable) strkes, and suspected strke during pregnancy (if nt thrmblysable and nt leading t significant delay). CT Perfusin (nly during hyper acute stage) Wake up strke (time f nset pssibly within 4.5 hurs) Fluctuating symptms Diagnstic dubts (eg seizure vs strke) High NIHSS scre (mre than ) and timing within t 4.5 hurs Urgent Bld tests All strke patients shuld have the fllwing bld tests n admissin: FBC LFT U&E and bne prfile ESR and CRP Trust Guideline fr the Management f Acute Strke and Authr/s: P. Suttn, S. Marrquí Authr/s title: Strke Cnsultant, Advanced Clinical Pharmacist - OPM Apprved by: CGAP Date apprved: 8//8 Review date: 8// Available via Trust Dcs Versin: Trust Dcs ID: 67 Page f 9

12 Trust Guideline fr the Management f Acute Strke and Randm bld glucse (HbAc if knwn diabetic) Chlesterl (randm) Cagulatin screen (URGENT if n ral anticagulants*) * warfarin, acencumarl, phenindine, dabigatran, apixaban, edxaban, rivarxaban Pregnancy test (if wman f child bearing age) Other Bld tests Depending n the circumstances, the fllwing tests may be indicated: Fasting Bld Sugar (FBS) r HbAc if randm bld glucse raised (this needs t be carried ut within 4 t 48 hurs f arrival; if patient is already knwn t have diabetes, FBS is nt needed) Thrmbphilia screen and vasculitic screen (NOT fr all strkes): Cnsider in yung patients (under 6 years) where an bvius pathlgy is nt fund. Cnsider testing fr Fabry s disease. ECG Urgent ECG ( lead) shuld be perfrmed n each patient, preferably in A&E. Chest X-ray Althugh nt a strke-specific investigatin, a chest X-ray is a valuable test in the management f strke t investigate e.g. cncurrent aspiratin pneumnia, cardiac disease r malignancy. Therefre, this needs t be carried ut within 4 hurs (urgently if any f the abve suspected). Cardiac investigatins (NOT fr all strkes, discuss with senir clinician) Applex cardiac mnitring whilst n HASU. If has 4 hurs f this may nt require OPD 4 hur tape depending n likelihd f AF as cause. 4 hur Hlter mnitr (t detect parxysmal AF). Echcardigram (Transthracic (TTE) r Transesphageal (TOE)) Bubble echcardigram Cartid vessels imaging Cartid ultrasund - all patients wh have had a cartid territry ischaemic strke shuld underg duplex cartid ultrasund scan if: they are cnsidered t be a suitable candidate fr endarterectmy they have made a reasnable recvery frm the strke (at least able t transfer with assistance f ne and cgnitively stable) If the ultrasund result is equivcal, prceeding t a CTA r MRA cartid is recmmended CTAs can be requested ver the weekend fr thse with TIAs either n the ward r as part f the TIA clinic. These need t be requested first thing in the mrning and discussed with the Radilgy registrar n call. Trust Guideline fr the Management f Acute Strke and Authr/s: P. Suttn, S. Marrquí Authr/s title: Strke Cnsultant, Advanced Clinical Pharmacist - OPM Apprved by: CGAP Date apprved: 8//8 Review date: 8// Available via Trust Dcs Versin: Trust Dcs ID: 67 Page f 9

13 Trust Guideline fr the Management f Acute Strke and ) Acute Therapy Avid r discntinue antithrmbtic therapy until brain imaging has been perfrmed. It is nt pssible t discriminate between infarctin and haemrrhage n clinical grunds. Ischaemic Strke Selected patients may be suitable fr intravenus thrmblysis with alteplase (rt-pa), after discussin between strke, AMU/A&E senir grade staff and a Cnsultant Strke Physician. This must be with strict adherence t the Trust Prtcl fr the use f alteplase fr acute ischaemic strke (SAN Versin ). See full prtcl fr management f anaphylaxis r any ther ptential cmplicatins with alteplase. Once brain imaging has excluded haemrrhage, give aspirin mg immediately as a STAT dse, rally r rectally, unless patient t be thrmblysed as abve. This shuld be given as sn as pssible after the brain imaging has been reviewed(liaise with nursing staff fr prmpt administratin). Cnsider lansprazle if previus dyspepsia with aspirin (available as rdispersible tablet if patient dysphagic). Cntinue aspirin mg nce daily fr up t weeks after symptm nset and then review aspirin and initiate lng-term antithrmbtic treatment. If the patient is allergic t r genuinely intlerant f aspirin, give a STAT dse f clpidgrel mg instead and cntinue clpidgrel 75 mg nce daily n regular prescriptin. If a patient has been thrmblysed, avid any antiplatelets fr the first 4 hurs pstthrmblysis and until a repeat CT scan f the brain has excluded haemrrhage. There are situatins where mre aggressive antiplatelet therapy may be apprpriate, e.g. basilar thrmbsis, stuttering nset f strke, cartid dissectin causing strke, r multiple TIAs in a shrt perid f time. Cnsider dual antiplatelet therapy with aspirin and clpidgrel fr 4 weeks (aspirin mg daily fr the first weeks, then reduced t aspirin 75 mg daily fr the next weeks, then aspirin stpped; Clpidgrel mg stat then 75mg OD lng term). Discussin with the strke physician in charge f the case r n-call cnsultant physician is advised in all cases. Cnsider gastrprtectin with lansprazle if apprpriate, due t the higher risk f bleed with this cmbinatin. Anticagulatin shuld nt be used rutinely fr the treatment f acute ischaemic strke. In peple with prsthetic valves wh have disabling cerebral infarctin and wh are at significant risk f haemrrhagic transfrmatin, anticagulatin treatment shuld be stpped fr ne week and aspirin mg substituted. Discussin with Strke Cnsultant required. Peple diagnsed with cerebral venus sinus thrmbsis (including thse with secndary cerebral haemrrhage) shuld be given full dse anticagulatin unless there are cmrbidities that preclude use. Haemrrhagic Strke In patients admitted n a cumarin ral anticagulant e.g. Warfarin, Phenindine r Acencumarl, anticagulatin shuld be reversed immediately with Vitamin K (see Adult Trust Guideline fr the Management f Acute Strke and Authr/s: P. Suttn, S. Marrquí Authr/s title: Strke Cnsultant, Advanced Clinical Pharmacist - OPM Apprved by: CGAP Date apprved: 8//8 Review date: 8// Available via Trust Dcs Versin: Trust Dcs ID: 67 Page f 9

