CV
CVA Management
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CVA Management
, CVA Evaluation, Cerebrovascular Accident Management, Stroke Management
See Also
Ischemic CVA
Transient Ischemic Attack
CVA Thrombolysis
CVA Blood Pressure Control
Prevention of Ischemic Stroke
(includes
Anticoagulation in Ischemic Stroke
)
Protocol
Step 1 Prehospital Assessment
Activate EMS system in all potential CVA patients
Fingerstick
Glucose
Prehospital evaluation of patient
Cincinnati Prehospital Stroke Scale
Los Angeles Prehospital Stroke Screen
(
LAPSS
)
VAN Score
Transport to hospital with Stroke Team if possible (otherwise nearest facility)
Assessment tools (e.g.
VAN Score
) help triage patients with large vessel
Occlusion
(LVO)
Consider direct transport to tertiary center for mechanical thrombectomy if suspected LVO
Protocol
Step 2 Immediate
Gene
ral Assessment (<10 minutes)
ABC Management
Obtain full
Vital Sign
s including
Oxygen Saturation
Deliver Oxygen by
Nasal Cannula
(if
Oxygen Saturation
<90%)
Do not delay
CT Head
(see Step 4 below)
Consider having paramedics wheel patient directly from
Ambulance
to CT (if stability allows)
Defer non-critical testing (e.g. EKG) until after
CT Head
Cardiovascular measures
Obtain
Intravenous Access
Electrocardiogram
Telemetry
Airway management
Maintain adequate airway and oxygenation throughout process (critical)
Intubation is indicated in unreliable airway or
Hypoxia
refractory to oxygenation
RSI medication selection should avoid ICP increase
Avoid pretreatment
Lidocaine
and
Fentanyl
(no proven efficacy)
Induction
Etomidate
Ketamine
(if not severely hypertensive)
Paralysis (either agent)
Succinylcholine
(may transiently increase ICP)
Rocuronium
(delays repeat neuromuscular exam for >40 minutes)
Obtain bedside
Serum Glucose
(fingerstick
Blood Sugar
)
Hypoglycemia
(<63 mg/dl): Administer
D50W
(do not over-correct)
Hyperglycemia
(>300 mg/dl): Administer
Insulin
Labs to obtain in all patients
Complete Blood Count
(CBC) with
Platelet Count
Basic metabolic profile (e.g. Chem8)
ProTime
(PT)
Partial Thromboplastin Time
(PTT)
Troponin I
(or other
Serum Cardiac Marker
)
Labs and other diagnostics to obtain in selected patients
Liver Function Test
s
Urine toxicology screen
Blood
Alcohol
level
Pregnancy Test
Arterial Blood Gas
Chest XRay
Protocol
Step 3 Immediate Neurologic Assessment (<25 minutes)
Alert Stroke Team of possible
Thrombolytic
candidate
History: Mnemonic ("LoST MIND")
Last well or Onset
Seizure
Trauma
(esp.
Closed Head Injury
)
Migraine
Illness (recent)
Neck injury
Diabetes Mellitus
Determine eligibility for fibrinolytics
Consider
Thrombolytic
s (must be started within 3 hours of onset)
Complete
CVA Fibrinolytic Checklist
CVA Blood Pressure Control
Neurologic Exam
ination
Assess
Level of Consciousness
(
Glasgow Coma Scale
)
Assess Stroke Severity
NIH Stroke Scale
(preferred in U.S.)
Hunat and Hess Scale
Physical Examination
Identify acute comorbidities
Consider most common differential diagnosis
Complicated
Migraine
(especially younger women)
Hemorrhagic Stroke
(
Intracerebral Hemorrhage
)
Hypoglycemia
Hypertensive Encephalopathy
Seizure
(post-ictal paralysis or
Todd's Paralysis
)
Protocol
Step 4 Rule-out
Hemorrhagic CVA
Imaging
Obtain urgent noncontrast
Head CT
(<25 minutes)
MRI Brain is as sensitive for
Hemorrhage
and may be substituted if no delay
However
CT Head
is typically the preferred study over MRI
Fiebach (2004) Stroke 35(2): 502-6 [PubMed]
Head CT
read by radiologist (<45 minutes)
CT C-Spine
Indications
Altered Level of Consciousness
Trauma
Head CT
suggests
Intracranial Bleeding
See
Hemorrhagic CVA
Immediate angiography (e.g. CT Angiogram, MR Angiogram) to evaluate for aneurysm
Neurosurgery
Consultation
Reverse
Anticoagulant
s or
Bleeding Disorder
Manage
Hypertension
appropriately
Head CT
negative despite high suspicion for
Subarachnoid Hemorrhage
Lumbar Puncture
contraindicates
Thrombolytic
s
Consider
Head CT
Angiogram (CTA) instead
Obtain
Lumbar Puncture
to assess for subarachnoid blood
Recommended at 12 hours after onset of symptoms
Send cell count (although blood cells can be seen also with
Trauma
tic LP)
Send specimen for spectrophotometry for
Bilirubin
(only produced in vivo)
Head CT
negative suggesting
Ischemic CVA
Consider
Thrombolytic
Therapy below for moderate to severe CVA (
NIH Stroke Scale
of 5 or more)
Consider mechanical thrombectomy for large vessel
Occlusion
(as early as possible, within 24 hours)
Additional imaging to consider (if no delay to
Thrombolytic
s)
Head and Neck CT Angiogram (CTA) with and without contrast
May help direct specific interventions
Examples: Directed
Thrombolysis
or clot extraction in large proximal thrombosis
Perfusion-weight CT or MRI
