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80103RIFFWAVEfmt ++data~~~~~~~~~~~~~~~~~~~~~~~~~~~|||~~~~~zvtvxz|~zvrnlrv||vtrpptz~|xvtv|~~zxvvvz|~xrlhntzzvrrpprrx~|j[QU_|bICCYn[ICY~zlnh]_r|]SUSSjz|x__l~v_]drnUb|nfd_]d]5=rrnj]jz~lMldrx[[_f|YQfWK_xh[zx[CIjzxxdSQz|_fI9WӹM;QnvK;OUx~xj]]YS~ɵlM?plM;CGpٵ[)Kh|% %;xtKQS]ɖbGr|lSnvz~nfS[nëx;Az=+AYݻ|=/1r_ ?|潄W5/Czãf)/pvbMQr|O=OtjdhjlG?G_ɊK3לdQCMppW;1SŷAMz/#?bx͖SAM[hvhYp~~zrvt[]ptWOUtxxd]v~vvxzd_xzh_nrSQltbdp~_lrQ_l][tf]W]~hWfp|fWhnhbU[hzlSCWbYbnxpdhjvjM9Ot]GQ[dpp~hhhdpx~xh]Yntnrp]dlvjQMb|vdjpzxzztljr||_[r~~jb_j|z|xpp~~v]Wh||zx|x|zzndhpxr]Yfntzjl|z||~vppnrzphrxz|~|xtrjjtv~~vz|z||xrrv~xrprtz|||vzxvx|xtx~~~~~~~zxxxx|zxz~~~rrz~|xz~~|vtx|zxz|~~~||zx|||~~zz|zz~~~~|~~||~~||zz|~||z~~~~zxzz|~~~~|~~~|~||~~~~~~~~~~~~~|||~~~~~~~~~~~~~||~~||~||~~~~|||~~~~||||~~~~~~||||~~~~~~~~~~~|~~~~|zz~~~~~~~||||~~||~~~~~|||~~~~~|||~|~|~~~~|z|~~~~~~~|||~~~~~~~~||~~~~~~~~ 4,H h         nn          CG CGCG&'?@ VXCG +/    CGVX&'?@ ! 9AktVXCGCGCGon           $b$ cB&H) J2$$$$$$$$$$2$6? nkSE22$l[Bߐh5L*2$g& 1sQ\*` 0e0e A@A18c8c     ?1d0u0@Ty2 NP'p<'p@A)BCD|E?`@@8qr g42d2d 0 ppp@ <4!d!dPAȷg4:d:d 0p@ pp<4BdBdPAȷf\  ___PPT9#,()T?.$ MB/ThrombosisO =*The Task.Guidelines for the Management of Stroke in A&EsStroke  Mr. Marco M. BOTROSReview of the topic.  Incidence  Heart disease and stroke combined cause four in ten of all deaths in England and Wales. 20% of all acute hospital beds will be occupied by patients suffering from stroke. (StrokeIncidence in UK. 110,000 patients/year, have a first stroke and 30,000 suffer a recurrent event. 2/1000 patients/year (aged 55-64). 20/1000/year (aged >85). P<P<   The RiskThe risk is higher in: African-Caribbean origin. South Asian origin. Lower socio-economic groups. The risk increases with age, Stroke can affect younger people. 10,000 people under 55 years. 1000 people under 30 years have a stroke.(DOH).ZLZZ"ZNZL"G    Situation in LeedsIt is estimated that, every year; ~ 1700 people will have a stroke and 400 will have a (TIA). 1100/Y are admitted to hospital with a median length of stay per patient of 20 days. ,National Service Framework for Older People --$There is strong evidence that people who have a stroke are more likely both to survive and to recover more function if admitted promptly to a hospital based stroke unit. (DOH). @ BThe Standards for the Development of Integrated Stroke Services:  CA$$Prevention: Including the identification, treatment and follow-up of those at risk of stroke. Immediate care: including care from a specialist stroke team. Early and continuing rehabilitation. Long-term support, for the stroke patient and their carers. v ZRZZ Q=$;DOH, Targets/milestones April 2002. Every general hospital which cares for people with stroke, will have plans to introduce a specialised stroke service as described in the stroke service model from 2004. April 2003. Every hospital which cares for older people with stroke, will have established clinical audit systems to ensure delivery of the royal college of physicians clinical guidelines for stroke care.\    !DOH, Targets/milestones April 2004. PCG/Ts will have ensured that: every general practice, will be using agreed protocols agreed to identify refer and treat patients at risk of stroke. ^ x v 'Royal College of Physicians Guidelines.Separate stroke (vascular event) from other causes of rapid-onset neurological dysfunction. Distinguish the pathological subtype of stroke if specific treatments are being considered. !,Royal College of Physicians Guidelines.cont. -'%The guidelines; Focus on patients presenting with. Acute-onset neurological deficit that is. Suspected to be a new clinical acute cerebrovascular event (first stroke or recurrent stroke). Focus on the positive diagnosis of stroke. They do not consider subarachnoid haemorrhage in any detail. pZ#ZZiZ!