14 Trust Guideline fr the Management f Acute Strke and patients requiring anticagulatin with warfarin CA85) and Prthrmbin Cmplex Cncentrate (PCC) as sn as pssible. Discuss with Haematlgy. In patients admitted n Dabigatran, if the last dse was given < 4h ag, discuss with n call Haematlgist in rder t give Idarucizumab (Praxbind) (see Haemrrhage prtcl fr patients n DOAC therapy) In patients admitted n Apixaban, Edxaban r Rivarxaban, cnsider ral charcal if the last dse was given <h ag (<6h ag fr apixaban) and give IV Tranexamic Acid. Discuss with n call Haematlgist and cnsider PCC (see Haemrrhage prtcl fr patients n DOAC therapy) If there is a pssibility that the bleed is frm an aneurysm, then the patient shuld have urgent CT angigraphy, either lcally r in a reginal neurscience centre. The aneurysm is at high risk f rebleeding, and may require urgent ciling r clipping. If in dubt, discuss with a reginal neursurgen r lcal strke physician/ neurlgist. A third f intracerebral haematmas will enlarge ver the first few hurs. Mnitr neurlgical functin carefully and cntrl bld pressure aiming fr a SBP f 4mmHg, ideally n the Hyperacute Strke Unit. If there is clinical deteriratin, repeat imaging and discuss with neursurgery regarding evacuatin f the haematma. In any case where there is dubt as t the benefit f neursurgical interventin, and in all cases f psterir fssa haemrrhage (where decmpressive surgery is cmmnly indicated), discuss with the reginal neursurgical team. Nte that in mst stable patients with supratentrial haemrrhage, particularly fr deep haemrrhages withut mass effect, neursurgical interventin will nt be indicated. Transient Ischaemic Attack (TIA) Patients with suspected TIA wh are at high risk f strke (ABCD 4, crescend TIA, AF, n anticagulants) shuld receive: Aspirin mg lading dse. This shuld be fllwed by up t weeks f aspirin mg OD and then clpidgrel 75mg OD lng term. If they are intlerant f aspirin the patient shuld be laded with mg clpidgrel and cntinue n 75mg OD lng term. The patient shuld als start a high intensity statin (e.g. Atrvastatin t 8 mg OD). If they are having recurrent episdes n antiplatelets then dual antiplatelets can be started (after discussin with cnsultant). The patient shuld have mg Aspirin and mg clpidgrel stat and then cntinue mg aspirin OD (drpping t 75mg OD after weeks) and 75mg OD clpidgrel fr ne mnth. At this pint aspirin shuld be stpped and clpidgrel cntinued. Specialist assessment and investigatin within 4 h f nset f symptms Measures fr secndary preventin intrduced as sn as the diagnsis is cnfirmed Patients with suspected TIA wh are at lw risk f strke (ABCD ) r wh present late shuld be treated as abve and receive Specialist assessment as sn as pssible and within week f nset f symptms Trust Guideline fr the Management f Acute Strke and Authr/s: P. Suttn, S. Marrquí Authr/s title: Strke Cnsultant, Advanced Clinical Pharmacist - OPM Apprved by: CGAP Date apprved: 8//8 Review date: 8// Available via Trust Dcs Versin: Trust Dcs ID: 67 Page 4 f 9

15 Trust Guideline fr the Management f Acute Strke and Patients with TIA in atrial fibrillatin shuld be anticagulated with an agent that has rapid nset in the TIA clinic nce intracranial bleeding has been excluded and if there are n ther cntraindicatins Trust Guideline fr the Management f Acute Strke and Authr/s: P. Suttn, S. Marrquí Authr/s title: Strke Cnsultant, Advanced Clinical Pharmacist - OPM Apprved by: CGAP Date apprved: 8//8 Review date: 8// Available via Trust Dcs Versin: Trust Dcs ID: 67 Page 5 f 9

