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All patients will benefit from appropriate management of their airway, breathing and circulation. Close control of temperature and glucose levels can reduce stroke-associated morbidity.

Airway protection and Breathing

A comatose patient may need careful positioning, and even intubation, if unable to maintain or protect an airway.

A patient with significant weakness can slump on the trolley, partially obstructing their airway, so reducing the effectiveness of their breathing. Secondary brain injury due to hypoxia must be avoided.

In general, patients with acute stroke without respiratory co-morbidities may be permitted to adopt any body position that they find most comfortable, while those with respiratory compromise should be positioned as upright as possible, avoiding slouched or supine positions to optimise oxygenation [12]. This must be balanced against the improved cerebral blood flow seen if a patient is lying flat [13].

Supplementary oxygen should not be administered routinely. It should only be given if required to achieve an oxygen saturation of 94-98% (88-92% for patients with co-existing risk of COPD or other risk of respiratory acidosis) [14].

Stroke patients should be nil by mouth until their ability to swallow (and therefore avoid aspiration) has been properly assessed.

Circulation

Patients are often dehydrated following a stroke. A patient may have been on the floor all night or may have swallowing difficulties.

Poorer outcomes occur if systolic BP is less than 100mmHg or diastolic is less than 70mmHg.

Hydration should be assessed and hypovolaemia treated with fluid boluses of 250-500ml of normal saline [15]. Fluid overload should also be avoided as it will exacerbate cerebral oedema – a cause of further brain injury in stroke. The aim is euvolaemia. Other causes of hypotension, such as sepsis or acute myocardial infarction, should be considered.

Hypertension should very rarely be treated in the acute phase [1]. Reasons for doing so include [16]:

• Hypertensive encephalopathy
• Hypertensive nephropathy
• Hypertensive cardiac failure/myocardial infarction
• Aortic dissection
• Pre-eclampsia/eclampsia
• Intracerebral haemorrhage with systolic blood pressure over 200 mmHg.

In patients being considered for thrombolysis, a blood pressure target of less than 185/110 mmHg should be achieved