How should a 72-year-old woman with hypertension, atrial fibrillation, and type 2 diabetes mellitus, diagnosed with an acute ischemic stroke, be managed given her current symptoms and condition?

A-E Assessment for Acute Ischemic Stroke Patient

A - AIRWAY

The airway is currently patent but requires close monitoring given the patient's GCS of 14 and risk of deterioration. 1

• Airway is patent at present with respiratory rate of 18 breaths/min and oxygen saturation of 97% on room air 1
• The patient has mild aphasia and right-sided facial droop, which increases aspiration risk 1
• Maintain nil by mouth status until formal swallow assessment by Speech and Language Therapist is completed - this is critical to prevent aspiration pneumonia 1
• Monitor for decreased consciousness or bulbar dysfunction that could compromise airway protection 1
• Be prepared for airway support and ventilatory assistance if consciousness deteriorates further 1

B - BREATHING

Breathing is adequate with no immediate intervention required beyond monitoring. 1

• Respiratory rate 18 breaths/min is within normal limits 1
• Oxygen saturation 97% on room air indicates adequate oxygenation 1
• Supplemental oxygen is not indicated for non-hypoxic patients (only administer if oxygen saturation falls below 94%) 1
• Continue monitoring respiratory status as neurological deterioration could compromise respiratory drive 1
• Cardiac monitoring is already in place to detect atrial fibrillation and life-threatening arrhythmias 1

C - CIRCULATION

Blood pressure is elevated at 156/84 mmHg, which is appropriate management for acute ischemic stroke post-thrombolysis. 1

Blood Pressure Management

• Current BP of 156/84 mmHg is acceptable post-thrombolysis - target is to maintain BP <180/105 mmHg for the first 24 hours after tenecteplase 1
• Monitor blood pressure every 15 minutes for 2 hours from start of thrombolysis, then every 30 minutes for 6 hours, then hourly for 16 hours 1
• Do not aggressively lower blood pressure unless systolic exceeds 180 mmHg or diastolic exceeds 105 mmHg, as this may reduce cerebral perfusion to the ischemic penumbra 1
• If BP rises above 180/105 mmHg, use labetalol 10 mg IV or nicardipine IV 5 mg/hr titrated up by 2.5 mg/hr every 5-15 minutes 1

Fluid Management

• Continue 0.9% NaCl IV at 75 mL/hr - isotonic crystalloids are appropriate for stroke patients 1, 2
• Avoid dextrose-containing fluids as hyperglycemia may worsen outcomes 1
• Maintenance fluid requirements are approximately 30 mL/kg/day 2

Cardiac Monitoring

• Heart rate 78 bpm is stable 1
• Continue cardiac monitoring for at least 24 hours to detect atrial fibrillation (known history) and potentially life-threatening arrhythmias 1
• Obtain 12-lead ECG to evaluate for acute myocardial infarction, as stroke patients with atrial fibrillation have underlying cardiac disease risk 2, 3

Anticoagulation Planning

• Patient is on apixaban for atrial fibrillation 4, 5
• Restart anticoagulation after 24 hours pending MRI review to assess for hemorrhagic transformation risk 3
• This timing balances stroke recurrence prevention against bleeding risk post-thrombolysis 3

D - DISABILITY (Neurological Assessment)

NIHSS score of 8/42 indicates moderate stroke severity with right-sided weakness and mild aphasia. 1

Current Neurological Status

• GCS 14 - alert but easily fatigued 1
• NIHSS 8/42 indicates moderate stroke severity 1
• Mild aphasia with frustration and tearfulness when attempting to speak 1
• Right-sided facial droop 1
• Right arm power 2/5 (severe weakness) 1
• Right leg power 3/5 (moderate weakness) 1
• Sensation intact 1

Monitoring Requirements

• Perform NIHSS assessments at baseline and repeat at least hourly for the first 24 hours to detect early neurological deterioration 3
• Monitor for signs of hemorrhagic transformation, cerebral edema, or stroke progression 3
• Watch for increased drowsiness or decreased GCS, which would indicate deterioration 1

Stroke Mechanism

• Left MCA territory ischemic stroke confirmed on CT 6
• Likely cardioembolic source given atrial fibrillation history 4, 7
• Patient has multiple vascular risk factors: hypertension, atrial fibrillation, type 2 diabetes, and recent medication non-adherence 4

E - EXPOSURE/EVERYTHING ELSE

Glucose Management

Capillary blood glucose of 12.2 mmol/L (220 mg/dL) requires treatment to prevent worsening outcomes. 1

• Hyperglycemia >200 mg/dL is associated with expansion of infarct volume and poor neurological outcomes 1
• Target blood glucose range of 140-180 mg/dL (7.8-10 mmol/L) per American Diabetes Association recommendations for hospitalized patients 1
• Initiate subcutaneous insulin protocol to safely lower and maintain glucose below 180 mg/dL 1
• Monitor blood glucose frequently (every 4-6 hours initially) to avoid hypoglycemia 1
• Avoid dextrose-containing IV fluids 1

Temperature

• Temperature 37.1°C is normal 1
• Treat any fever promptly with antipyretics as elevated temperature worsens stroke outcomes 1

Venous Thromboembolism Prophylaxis

• Implement intermittent pneumatic compression immediately for DVT prevention 3
• Avoid pharmacological anticoagulation for first 24 hours post-thrombolysis 3

Multidisciplinary Care Planning

• Physiotherapy and occupational therapy assessments scheduled for tomorrow are appropriate 3
• Speech and Language Therapy swallow assessment is pending and must be completed before oral intake 1, 3
• Early mobilization should begin once neurologically stable 3

Psychosocial Considerations

• Patient lives alone and daughter has concerns about ability to cope at home 1
• Patient is frustrated and tearful about aphasia - this is expected and requires supportive communication 1
• Begin discharge planning early with social work involvement given living situation and functional deficits 3
• Daughter has been managing medication compliance with pill box - continue this support system 1

Medication Review

• Continue ramipril for hypertension (do not hold unless BP drops significantly) 1
• Continue metformin for diabetes but monitor for lactic acidosis risk 4
• Continue simvastatin for secondary stroke prevention 4
• Plan to restart apixaban after 24 hours pending MRI confirmation of no hemorrhagic transformation 3

Common Pitfalls to Avoid

• Do not aggressively lower blood pressure - this may extend the infarct by reducing perfusion to the penumbra 1
• Do not use sublingual nifedipine or agents causing precipitous BP drops 1, 3
• Do not give oral intake before swallow assessment - aspiration pneumonia is a major complication 1, 3
• Do not delay recognition of neurological deterioration - hourly NIHSS monitoring is essential 3
• Do not restart anticoagulation too early - wait 24 hours and confirm no hemorrhage on imaging 3