16 Trust Guideline fr the Management f Acute Strke and 4) Physilgical Supprt All patients shuld be assessed fr airway, breathing, and circulatin, and resuscitated apprpriately. Oxygen Give supplementary xygen if the xygen saturatin is belw 95% n air. Aim fr nrmal xygen sats 96-99% unless COPD (88-9%). Oxygen shuld be prescribed n EPMA. Bld glucse Aim t maintain a bld glucse cncentratin between 5-5 mml/l. Start a VRIII if the bld glucse is >5mml/L n the initial reading, r at any pint ver the first 4-48 hurs. This shuld be started as sn as pssible, and cntinued until 48 hurs after the nset f the strke, unless risk f fluid verlad. Hyperthermia Treat hyperthermia (temperature >7.5 C) immediately with paracetaml and cling (fans, spnging). Identify and treat any infectin fllwing the guidelines given n the Antibitic Plicy. Fluid and electrlytes Crrect hypvlaemia, and then give maintenance fluids. Cnsider using sdium chlride.9% fr fluid replacement. Avid dextrse fr first 4h if pssible (unless hypersmlar, hypglycaemic, r n a VRIII). Dextrse will lwer the serum smlality, tends t increase cerebral edema, and will prmte lactic acidsis in the ischaemic penumbra, ptentially increasing the infarct size. Mnitr urea & electrlytes daily ver the first few days. Hypertensin In general, stp pre-existing antihypertensive medicatin fr 48-7 hurs unless there is a clinical need t cntinue (e.g. beta-blckers fr IHD). High bld pressure shuld generally nt be treated unless it is excessive. Lss f cerebral autregulatin will mean that a drp in bld pressure will lead t a lss f cerebral bld flw, which may threaten the ischaemic penumbra. Calming the patient, treating painful stimuli such as urinary retentin, and nursing in a side rm if pssible will ften be all that is required. Treatment will need t be given if there is a c-existing hypertensive emergency, e.g. hypertensive encephalpathy, acute renal failure, acute pulmnary edema, acute mycardial infarctin r artic dissectin. Treat hypertensin as belw if cnservative attempts at bld pressure reductin have failed. Aim fr a small reductin in bld pressure nly. Avid sublingual nifedipine due t the risk f abrupt BP reductin. Haemrrhagic Strke If SBP repeatedly >5 mmhg (target SBP 4 mm Hg fr at least 7 days): First line - Labetall IV (unless cntraindicated, see Appendix 4). Give mg slw IV blus ver - minutes. A secnd slw IV blus f - mg may be Trust Guideline fr the Management f Acute Strke and Authr/s: P. Suttn, S. Marrquí Authr/s title: Strke Cnsultant, Advanced Clinical Pharmacist - OPM Apprved by: CGAP Date apprved: 8//8 Review date: 8// Available via Trust Dcs Versin: Trust Dcs ID: 67 Page 6 f 9

17 Trust Guideline fr the Management f Acute Strke and given after - minutes. If inadequate respnse, start Labetall IV infusin (Appendix 4). Secnd line - Glyceryl trinitrate (GTN) IV infusin (see Appendix 5) Pst-thrmblysis If SBP repeatedly >8 mmhg and DBP >5 mmhg then treat as per haemrrhagic strke abve. Ischaemic strke If SBP repeatedly > mmhg and DBP > mmhg: Lisinpril 5 mg r Amldipine 5 mg PO (dse may be repeated nce if BP still high after hur) If patient is NBM, cnsider ne f the fllwing ptins: Lisinpril 5 mg tablet given sublingually (unlicensed use) Glyceryl trinitrate (GTN) 5 mg/4h patch (unlicensed use) IV therapy as fr haemrrhagic strke/ pst-thrmblysis Hyptensin Hyptensin may lead t infarctin f the ischaemic penumbra thrugh cerebral hypperfusin, particularly if there is cartid stensis. If the bld pressure is belw mmhg systlic then mit nrmal antihypertensives, and crrect hypvlaemia with sdium chlride.9%. Cnsider a cause fr the hyptensin e.g. cardiac ischaemia, arrhythmia, sepsis, artic dissectin r pulmnary emblus. Cardiac arrhythmias Patients with a histry f cardiac disease r thse wh are haemdynamically unstable shuld have cntinuus cardiac mnitring fr the first 48 hurs. 5) Preventin and Management f Cmplicatins Preventin f Cmplicatins Aspiratin pneumnia caused by dysphagia A Strke Dysphagia Screening Test will be perfrmed by a Dysphagia Trained Nurse (DTN) within 4 hurs f admissin t NNUHFT, r as sn as Strke diagnsis has been cnfirmed fr current inpatients, and befre ral nutritin, fluid r medicatin is given, n patients deemed t be apprpriate. Dysphagia Trained Nurses must have cmpleted the relevant training prir t administering the screening test. Please see Trust Prtcl fr Nurse Screening f Dysphagia in Adults (SLT ) fr full criteria and guidance. Referral t SLT fr further assessment will be indicated fllwing the cmpletin f the abve DTN screen. Cnsider referring t a Physitherapist if the patient has suspected aspiratin pneumnia with sputum retentin. Trust Guideline fr the Management f Acute Strke and Authr/s: P. Suttn, S. Marrquí Authr/s title: Strke Cnsultant, Advanced Clinical Pharmacist - OPM Apprved by: CGAP Date apprved: 8//8 Review date: 8// Available via Trust Dcs Versin: Trust Dcs ID: 67 Page 7 f 9

