Discussion
Given the recent dominance in academic discussions within the Australasian Emergency Medical Literature regarding Thrombolysis (1)(2), it is interesting to also think about the acute management of stroke when Thrombolysis is not used or has already been given.
Other than regular observations, a dose of Aspirin and good supportive care, the role of the Emergency Department (ED) has historically been considered limited by many.
I have frequently gone on ward rounds to discover that a stroke patient hasn’t had a blood sugar for several hours and they are lying flat…
Given the excellent evidence base for Stroke Units (SU) in improving outcome (3), we need to think further about other approaches that might be necessary including the use of Acute Stroke Unit management in the ED (4).
This is especially important because of the issues with access block and delays in stroke patients getting to the specialist stroke unit.
Middeton’s paper in the Lancet (2011) outlined an approach to managing the supportive care needs of Acute Stroke patients (5).
In particular the authors looked at 3 factors in combination:
- Fever
- Swallowing
- Blood Sugar Level (Hyperglycaemia)
Patients presenting to Australian Acute Stroke Units (ASUs) were assigned to either a control group or intervention group. The intervention group’s management was supplemented by the use of specific protocols to manage fever, hyperglycaemia, and swallowing dysfunction. In addition, there were team building workshops to address implementation barriers in the intervention centres. As a result, the trial was randomised with a ‘quasi’ study methodology (5).
In measuring outcomes the study used standardised scores of morbidity and function:
The final results were encouraging, at 90 day follow up intervention patients were significantly less likely to be dead or dependent (p=0·002).
In conclusion, putting Middleton’s findings together with our knowledge that the good supportive care provided in stroke units improves functional outcome supports the argument that the ED team should try to initiate many of these simple measures early. This can be done through a process of education and quality improvement in particular regarding methods of swallowing assessment, glucose control and fever.
References
(1) Fatovich DM. Believing is seeing: stroke thrombolysis remains unproven after the third international stroke trial (IST-3). Emerg. Med. Australas. 2012; 24: 477–479.
(2) Kleinig TJ. Stroke thrombolysis and the third international stroke trial; Examining the totality of the evidence. Emerg. Med Australas 2013; Apr; 25(2):107-9
(3) Cochrane Review (2007) – Stroke Unit Care – CLICK HERE
(4) Candelise L et al (PROSIT Study Group). Stroke-unit care for acute stroke patients: an observational follow-up study. Lancet 2007; 369: 299-305.
(5) Middleton S et al. Implementation of evidence-based treatment protocols to manage fever, hyperglycemia and swallowing dysfunction in acute stroke (QASC): a cluster randomised controlled trial. The Lancet, 378 (9804), 1699-1706
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