What management is recommended for a patient with a history of stroke who has fallen and developed soft tissue swelling on the frontal cheek?

Management of Post-Fall Soft Tissue Swelling in a Stroke Patient

For a stroke patient who has fallen and developed soft tissue swelling on the frontal cheek, immediate assessment should focus on ruling out intracranial injury with urgent neuroimaging, evaluating for facial fractures, and implementing fall prevention strategies while maintaining standard stroke care protocols.

Immediate Assessment Priorities

Neurological Evaluation

• Perform urgent neurological assessment using the National Institutes of Health Stroke Scale (NIHSS) to detect any acute deterioration or new deficits that may indicate intracranial hemorrhage or worsening cerebral edema 1, 2.
• Assess level of consciousness using the Glasgow Coma Scale, as any decline may signal complications requiring immediate intervention 1.
• Monitor for signs of increased intracranial pressure or herniation, including pupillary changes, worsening motor function, or altered respiratory patterns 3.

Imaging Requirements

• Obtain non-contrast head CT immediately to rule out intracranial hemorrhage, new infarction, or progression of cerebral edema 3.
• Serial CT imaging may be necessary if clinical deterioration occurs, as this is useful for identifying patients at high risk for symptomatic swelling 3.
• Consider facial bone imaging if there is concern for orbital or maxillary fractures given the location of swelling 4.

Management of Soft Tissue Injury

Local Wound Care

• Apply ice to reduce swelling and provide analgesia for the first 24-48 hours 5.
• Assess for lacerations requiring closure or signs of infection 5.
• Document the extent and location of swelling for serial monitoring 3.

Anticoagulation Considerations

• If the patient is on warfarin, carefully assess the need for reversal based on INR levels and bleeding risk, though this decision must weigh the risks of not anticoagulating the patient 3.
• Aspirin may be continued for secondary stroke prevention even with minor soft tissue injury 3, 1.
• Subcutaneous heparin or low-molecular-weight heparin should be administered for deep venous thrombosis prophylaxis, even if there is minor bleeding or soft tissue injury 3.

Critical Monitoring Parameters

Hemodynamic Management

• Avoid aggressive blood pressure reduction unless systolic BP >220 mmHg or diastolic BP >120 mmHg, as lowering blood pressure can worsen ischemic injury 1, 2.
• Maintain adequate mean arterial pressure to ensure cerebral perfusion, though specific evidence-based targets are not established 3.
• Use isotonic saline for fluid management and avoid hypo-osmolar fluids that could worsen cerebral edema 3.

Metabolic Control

• Treat glucose levels >180 mg/dL, as hyperglycemia is associated with increased edema and hemorrhagic transformation risk 3.
• Maintain normothermia and treat temperatures >37.5°C, as fever worsens stroke outcomes 3, 6.
• Ensure oxygen saturation remains >94% to prevent hypoxemia, which worsens prognosis 1, 6.

Fall Prevention and Safety Measures

Immediate Interventions

• Transfer to intensive care or stroke unit for close monitoring if there are signs of neurological deterioration 3.
• Implement fall precautions including bed alarms, frequent rounding, and assistance with mobility 5, 7.
• Assess for contributing factors such as orthostatic hypotension, medication effects, or visual-spatial deficits 5.

Ongoing Stroke Care

• Continue aspirin 160-325 mg daily if already initiated for secondary prevention, unless contraindicated by significant bleeding 3, 1, 2.
• Maintain stroke unit care with interdisciplinary team involvement, as this reduces mortality and disability 2.
• Monitor for other medical complications common after stroke, including pneumonia, cardiac arrhythmias, and venous thromboembolism 5, 7.

Key Pitfalls to Avoid

• Do not routinely use urgent anticoagulation for acute ischemic stroke, as it increases hemorrhagic risk without proven benefit 1.
• Avoid using corticosteroids for cerebral edema management, as they are ineffective and potentially harmful 3, 2.
• Do not delay neuroimaging to manage the soft tissue injury, as intracranial complications take priority 3, 4.
• Do not aggressively lower blood pressure in the acute setting unless it exceeds the thresholds noted above 1, 8.

When to Escalate Care

• Neurosurgical consultation should be sought early if there is evidence of progressive cerebral edema, midline shift, or clinical deterioration despite medical management 3.
• Consider decompressive craniectomy if the patient continues to deteriorate neurologically from hemispheric swelling 3.
• Transfer to a higher level of care is reasonable if comprehensive stroke care and timely neurosurgical intervention are not available locally 3.