Immediate Modern Treatment of Emergency Stroke Guidelines

The name of the village is Rasulpur. A winding road runs past the village to the district town. The village is very beautiful. Sugandha River flows past the village. Every house has a fixed latrine, electric line, and dis line. The village has a primary school, a reputed secondary school, and a college. There is a beautiful market called Palashpur market. Every Saturday and Tuesday the market is held. Ishaq Ali is a famous rural doctor of this village. He has a pharmacy in the Palashpur market.

 Abdul Matin runs a grocery store in Palashpur Bazar. The age will be 46 years. Business is not going well lately. Two boys and girls. The daughter is older, studying in class nine and the boy is studying in class five. Abdul Matin studied till class nine but his wife passed matric. Abdul Mateen's wife went to Dubai two months ago due to a financial crisis. Abdul Matin has to take care of his son and daughter and his business. Suddenly one day while sitting in a shop, he realized that he was not able to speak clearly and had no strength in his right arm and right leg. Market people took him home in a van.

Abdul Matin's younger brother brought the doctor. Ishaq Ali is a well-known rural doctor of the village. He has been treating the village for 40 years. The people of the village have a lot of trust in him. Many people do not know the educational qualification of a doctor. But everyone knows that he is a very big doctor. You can tell the disease by looking at the patient's pulse. He did well by treating many dying patients in the village. The patient sent back from the big hospital in the city is also done well by Mr. Ishaq. Dr. Gurugambhir came. With an assistant. Looked beautiful. He asked if he could eat. Blood pressure measured. He saw the eyes with a torch. Mateen had a stroke.
There is no use in the city. Only money will be spent. I can do better. If you agree then I will start the treatment. Everyone agreed.

Cook rice and eat it every day. The patient will find it difficult to eat but cannot stop feeding.

• As I started to eat, I coughed, Matin said slowly.
• Eat even if you cough. Dr. Ishaq of Gurgambhir exclaimed

Mr. Ishaq pushed a DNS saline. DNS stands for Dextrose Normal Saline i.e. salt saline in glucose. Steroid injections are given. 3 Carva 75 tablets taken together. Vitamin injection. As the patient's blood pressure was 160/90, pressure medicine tablet Amdocal 5 was given. The doctor said, every day I will visit and push medicine and injection.

Treatment continued as usual. The patient cannot eat. Still being force-fed. The doctor is coming every day. Giving medicine, giving injections. The patient's people are being told that before the patient's blood pressure was 160/90, now it is 100/60. Much progress has been made. Slowly everything will get better. After 3 days, the patient was found to have a high fever. Before I could talk a little but now I can't talk. While the eyes were open before, now the eyes are often closed. The right arm and right leg were moving a little before but now they are not moving at all.

When Dr. Ishaq Sahib was informed about this, he is not coming anymore. Being desperate, the people of the village rushed him to the Medical College Hospital in an ambulance.

 After admission, the doctor did a CT scan and conducted many other tests. He started treatment. Good expensive antibiotics are given. But the patient's fever is not reduced. As treatment is given the patient is not improving but is deteriorating. Abdul Matin of Rasulpur village left this land after 3 days of treatment.



The above phenomenon is a common phenomenon in our medical system. We doctors often witness this phenomenon. About 68 thousand villages in Bangladesh. 70-80% of people live in villages. The contribution of rural doctors in providing medical services to them is no less. In present reality, it is not possible to provide medical services to people in rural areas by only MBBS doctors excluding them. For this reason, the readers may ask whether Dr. Ishaq Saheb showed ignorance while giving the treatment to Ah Matin.

One: In any case, the patient should be fed by mouth, was this decision correct?

Two: DNS was given by Saline. Was it necessary to give?

Three: Carva 75 tablets 3 were fed together, was it necessary?

Fourth: Blood pressure was 160/90. Was it right to give pressure medicine in this situation?

Fifth: whether it was necessary to give vitamin injections?

Sixth: Was it correct to give steroid injections?

I am trying to answer the questions one by one.

