General measures for acute ischaemic stroke

Assess a patient's ability to swallow before giving oral drugs—the gag reflex is not a useful measure. If the patient has difficulty swallowing, maintain them nil-by-mouth and refer to a speech pathologist for assessment. Dysphagia often improves rapidly, but for the first few days fluids and drugs can be given parenterally. Before deciding to insert a nasogastric tube, the harms and benefits must be assessed, taking into account the patient's prognosis.

Blood pressure is often raised after an acute ischaemic stroke, but usually reduces spontaneously. In general, avoid lowering blood pressure in the acute phase of ischaemic stroke (first 48 hours); exceptions can include patients with malignant hypertension or hypertensive encephalopathy, or patients receiving alteplase. Cautious use of blood pressure–lowering drugs (preferably oral) is recommended for patients with markedly raised blood pressure (systolic blood pressure greater than 220 mmHg, diastolic blood pressure greater than 110 mmHg)—the aim is to reduce the blood pressure by about 20%. Standard drugs can be used (see advice on urgent reduction of blood pressure).

Give supplemental oxygen to patients who are hypoxic—routine use of oxygen is not supported. Lower fever with paracetamol.

Hyperglycaemia is associated with a worse outcome after stroke, so avoid intravenous fluids containing glucose. About 20% of patients admitted with acute stroke have unrecognised diabetes. Monitor the blood glucose concentration and maintain euglycaemia, but avoid aggressive management of blood glucose.

Early mobilisation, adequate hydration and antiplatelet therapy can help prevent deep vein thrombosis in patients with ischaemic stroke. If a patient is immobilised by the ischaemic stroke, give low molecular weight heparin (eg enoxaparin, dalteparin) in doses used for prophylaxis (see advice), or apply an intermittent pneumatic compression device.