18 Trust Guideline fr the Management f Acute Strke and Venus thrmbemblism (VTE) preventin Many venus thrmbi ccur in the first 48 hurs, and preventative measures shuld be initiated in A&E. VTE shuld be prevented with timely use f antiplatelets, adequate hydratin and early mbilisatin. VTE prphylaxis shuld be cnsidered fr all immbile strke patients. VTE prphylaxis shuld be cnsidered at the first HASU ward rund if nt previusly dcumented. Cnsider Intermittent Pneumatic Cmpressin stckings (IPC) in the initial phase (as sn as pssible after admissin r within 7 hurs) fr haemrrhagic strke and large ischaemic strkes at risk f haemrrhagic transfrmatin (e.g. large PACS r TACS). See belw fr guidelines. TED stckings are nt recmmended. Prphylactic LMWH is nt recmmended in Acute strkes (first weeks). The decisin shuld be dcumented in the VTE Assessment sectin f EPMA and reviewed at 4 h. Cnsider prphylactic LMWH at weeks in immbile patients with ischaemic strke, as the risk f haemrrhagic transfrmatin substantially reduced. Review if the patient becmes mbile and update VTE Assessment n EPMA. IPC Stckings Guidelines The 5 th RCP strke guidelines say IPC stckings shuld be ffered in thse with lw mbility cmpared t their usual. Pr mbility is defined as an inability t walk t and frm the bathrm. A decisin shuld be made within days n whether t start these. The CLOTS trial (4) shwed that they reduce mrtality but predminately in the mrs 5 end f the spectrum. Patients and/r families shuld have this explained prir t a decisin t start IPC stckings as they may find this an unacceptable benefit. Infrmatin t tell patient/family: ) These stckings will reduce the risk f DVT. ) This shuld reduce the risk f pulmnary emblus and death. ) In patients with massive disabling strkes the net result f this is increased survival rates whilst still being fully dependent. 4) In additin t this, stckings can be quite uncmfrtable and are nt always well tlerated. If this is the case then even when a decisin has been made t use them their use may be stpped early. 5) Because they are cmpressin stckings they can smetimes cause ulceratin and skin break dwn. Once a decisin that IPC stckings are apprpriate has been made by a cnsultant then cnsent can be taken by any member f the multidisciplinary team. This shuld be dcumented n the medical ntes. IPC stckings need t be prescribed n EPMA. IPC Stcking use: Trust Guideline fr the Management f Acute Strke and Authr/s: P. Suttn, S. Marrquí Authr/s title: Strke Cnsultant, Advanced Clinical Pharmacist - OPM Apprved by: CGAP Date apprved: 8//8 Review date: 8// Available via Trust Dcs Versin: Trust Dcs ID: 67 Page 8 f 9

19 Trust Guideline fr the Management f Acute Strke and Cntraindicatins: Age <6 Patient nt n strke ward unless nurses trained and cmpetent. Severe leg edema. Leg ulceratin PVD Leg Cellulitis. Diabetics with ft lesins. Cnfused agitated patients wh are at risk f falling. relative risk. SAH, subdural r extradural haemrrhage. Patient wishes. Palliative patient. IPC stckings shuld be wrn fr days r until patient mbile. If they are nt tlerated well then the using n affected side r the belw knees versin can be tried. If they are still nt tlerated then dn t persist. If stckings are nt wrn fr mre than 48 hurs they shuld nt be replaced. Fr patients wh are nrmally immbile if their mbility has nt changed and they are nt acutely ill (e.g. physilgical changes, deranged U+Es etc.) there is n need t use IPC stckings. Whatever methd f prphylaxis is used, it des nt need t be carried n beynd days unless the patient is acutely unwell. Shuld they then decmpensate (unless new strke) then standard dse prphylactic LMWH shuld be used. Urinary catheters Catheters shuld be avided where pssible. Apprpriate indicatins fr urinary catheterisatin in strke patients are: urinary retentin (measure residual) need fr accurate fluid balance sacral pressure area skin breach dignity in end-f-life care If a patient has been catheterised, every effrt must be made t have a trial withut the catheter at the earliest pprtunity. The majrity f hspital-acquired urinary tract infectins are assciated with indwelling urinary catheters. Patients with urinary incntinence shuld have a cntinence plan within weeks f admissin. Bwel care Faecal incntinence Trust Guideline fr the Management f Acute Strke and Authr/s: P. Suttn, S. Marrquí Authr/s title: Strke Cnsultant, Advanced Clinical Pharmacist - OPM Apprved by: CGAP Date apprved: 8//8 Review date: 8// Available via Trust Dcs Versin: Trust Dcs ID: 67 Page 9 f 9