One: When a person has a stroke, it is difficult to eat or cough for the first few days. This is because the food we eat goes into the stomach through a process called the Deglutaion Reflex. After a stroke, this reflex becomes temporarily useless and the person cannot eat if they try to eat forcefully, the food goes to the lungs instead of the canal and causes lung infection. The patient has a high fever. Then it is not possible to save the patient even with high doses of antibiotics. Ah, Mateen died due to a lung infection. Therefore the decision of Dr. Ishaq Saheb was wrong. The patient should not be fed by mouth if there is any difficulty or cough during feeding. Dr. Ishaq Sahib should have advised him that if there is any difficulty in eating, then he should not eat by mouth.



Two: Dr. Ishaq Saheb gave DNS Saline to Mateen. After a stroke, the neurons of some parts of the brain die, and the neurons of some parts are in a state between death and survival. If for some reason the amount of glucose in the body increases, then the death of neurons that are in the intermediate state is accelerated. The patient's condition may worsen. Therefore Dr. Ishaq's administration of DNS Saline was wrong. A stroke can increase the amount of salt in the body. So normal saline is given after stroke because normal saline contains only salt and no glucose. Dr. Ishaq Sahib would have done the right thing by giving normal saline but giving DNS was wrong.

Three: Dr. Ishaq Saheb was wrong to take Carva 75 tablets together. It can cause irreparable damage to the patient. Carva 75 Tablet Generic Name Aspirin. Aspirin works to prevent blood clotting. Ischemic stroke is a stroke that occurs due to blood clot obstruction. Carva 75 is given in ischemic stroke. But giving medicine for Hemorrhagic Stroke can increase the amount of stroke and worsen the condition of the patient. Since the CT Scan of the patient did not understand Ischemic Stroke or Hemorrhagic Stroke. So giving Carva 75 was wrong. It has caused a lot of damage to the patient.

Fourth: Ah Mateen's blood pressure was 160/90. Since our normal blood pressure is 120/80, Dr. Ishaq thinks that since the pressure is high, it would be better to take high blood pressure medicine. According to modern medicine, it was not right to take high blood pressure medicine.
It is not known whether Mateen had high blood pressure before the stroke and was not taking any medication. Our brain is a collection of millions of neurons. Brain cells are called neurons. When a part of the brain has a problem with blood flow, the neurons in that part of the brain start dying. In order to increase the blood flow to that part of the brain, the body naturally increases the blood pressure from what it was before. In medical science, it is called Reactionary Hypertension. This blood pressure can last for 7-10 days. After this period the blood pressure becomes normal. Since this hypertension is beneficial, it should not be lowered with medication. Therefore, high blood pressure medication should be given with caution immediately after a stroke because the risk of harm is high then. The patient is likely to do more harm than good. Many times, immediately after a stroke, i.e. within 10 days, high blood pressure should be given, in that case, high blood pressure medicine should be given according to the expert doctor's opinion and instructions.

Fifth: Vitamin injection is a very common treatment for any sick patient by village doctors in our rural areas. Dr. Ishaq did so. However, Dr. Ishaq did not do it wrong. Proper treatment is given. Vitamins help in rebuilding our nervous system if it is damaged somewhere. Therefore, vitamins will help in stroke and not harm.

Sixth: Dexamet injection, which is called Steroid injection in medicine. A stroke can cause fluid to build up around the part of the brain that is damaged. In medicine it is called Cerebral Oedema Doctors sometimes give Dexamet injection to reduce cerebral edema. The cerebral Edema of that patient was not proved by CT Scan. So In. There was no need to give Dexamet. The reader may wonder why Dr. Ishaq used these medicines when there are so many medicines on the market because he has no formal education. The interesting thing here is that when a patient is hospitalized after a stroke in his village, he often comes with the patient and sees the use of these medicines. Doctors still prescribe these medicines when the patient is discharged from the hospital. Seeing them, he very confidently gave these medicines. The problem is stroke 2 types Ischemic Stroke and Hemorrhagic Stroke. Treatment of these 2 types of stroke is different. But Dr. Ishaq did not understand it and treated him like a blind man. Treating one type of stroke with another can cause harm. Dr. Ishaq did so.

 A request to the rural doctor, when you get a stroke patient, you must immediately send him to a government hospital. Advise if it is difficult to eat by mouth, do not feed by mouth. No further medication is required. If you want to give any medicine then you can give normal saline 20-30 drops per minute and vitamin injection. But remember that while giving too much medicine, you don't want to present yourself as a big doctor to the patient and the patient's relatives, it will harm the patient. But if you send to the hospital only with the above advice, the patient will benefit and your status will also increase.