#!!h!"-Royal College of Physicians Guidelines. cont. .( Stroke is primarily a clinical diagnosis Care is needed in The young If the history is uncertain If there are other unusual clinical features; As Gradual progression over days, Unexplained fever, Severe headache Symptoms and signs of raised intracranial pressure.p=ZVZZzZ=fVfz  f  .-Royal College of Physicians Guidelines. cont. .(RThe initial neurological assessment should allow localisation of the likely cerebral area affected Brain imaging should be undertaken to detect intracerebral or subarachnoid haemorrhage, and to exclude other causes of the stroke syndrome, in all patients within 48 hours of onset unless there are good clinical reasons for not doing so "SRf#-Royal College of Physicians Guidelines. cont. .(Brain imaging should be undertaken as a matter of urgency if: There is a clinical deterioration in the patient s condition; Subarachnoid haemorrhage is suspected; Hydrocephalus secondary to intracerebral haemorrhage is suspected; Trauma is suspected; The patient is on anticoagulant treatment, or has a known bleeding tendency; The diagnosis is in doubt because of other unusual features. N?ZMZZ?fMf$-Royal College of Physicians Guidelines. cont. .(Brain imaging should always be undertaken before anticoagulant treatment is started The patient s cardiovascular status must be reviewed Chest X-ray should not be undertaken as a routine investigation at admission unless symptoms specifically indicate it MRI only considered when diagnostic confirmation of a stroke in the posterior fossa is needed $dZcf%'Royal College of Physicians Guidelines.QAspirin (300 mg) should be given as soon as possible after the onset of stroke symptoms if a diagnosis of haemorrhage is considered unlikely. No other drug treatment aimed at treatment of the stroke should be given unless as part of a randomised controlled trial (RCT) Neurosurgical opinion should be sought for cases of hydrocephalus RRf 7&'Royal College of Physicians Guidelines.Anticoagulation should be considered for all patients in atrial fibrillation, but not started until intracerebral haemorrhage has been excluded by brain imaging, and usually only after 14 days Centrally acting drugs should be avoided if possible f''Royal College of Physicians Guidelines.Thrombolytic treatment with (tPA), only be given provided that It is administered within 3 hours of onset of stroke symptoms. Haemorrhage has been definitively excluded. Patient is in a specialist centre with appropriate experience and expertise (there is no license in the UK at the time of going to press!). Local policies should be agreed in relation to the early management of Hypertension, hyperglycaemia, hydration and pyrexia. ?ZZHZ5ZZ?ff?fHf5f(7Royal College of Physicians Guidelines.Local guidelines 8'$Local guidelines should specify details on: Aspirin use, and whether or when brain imaging should be undertaken; Anticoagulation (eg who will be responsible for monitoring); neurosurgical referrals for intercerebral haemorrhage; 0,,!>))7Royal College of Physicians Guidelines.Local guidelines 8'$Acute management of common areas of clinical concern. Blood pressure should not be lowered in the first week unless there is accelerated hypertension or dissection. 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