20 Trust Guideline fr the Management f Acute Strke and Patient shuld be fully assessed fr ptential treatable causes Shuld have dcumented actin plan Cnstipatin Shuld have their medicatins reviewed fr cnstipating drugs Oral laxatives shuld be ffered as first line Cnsider rectal laxatives as secnd line if cnstipatin persists Feeding and Nutritin Screening A weight and MUST (Malnutritin Universal Screening Tl) scre shuld be cmpleted within 4 hurs f admissin and weekly thereafter. If patients are n a mdified cnsistency diet (e.g. puree diet), r risk f malnutritin is identified via MUST, the MUST care guidance shuld be implemented. Dietitian referral t be made if indicated. Refeeding Syndrme Patients with little r n nutritinal intake fr mre than 5 days and/r significant weight lss and/r a BMI less than 8.5 kg/m are at risk f refeeding syndrme. Refer t the Trust Plicy n Enteral Tube Feeding in Adults, sectin 4., fr identificatin and management f Refeeding Syndrme. Liaise with Dietitian t ensure safe feeding. Enteral Feeding Feed all patients as sn as pssible after strke t reduce the risk f malnutritin and refeeding syndrme. If the patient is nil by muth, cmmence nasgastric feeding within 4 hurs. Cntraindicatins: patients with a pr prgnsis Cnsider withhlding feeding if end f life care is agreed fllwing discussin with family and all active treatment is t be withdrawn If prgnsis unclear, cnsider a time-specific trial f NG feeding after discussin with family and cmmence feeding as sn as pssible In cases f cughing, chestiness and suspected aspiratin (with r withut pneumnia), fllw the guidelines belw and cntinue t feed patient: Re-check nasgastric tube psitin Ensure patient crrectly psitined fr feeding (see belw) Feeding rates may be reduced; hwever there is n evidence t supprt this need. Liaise with Dietitian in this instance With repeated aspiratins: Trust Guideline fr the Management f Acute Strke and Authr/s: P. Suttn, S. Marrquí Authr/s title: Strke Cnsultant, Advanced Clinical Pharmacist - OPM Apprved by: CGAP Date apprved: 8//8 Review date: 8// Available via Trust Dcs Versin: Trust Dcs ID: 67 Page f 9

21 Trust Guideline fr the Management f Acute Strke and Increase attentin t muth care Increase mnitring f patient during feeding and ptimise best times t feed Cnsider prkinetics t imprve gut mtility Cnsider hyscine patches t reduce ral secretins If feed withheld, liaise with dietitian and review regularly in rder t prevent unnecessary starvatin. When feeding is stpped e.g. bwel bstructin, pre-/pst-prcedure, GI bleed: If less than 5 days since last feed and patient n established feed, re-cmmence previus regime If mre than 5 days since last feed r patient nt n established feed, start temprary regime Day. Infrm Dietitian as patient may be at risk f Refeeding Syndrme Cntact Dietitian in all cases f uncertainty Refer patient t Nutritin Supprt Team: If nasgastric feeding unsuccessful e.g. NG tube with bridle repeatedly pulled ut If NG feeding is cntraindicated e.g. nn-functining GI tract r requiring cmplete bwel rest Lng term feeding Patients wh are NBM r unable t maintain their nutritin and hydratin needs rally shuld be cnsidered fr PEG/RIG fur weeks pst-strke and referred t the Nutritin Supprt Team fllwing discussin with the Speech & Language Therapist and Dietitian. Discharging patients with NG tubes Generally, discharging patients n NG tubes shuld be avided It is the respnsibility f the cnsultant t ensure the NG tube is changed every 4 mnths r replaced in the event f displacement r blckage This is t be dne n the discharging ward by a nurse Fr further infrmatin see Trust Plicy n Enteral Tube Feeding in Adults. Psitining Dependent patients shuld be placed supine at 5-45 degrees if being PEG r NG fed and fr minutes after feeding; r lying n alternative sides, if tlerated, when feed nt running. Pressure areas shuld be prevented by pressure area risk assessment (e.g. Waterlw), pressure-relieving mattresses where apprpriate, regular inspectin, and attentin t nutritin (see Trust Guideline B). Trust Guideline fr the Management f Acute Strke and Authr/s: P. Suttn, S. Marrquí Authr/s title: Strke Cnsultant, Advanced Clinical Pharmacist - OPM Apprved by: CGAP Date apprved: 8//8 Review date: 8// Available via Trust Dcs Versin: Trust Dcs ID: 67 Page f 9

22 Trust Guideline fr the Management f Acute Strke and The psitin f limbs will be dependent n abnrmal muscle tne, sft tissue length and ther c-mrbid factrs. Therefre the paretic limb shuld be prperly psitined whenever the patient is in bed, sitting r standing r during mvement t prevent shulder pain and subluxatin. Sme patients will have mre detailed psitining plans (including the use f splints) due t abnrmal muscle tne/spasticity. In these cases individual plans will be dcumented n the handver and in sme cases phts placed in bedside ntes. Liaise with PT/OT if any cncerns. Patients shuld be transferred int the apprpriate chair via the apprpriate manual handling device (identified in the medical ntes and n nursing handver fllwing their physitherapy assessment) as sn as they are stable enugh t d s. Management f Medical and Neurlgical Cmplicatins Listed belw are cmmn cnditins leading t a wrsening neurlgical status f a pst strke patient: Sepsis Hypglycaemia Hypxia Hyptensin Evlving infarctin Haemrrhagic cnversin f infarctin VTE Cerebral edema Malignant MCA syndrme Hydrcephalus (ICH with intraventricular bld, psterir fssa bleed/infarct) Seizures (especially after haemrrhage) Cartid stensis with recurrent emblisatin Cartid stensis with lw-flw (pssibly with hyptensin) Recurrent cardiemblism Venus thrmbemblism (VTE) Ischaemic strke patients with symptmatic prximal DVT r PE shuld be treated with anticagulatin instead f Aspirin except where there are cntraindicatins t anticagulatin. Haemrrhagic strke patients with symptmatic prximal DVT r PE shuld be treated either with anticagulatin r insertin f vena cava filter (IVC). Cerebral edema This tends t peak at -5 days after cerebral infarctin. Manage by nursing at degrees head-up tilt and aviding hyptnic intravenus infusins (i.e. glucse 5%). Avid pain and ther nxius stimuli. Trust Guideline fr the Management f Acute Strke and Authr/s: P. Suttn, S. Marrquí Authr/s title: Strke Cnsultant, Advanced Clinical Pharmacist - OPM Apprved by: CGAP Date apprved: 8//8 Review date: 8// Available via Trust Dcs Versin: Trust Dcs ID: 67 Page f 9