Stroke patients are in very poor condition for the first week. Most stroke patients die during this period. So time management is very important. For this reason, it is better to be hospitalized for a week after a stroke.

After admission to the hospital, doctors take the patient's history. If the patient can speak then history can also be taken from him and if the patient cannot speak then history can be taken from relatives of the patient. When the patient had a stroke, what was he doing? Whether the patient vomits? Whether the patient had high blood pressure or diabetes? Do you take any medicine? etc.

After history taking the patient's pulse, blood pressure is measured. Whether the patient's eyes are closed? Or if you can open it if you talk? Or can speak? Can the arms and legs move? Do you have trouble eating or coughing? Can urinate in the toilet?

Some laboratory tests are done on an urgent basis after the patient is admitted. Many times the patients can get upset. As soon as admission, so many examinations. But for common people, some tests are very necessary before starting the treatment. For example:

CT Scan of Brain - By examining the CT Scan of the brain it is possible to understand the type of stroke. In the case of hemorrhagic stroke, the CT scan is white and in ischemic stroke it is black. The type of treatment can be determined. Treatment will be easier by seeing the CT Scan report. Because these 2 types of stroke are treated differently.

RBS (Random Blood Sugar) is done to check blood glucose. Because if the glucose is high, it needs to be treated because if the glucose is high, the stroke patient may get worse.

ECG- Heart disease can lead to stroke. So ECG is done. Whether the patient has heart disease? If there is heart disease then heart disease should be treated. Besides some other tests are conducted in special cases but Routinely above tests are very important.

Treatment of the patient is initiated by assessing the patient. Treatment is mainly general treatment and specific treatment. General treatment is applicable to 2 types of stroke but specific treatment is one for Ischemic Stroke and another for Hemorrhagic Stroke. A stroke patient should be hospitalized for the first few days.

General Treatment

 The patient is often unconscious. So the patient's position is very important. Because if not positioned correctly, the risk of infection increases. According to doctors, the two most common types are kept.

One: Lying straight on the bed and using a pillow under the head to keep the head 15 to 30 degrees above.

Two: Sleep on your side. The weaker side will be on top and the stronger side will be on the bottom of the bed. The patient's nose and mouth should be kept clean so that breathing is not difficult.

Food is essential in human life. If we don't eat, the stored energy in our bodies gets destroyed. First, try to eat by mouth while sitting. If there is pain or cough then food cannot be given by mouth. Then liquid food should be provided through a tube in the nose.

 Urinary retention is often seen after a stroke. Urine is then administered through the catheter.

After a stroke, many times the body temperature rises due to various reasons. If the temperature rises, the stroke patient is likely to deteriorate, so the temperature is reduced by using a Paracetamol suppository.

After a stroke, the body's own processes are disrupted, so the amount of salt in the body decreases. If the salt in the body decreases, the patient may deteriorate, so 2-3 liters of normal saline are given daily.

 If the patient has diabetes or high blood glucose levels after a stroke, it must be treated. Because if the amount of glucose in the blood is high, the patient deteriorates.

Usually, the patient's blood pressure is high for a week after the stroke. This blood pressure brings benefits to the body. So this time is not usually treated for high blood pressure? But if the blood pressure is too high, it is treated. Here are some differences between Ischemic Stroke, Hemorrhagic Stroke. Ischemic stroke occurs when BP is> 200/110. Then only high blood pressure medicine is given and in the case of hemorrhagic stroke, high blood pressure medicine is given if it is above 180/105. However, specialist doctors will decide when to give high blood pressure medication. In the first week of a stroke, if the blood pressure needs to be reduced with high blood pressure medication, it must be treated by specialist doctors. The patient has to change his position in the bed every two hours or else the wound may develop in different parts of the body. Nowadays, pneumatic beds are available in the market, which does not cause injury to the body when used.

If the patient has convulsions, of course, medicine is given for convulsions. Phenytion is the best drug for post-stroke seizures. A stroke patient is more likely to develop an infection, so antibiotics may be required. Since the patient is weak and often unconscious, the patient's eyes should be flushed frequently with clean water and cleaned if there is any dirt.

A stroke patient is often unable to eat by mouth so various types of bacteria can become infected. In that case, the patient's face should be cleaned repeatedly with clean water and a cloth.

