II. Indications: Endotracheal Intubation
- See Advanced Airway
- Aspiration risk
- Decreased Level of Consciousness
- High NIH Stroke Scale
- High risk for hemorrhagic conversion and decompensation
- Posterior stroke
- Consider Endotracheal Intubation if neurointervention planned
- Interfacility Transfer
- Consider before transport, allowing for stabilization and decreased risk for decompensation during transport
III. Management
- Use Rapid Sequence Intubation (RSI)
- Intubate with head of bed at 30 degrees
- Maintain Blood Pressure in range in the intubation and peri-intubation period
- See Blood Pressure Control after Cerebrovascular Accident
- Target systolic Blood Pressure (SBP): 140 to 180 mmHg
- Target mean arterial pressure (MAP): 70 to 90 mmHg
- Hypotension
- Consider starting Vasopressors before intubation, targeting SBP 160 mmHg
- Avoid IV fluids to maintain Blood Pressure in adequately hydrated patients
- Hypertension (most CVA patients)
- Systolic Blood Pressure >180 mmHg is at increased risk of hemorrhagic conversion
- RSI Medication Selection
- Sedation
- Etomidate or
- Ketaphol (Ketamine with Propofol 1:1)
- Paralysis
- Rocuronium 1.2 to 1.5 mg/kg (preferred)
- Succinylcholine may be preferred by neurointensivists
- Sedation
- Post-Intubation
- Nasogastric or Orogastric Tube
- Sedation
- Combination of Propofol and Fentanyl
- Start Norepinephrine for Hypotension on sedation (see Blood Pressure targets as above)
- Maintain normocapnea
- Target End-Tidal CO2: 35-45 mmHg
- Avoid Hyperventilation
- Risk of vasonstriction and associated with worse outcomes
- Avoid hyperoxia
- Maintain Oxygen Saturation 95-98%
IV. References
- Swaminathan and Weingart (2026) Stroke Airway, EM:Rap, 2/23/2026