23 Trust Guideline fr the Management f Acute Strke and Patients with space-ccupying cerebellar infarctin and reduced cnscius level shuld be discussed with neursurgery fr cnsideratin f decmpressive surgery. Malignant middle cerebral artery syndrme Referral t Addenbrke s Strke Team fr hemicraniectmy by cntacting n-call strke registrar. Hemicraniectmy may be cnsidered in the fllwing circumstances: Age < 6yrs (<45 years if mre than vascular territries invlved) Imaging evidence f: >5% MCA infarctin (invlving deep and superficial MCA territry) > / MCA infarctin (if nly superficial territry invlved) >45 cm vlume f infarctin (if lcal imaging allws quantificatin) Within 48 hrs f strke nset Patients will usually have an NIHSS scre >5, particularly if dminant hemisphere infarct Patients with dminant as well as nn-dminant hemisphere infarcts are suitable fr decmpressin Hydrcephalus Cnsider hydrcephalus if there is neurlgical deteriratin, especially if there has been intraventricular haemrrhage, r if there has been psterir fssa strke (e.g. cerebellar bleed r infarctin). Urgent ventriculstmy may be required. Seizures Seizures are cmmn, especially after cerebral haemrrhage. Cnsider in any deteriratin, and treat cnventinally (see Trust Guideline fr the Management f Generalised Cnvulsive Status Epilepticus) Agitatin and delirium Cnsider urinary retentin r ther surces f pain and manage apprpriately. Every effrt shuld be made t rule ut wrsening f strke as a cause f agitatin (i.e. neurlgical evaluatin and brain imaging). Once all the abve ptential causes have been ruled ut and if it appears that agitatin may pse a risk t the patient s health, cnsider shrt-acting benzdiazepines in the first instance (e.g. midazlam.5 mg by subcutaneus injectin- unlicensed use). Delirium is a cmmn prblem in the acute strke setting and can be present in up t half f patients especially in the first week after ischaemic strke (see Trust Guideline fr the acute management f delirium in lder patients) Md disturbance (Depressin) Depressin is cmmn pst strke, ccurring in abut % f patients. Trust Guideline fr the Management f Acute Strke and Authr/s: P. Suttn, S. Marrquí Authr/s title: Strke Cnsultant, Advanced Clinical Pharmacist - OPM Apprved by: CGAP Date apprved: 8//8 Review date: 8// Available via Trust Dcs Versin: Trust Dcs ID: 67 Page f 9

24 Trust Guideline fr the Management f Acute Strke and All patients shuld receive a md and cgnitin screen by discharge If depressed shuld be ffered antidepressant Mirtazapine is suitable particularly in patients with pr r reduced appetite Trust Guideline fr the Management f Acute Strke and Authr/s: P. Suttn, S. Marrquí Authr/s title: Strke Cnsultant, Advanced Clinical Pharmacist - OPM Apprved by: CGAP Date apprved: 8//8 Review date: 8// Available via Trust Dcs Versin: Trust Dcs ID: 67 Page 4 f 9

25 Trust Guideline fr the Management f Acute Strke and Pst strke pain Pain is a cmmn cmplicatin fllwing strke which can be distressing fr patients and has been shwn t be cmmn in the first days pst-strke. The cmmn types f pain include headache, hemiplegic shulder pain (HSP) and neurpathic pain including central pst strke pain (CPSP). Hwever, strke patients may experience pain due t ther preexisting cnditins. Early recgnitin f the type f pst strke pain is vital fr apprpriate pain management. Headache: Headache is cmmn with acute ischaemic strke, ccurring prir t (sentinel headache), cncurrently (nset headache) r fllwing (late-nset headache) fcal neurlgical signs. Headache culd be secndary t medicatins (e.g. dipyridamle, GTN, nifedipine) Cnsider simple analgesia such as paracetaml Avid piates as they may bscure the clinical picture as well as have pssible adverse effects such as respiratry depressin and hyptensin Hemiplegic Shulder pain /subluxatin: Cnsider imaging in sme patients t rule ut a fracture r dislcatin Avid pr handling and psitining f the affected shulder as well as the use f verhead hand sling Cnsider simple analgesics such as paracetaml and cdeine Nn-steridal anti-inflammatry drugs culd be used fr a shrt perid Intra-articular sterid injectins shuld nly be used if they als have inflammatry arthritis Functinal electrical stimulatin f the supraspinatus and deltid muscles has been recmmended fr shulder subluxatin Neurpathic pain including central pst strke pain (CPSP): Pharmactherapy Amitriptyline ( mg daily with gradual increase t an effective dse; max. 75 mg daily), Gabapentin ( mg twice daily with gradual increase t max..6 g daily in divided dses) r Pregabalin (75 mg twice daily with gradual increase t max. mg BD; Nn-frmulary at NNUH) Trust Guideline fr the Management f Acute Strke and Authr/s: P. Suttn, S. Marrquí Authr/s title: Strke Cnsultant, Advanced Clinical Pharmacist - OPM Apprved by: CGAP Date apprved: 8//8 Review date: 8// Available via Trust Dcs Versin: Trust Dcs ID: 67 Page 5 f 9