If the patient is very unconscious, oxygen may be necessary, and if worse, transfer to ICEO may be necessary. Everything will be decided by the doctors.

General treatment should be followed by specific treatment. In this case, Ischemic and Hemorrhagic treatment types are different.  

Specific treatment of ischemic stroke

In the modern world, the following treatments are currently given for Ischemic Stroke. Aspirin works to prevent blood clotting. After the atherosclerotic plaque rupture of the blood vessels, blood clots begin to block the area. Because Ischemic Stroke occurs due to blood clots in blood vessels. Therefore, medicines like aspirin are given to prevent blood clots in the blood vessels. Aspirin causes damage to the stomach, so if one has peptic ulcer disease, Omeprazole should be taken. Nowadays, Clopidegrol is available as an alternative to Aspirin, which has the same effect as Aspirin but does not harm the stomach.

Vinpocetine is widely used by specialist doctors. Vinpocetine works by dilating blood vessels to increase blood flow to the brain. Effective treatment in ischemic stroke is tPA (tissue plasminogen activator) which breaks the blood vessel clot. As a result, applying ischemic stroke tPA improves blood circulation a lot. tPA is given IV. tPA should be given within 3 hours of the patient's symptom onset.

 In case of stroke due to heart disease, drugs like heparin should be used. This medicine must be given in the hospital and must be treated under the supervision of a specialist doctor.

Atherosclerosis plays a major role as a cause of blood clotting. Excess blood fat plays a major role in the formation of atherosclerosis. Therefore, drugs like Atovastin are used to reduce fat. Ischemic stroke due to massive infarction can lead to an accumulation of water in the brain. In medical science, it is called Cerebral Edema. In that case, medicine like Mannitol should be given. In many cases, Ischemic stroke may require neurosurgery. However, the decision of a specialist doctor must be made.

Specific treatment of hemorrhagic stroke

As there is air in the skin of a ball and the air has a certain pressure that keeps the ball in normal condition. If the air pressure inside the ball decreases, the ball goes flat, or if the pressure is high, the ball may burst. Our brain, which is inside our skull, is surrounded by a water-like substance. There is pressure inside the skull called ICP (Intracranial Pressure). Brain ICP is 2-12 mm of Hg If the ICP is high, the headache starts, and if it is too high, the person collapses (passes out). It can even lead to death. A common cause of increased ICP is if another substance lodges in the brain. Such as brain tumors, brain hemorrhages, etc.

 As the hemorrhage builds up in the brain, the ICP increases and the patient may experience headaches, vomiting, and even fainting. Therefore, in the case of hemorrhage, the main mantra of treatment is to reduce ICP. If the ICP can be kept low then the blood slowly perfuses the brain and the patient improves. But no medicine has been discovered so far to absorb the blood suddenly. Medicines like lowering ICP are not enough at our disposal. But all the medicines that are used are:
The mainstay of modern treatment of hemorrhagic stroke is neurosurgical treatment. By removing the internal blood through operation, the patient recovers. The name of this operation is Bur hole operation. Which is increasing in Bangladesh.

Many patients die of various causes even after receiving treatment in the hospital for a few days. Most people who die from a stroke die within the first few days. Hemorrhagic stroke has a higher mortality rate than ischemic stroke. There can be many causes of death but in most cases, the patient dies due to the following reasons. The hope is that most patients recover slowly. After the first few days, the patient can eat by himself. The urethra can be opened. can speak Can sit up in bed. Only those arms and legs that have become weak have difficulty moving the arms and legs. If the patient is healthy like this, the doctors send the patient out of the hospital with a discharge certificate. The patient returned home smiling. The apprehension and fear during admission are gone. Now started to dream of living anew. But later to live beautifully and healthily till death some rules and regulations have to be followed otherwise there is a possibility of stroke again. So everyone should follow the rules.

So stroke is not a threat. Complete recovery is possible with proper treatment. In this case, the doctor, the patient, and the patient should play their respective roles. Another thing to remember is that weak arms and legs can take a long time to get stronger. The time may take from 1 month to 1 year. But relatives of stroke patients get very worried about why their arms and legs are not getting strong. But getting stronger will take time, proper treatment, and physiotherapy. Everyone has to accept this hard reality. Because there is no medicine to suddenly strengthen weak arms and legs.