Identifies the penumbra (ischemic brain surrounding the infarct)
May be salvageable outside the 3-4.5 hour window (with endovascular therapy)
Transcranial
Doppler Ultrasound
Identifies arterial vasospasm
Protocol
Step 5
Thrombolytic
Therapy (if indicated)
Immediate
Consultation
with stroke team (where available)
Evaluate for
Thrombolytic Contraindication
s
See
CVA Fibrinolytic Checklist
Blood Pressure
(if SBP >185 mmHg or DBP >110 mmHg)
See
CVA Blood Pressure Control
Failure to control
Blood Pressure
<185/110 mmHg with the following agents contraindicates
Thrombolysis
Consider administering
Labetalol
10 mg dose while obtaining
CT Head
if presenting BP >185/110
Preparations
Labetalol
10-20 mg IVP for 1-2 doses or
Nicardipine
or
Nitropaste 1-2 inches or
Enalapril
1.25 mg IVP
Review risks and benefits of
CVA Thrombolysis
with patient and family
Given 18 patients with moderate to severe stroke (
NIH Stroke Scale
of 5 or more)
No TPA given
Good CVA recovery: 6 patients (33% or one third)
Poor or no CVA recovery: 12 patients (66% or two thirds)
TPA given within 3 hours
Major CNS bleeding: 1 patient (6%)
With 45% of those patients dying and the others with typically severe
Disability
Good CVA recovery: 8 patients (44%) or an additional 2 patients more than if no TPA had been given
Poor or no CVA recovery: 9 patients (50%)
References
(1995) N Engl J Med 333:1581-1587 [PubMed]
Review indications for
CVA Thrombolysis
Age over 18 years old
Persistent neurologic deficits with
NIH Stroke Scale
of 5 or more
Large vessel
Occlusion
(e.g.
Middle Cerebral Artery
, cerebellar artery) may have low
NIH Stroke Scale
See
VAN Score
NIH Stroke Score particularly underestimates deficits from
Cerebellar Stroke
s
These patients may significantly benefit from
Thrombolysis
CTA Head and Neck identifies large vessel
Occlusion
and can help inform decision
Orman and Schrock in Herbert (2017) EM:Rap 17(10):16-7
Consider TPA in significant focal deficits despite
NIH Stroke Scale
<5
Even low NIH Stroke Scores can have significant
Disability
Demaerschalk (2016) Stroke 47:581-641 [PubMed]
Mild strokes may also dramatically worsen in first 24 hours
Consider CT perfusion study if no delay (identifies at risk prenumbra)
Ng (2016) Stroke 47(7): 1914-6 +PMID:27197850 [PubMed]
CVA Symptom onset <3 hours prior
May consider for <4.5 hours from onset in some patients based on ECASS3 trial
See
CVA Fibrinolytic Checklist
Cases in which extended time limit to 4.5 hours may be appropriate
Consider
CT Head
with perfusion-weighted imaging to define penumbra
Late presentations may be considered if no delay
Consider in wake-up stroke (limited evidence, discuss with stroke consultant)
Barreto (2016) Ann Neurol 80(2): 211-8 +PMID:27273860 [PubMed]
However no benefit and increased risk
Intracranial Hemorrhage
when extended to 6 hours
Arora and Menchine in Herbert (2014) EM: Rap 14(1): 8
Precaution
Do not delay
CVA Thrombolysis
for lab results unless high suspicion of abnormality
Management
See
CVA Thrombolysis
Hypertension
control is critical not only before
Thrombolysis
, but especially after
Thrombolysis
Protocol
Step 6
Gene
ral Measures
Admit all stroke patients for 24-48 hours
Cardiac monitoring (telemetry)
Frequent neurologic checks (every 2-3 hours is a common interval)
Speech
Extremity
Motor Strength
Facial symmetry
Consider transfer to stroke center
All patients receiving
CVA Thrombolysis
should be transferred to stroke center (neurology ICU)
Keep patient NPO acutely to lower risk of aspiration
Swallowing assessment for aspiration risk
Gentle
Intravenous Fluid
hydration only (avoid D5W)
Normal Saline
or
Lactated Ringers
at 50 cc/hour
Maintain
Body Temperature
<97.5
Acetaminophen
(
Tylenol
)
Cooling blankets
Continue Oxygen by
Nasal Cannula
to keep
O2 Sat
>92%
Consider
Thiamine
in
Alcohol
ics and malnourishment
Protocol
Step 7 Observe for and treat complications
Blood Sugar Monitoring
Hypoglycemia
(<63 mg/dl): Administer
D50W
(do not over-correct)
Hyperglycemia
(>300 mg/dl): Administer
Insulin
CVA Blood Pressure Control
See
CVA Blood Pressure Control
Post-tPA
Blood Pressure
control is initiated at BP >180/105
Non-tPA
Blood Pressure
control is initiated if BP >220/120 mmHg
Avoid lowering
Blood Pressure
too low in first 24 hours
Anticipate spontaneous resolution over days
Seizure
s
Evaluate with
Glucose
and
Serum Sodium
Treat with
Diazepam
and
Phenytoin
Cerebral edema (peaks on day 3-5, duration 10 days)
Severe, large volume cerebral edema (malignant edema)
Responsible for one third of the 25% of CVA cases that deteriorate
RSI and Intubate
Mannitol
Neurosurgery
Consultation
for decompression
Corticosteroid
s are not indicated
Delirium
Avoid medications that cause
Altered Level of Consciousness
(e.g.