26 Trust Guideline fr the Management f Acute Strke and Surgery Deep Brain Stimulatin is effective in severe cases r thse unrespnsive t drugs Palliative Care Strke patients deterirating with pr prgnsis r imminent death shuld be referred with their families/carers t the specialist palliative care team t receive care and supprt that is cnsistent with the principles and philsphies f palliative care. This referral is made n ICE. 6) Early secndary preventin Patients shuld have brain imaging within hurs, and all investigatins cmpleted within 7 days f the strke. The main causes f early recurrence are cartid stensis and atrial fibrillatin. Psterir circulatin infarctin als has a high rate f early recurrence. Antiplatelet therapy Patients shuld receive lng-term antithrmbtic treatment fllwing an ischaemic strke, in rder t reduce the risk f further cardivascular events. In ischaemic strke nt assciated with atrial fibrillatin, clpidgrel 75 mg nce daily lng-term is recmmended fllwing up t 4 days f aspirin mg daily. If clpidgrel is cntra-indicated r nt tlerated, patients shuld receive aspirin 75 mg daily cmbined with dipyridamle M/R mg twice daily. If bth clpidgrel and dipyridamle are cntra-indicated r nt tlerated, patients shuld receive Aspirin 75 mg daily mntherapy. If there is a plan fr anticagulatin with warfarin (e.g. fr atrial fibrillatin) r fr a surgical prcedure (e.g. PEG insertin), avid clpidgrel and change patient t Aspirin 75 mg daily fllwing acute treatment with aspirin mg daily fr 4 days. This is due t the need t avid clpidgrel fr 7 days pre-surgery and t the very high risk f bleeding when cmbining clpidgrel with warfarin. Anticagulant therapy Heparin, warfarin and DOACs are cntraindicated in all kinds f primary cerebral haemrrhages. There are very few indicatins fr therapeutic heparin in acute ischaemic strke. The danger f therapeutic heparin is haemrrhagic cnversin f infarctin. The risk is greater with large infarcts (e.g. >5% f the MCA territry) and with elevated bld pressure (e.g. SBP >8mmHg). The selected indicatins fr heparin after strke are (discuss with cnsultant. see Appendix 7 fr dsing): Initial stages f cerebral venus sinus thrmbsis leading t infarcts (even with mild t mderate secndary haemrrhage int it) until warfarin is initiated Cartid and vertebral/ basilar artery dissectin leading t recurrent TIA and ischaemic strkes (despite being n aspirin) Evidence f DVT and/r PE until warfarin is safe Mechanical heart valve Trust Guideline fr the Management f Acute Strke and Authr/s: P. Suttn, S. Marrquí Authr/s title: Strke Cnsultant, Advanced Clinical Pharmacist - OPM Apprved by: CGAP Date apprved: 8//8 Review date: 8// Available via Trust Dcs Versin: Trust Dcs ID: 67 Page 6 f 9

27 Trust Guideline fr the Management f Acute Strke and In mst cases f cardiemblic ischaemic strke (e.g. atrial fibrillatin) the benefit f anticagulatin with heparin is ffset by the risk f haemrrhagic transfrmatin f the infarct. These patients shuld be managed with antiplatelet therapy fr abut tw weeks (lnger in patients with very large infarctin r severe hypertensin) and then carefully started n warfarin, stpping aspirin when the INR is greater than. Anticagulatin shuld nt be used in the first weeks fllwing an ischaemic strke except n specialist advice. Hwever, anticagulatin may be started sner in a diagnsis f transient ischaemic attack where CT has excluded majr cerebral injury. In instances where cerebral infarctin is cmplicated by secndary haemrrhage, initiatin f anticagulatin may need t be delayed fr mre than weeks. A DOAC may be cnsidered as an alternative t warfarin in the fllwing situatins: ischaemic strke whilst n therapeutic warfarin, warfarin intlerance r pr cmpliance, in line with the cmmissined flw chart issued by the Therapeutics Advisry Grup (Oral Anticagulant Therapy in Atrial Fibrillatin). Antiplatelets may be stpped and DOAC initiated withut verlapping. See Advice sheet n starting DOACs. Cartid Endarterectmy (CEA) Cntact Cnsultant Vascular Surgen n call via switchbard if symptmatic cartid stensis ASAP. Symptmatic cartid disease: Lcally, we ffer CEA t thse with 5-69% ICA stensis within weeks f symptms >=7% ICA stensis within 6 mnths f symptms We d nt ffer CEA t thse with Occluded ICA Near-ccluded ICA with string sign We nly cnsider CAS fr thse unsuitable fr CEA. Asymptmatic cartid disease: Guideline currently under discussin. D/w vascular team. Bld pressure management Elevated bld pressure is very cmmn after acute strke, and ften settles ver the curse f the first week. In general, bld pressure shuld nt be lwered fr the first week r tw. Stp pre-existing anti-hypertensives fr the first 48-7h unless clinical need t cntinue. After this perid, BP may be treated accrding t current hypertensin guidelines. An ptimal target BP is /8 mm Hg. Cautin shuld be exercised in bld-pressure lwering in patients with haemdynamically significant extracranial r intracranial arterial Trust Guideline fr the Management f Acute Strke and Authr/s: P. Suttn, S. Marrquí Authr/s title: Strke Cnsultant, Advanced Clinical Pharmacist - OPM Apprved by: CGAP Date apprved: 8//8 Review date: 8// Available via Trust Dcs Versin: Trust Dcs ID: 67 Page 7 f 9