Sedative
s,
Anticholinergic
s)
Preserve normal sleep-wake cycle by avoiding disturbing night-time sleep
Maintain orientation by maximizing sensory input (adequate lighting, eliminate background noise)
Pressure Sore
s (
Decubitus Ulcer
)
Early mobilization and frequent turning
Frequent skin examination
Alternating pressure mattresses
Maintain adequate nutrition (see below)
Malnutrition
Assess albumin,
Prealbumin
, and
Cholesterol
as markers of
Malnutrition
Fever
Associated with worse outcome in
Ischemic Stroke
Thoroughly investigate for fever cause
Lower fever with antipyretics
Pneumonia
Early mobilization
Incentive
Spirometry
hourly
Decrease
Aspiration Pneumonia
risk
Avoid medications that cause
Altered Level of Consciousness
Assess swollowing study
Urinary Tract Infection
s
Avoid indwelling catheters as much as possible
Other common complications
Serum
Inappropriate ADH Syndrome
Pulmonary Embolism
Protocol
Step 8 Adjunctive Therapy
See
Prevention of Ischemic Stroke
Includes
Anticoagulation in Ischemic Stroke
Avoid
Heparin
Start
Antiplatelet Therapy
(e.g.
Aspirin
325 mg daily,
Aggrenox
,
Clopidogrel
)
See
Prevention of Ischemic Stroke
Do not start within the first 24 hours if
Thrombolysis
(e.g. tPA) is used
See
Dysphagia after Cerebrovascular Accident
Early rehabilitation
Speech Therapy
Physical Therapy
Occupational Therapy
Precautions
Neurointerventional Endovascular Procedures (e.g. Thrombectomy, Directed
Thrombolysis
)
CT perfusion imaging (or diffusion weighted) may be used to identify patients who will benefit
Best candidates are those with small infarct and large prenumbra (viable tissue at risk)
Collateral circulation may sustain prenumbra area to allow for intervention well past 3 to 4.5 hours
Orman and Radecki in Herbert (2017) EM:Rap 17(5):10-11
Neurointerventional Endovascular Procedure Indications
Not recommended for most acute
Ischemic CVA
based on current data
Indications for directed
Thrombolysis
in moderate to severe CVA patients (NIHSS>8-15)
May be considered in large vessel, proximal
Occlusion
unchanged at 1 hour following tPA
Consider within 6 hours if standard tPA protocol contraindicated (per AHA/ASA and ACCP)
Studied for severe ischemic
Cerebrovascular Accident
with high NIH Score (>15-16)
Studies that showed benefit with severe CVA with proximal lesions by CTA or MRA, and intervention <6 hours
MR CLEAN Study showed benefit but 5% risk of new CVA and no mortality benefit
Most patients also received TPA (90%)
Berkhemer (2015) N Engl J Med 273(1):11-20 [PubMed]
Studies ESCAPE, SWIFT-PRIME and EXTEND-IA show significant functional improvements
Radecki and Orman in Herbert (2015) EM:Rap 15(5): 14-16
DAWN Study found benefit from 6 to 24 hours after onset
Nogueira (2018) N Engl J Med 378(1):11-21 [PubMed]
Studies that showed no benefit compared with
Thrombolysis
(less rigid in patient selection, timing)
Broderick (2013) N Engl J Med 368(10):893-903 [PubMed]
Cicone (2013) N Engl J Med 368(10): 904-13 [PubMed]
Kidwell (2013) N Engl J Med 368(1): 914-23 [PubMed]
Prognosis
Indicators of poor outcome
Hyperglycemia
Fever
Hypertension
Factors with positive impact on functional recovery
Family Support has significant positive impact
Prevention
See
Prevention of Ischemic Stroke
Resources
tPA for Stroke Patient Information - Risks and Benefits
http://www.aaem.org/UserFiles/file/tpaedtool-AAEM.pdf
References
(2000) Circulation 102(suppl I):I-204 to I-216 [PubMed]
Lewandowski (2001) Ann Emerg Med 37:202-21 [PubMed]
Tsouna-Hadjis (2000) Arch Phys Med Rehabil 81:881-7 [PubMed]
Beauchamp (1999) Radiology 212(2):307-24 [PubMed]
Adams (2007) Stroke 38(5): 1655-711 [PubMed]
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