28 Trust Guideline fr the Management f Acute Strke and stensis. A slightly higher target may be apprpriate in this case (e.g. SBP 4-5 mm Hg). Cnsider c-mrbidities when starting treatment. The preferred antihypertensive agents in strke care are ACE inhibitrs, calcium-channel blckers and thiazide and related diuretics. Beta blckers shuld nt be initiated fr secndary preventin after strke, unless there are specific indicatins (e.g. ischaemic heart disease, tachyarrhythmia). Lipid-lwering therapy Statins are nt recmmended in patients with haemrrhagic strkes (including haemrrhagic infarcts) due t the risk f further bleeds. An exceptin t this is patients wh have existing r new ischemic heart disease r peripheral vascular disease, as benefits may utweigh the risks. All patients wh have had an ischaemic strke wh are nt n a lipid-lwering medicatin shuld have their chlesterl checked n admissin and be treated with a high intensity statin (e.g. Atrvastatin mg t 8 mg OD) unless cntraindicated. Aim fr >4% reductin in nn-hdl chlesterl. If high intensity statin unsuitable r nt tlerated, cnsider alternative statin at maximum tlerated dse. Fibrates, bile acid sequestrants, nictinic acid r mega- fatty acid cmpunds are nt recmmended. Ezetimibe shuld be used nly in peple wh als have familial hyperchlesterlaemia. Lifestyle mdificatin Apprpriate lifestyle advice shuld be given n: Smking cessatin (cnsider Nictine Replacement Therapy as per Clinipharm with ICE referral t SmkeFree Nrflk) Weight lss t achieve BMI -5 Reductin in saturated fat Increase in fresh fruit and vegetables at least 5-a-day Increase in cnsumptin f fish and ther surces f mega fatty acids Reductin in salt intake target f 6g/day r less Reductin in alchl intake (current recmmendatins maximum units/week fr men; 4 units/week fr wmen) Regular exercise (5 minutes/week) Driving after strke: The DVLA guidelines advice nt t drive fr at least ne mnth fllwing a strke r mnths fllwing multiple TIAs, depending n a satisfactry recvery. Sexuality: Sexuality is an issue that is ften ignred amng strke survivrs with partners. Issues relating t sexuality shuld be discussed with strke survivrs and their partners were apprpriate. Trust Guideline fr the Management f Acute Strke and Authr/s: P. Suttn, S. Marrquí Authr/s title: Strke Cnsultant, Advanced Clinical Pharmacist - OPM Apprved by: CGAP Date apprved: 8//8 Review date: 8// Available via Trust Dcs Versin: Trust Dcs ID: 67 Page 8 f 9

29 Trust Guideline fr the Management f Acute Strke and Strke patients with interest in sexual activity r with sexual dysfunctin wh want further help: 7) Early rehabilitatin Shuld be reassured that sexual activity is unlikely t trigger anther attack f strke and as such nt a cntraindicatin after strke. Shuld be assessed fr pssible treatable causes Culd be referred t a psychsexual expert Early sitting ut and mbilisatin help t reduce the incidence f stasis pneumnia, venus thrmbemblism, and pressure ulceratin, and shuld ccur as sn as pssible after admissin prviding the patient is stable. Sme patients suffer neurlgical deteriratin when placed in an upright psitin early after strke, and apprpriate mnitring is necessary. Once stable, apprpriate assessment f the mst suitable discharge destinatin frm the NNUH can be determined. When all assessments are cmpleted by the multidisciplinary team, the transfer f a patient suitable fr rehabilitatin shuld be timely. Patient utcmes are imprved if patients receive as much rehabilitatin as tlerated. Return t wrk; Strke survivrs wh wish t take up r return t wrk shuld have their cgnitin and practical skills assessed. Where apprpriate they shuld be ffered sme assistance r referred t a supprted emplyment service Clinical audit standards SSNAP audit Any incidents will be recrded using the Trust incident recrding system (DATIX) and an actin plan put in place Staff will be assessed as fllwing the prtcl thrugh the PDR prcess Summary f develpment and cnsultatin prcess undertaken befre registratin and disseminatin The authrs listed abve drafted this guideline n behalf f the Acute Strke Grup, wh has agreed the final cntent. This versin has been endrsed by the Clinical Guidelines Assessment Panel. Distributin list / disseminatin methd Nrflk & Nrwich University Hspitals NHS Fundatin Trust Intranet References/ surce dcuments. Natinal clinical guidelines fr strke, 5th editin. 6. Intercllegiate Strke Wrking Party, Ryal Cllege f Physicians.. Diagnsis and initial management f acute strke and transient ischaemic attack. NICE Clinical Guideline 68, 8.. Clpidgrel and mdified-release dipyridamle fr the preventin f cclusive vascular events. NICE technlgy appraisal guidance, Trust Guideline fr the Management f Acute Strke and Authr/s: P. Suttn, S. Marrquí Authr/s title: Strke Cnsultant, Advanced Clinical Pharmacist - OPM Apprved by: CGAP Date apprved: 8//8 Review date: 8// Available via Trust Dcs Versin: Trust Dcs ID: 67 Page 9 f 9