CVA Management

1. See Also
   1. Ischemic CVA
   2. Transient Ischemic Attack
   3. Anticoagulation in Ischemic Stroke
   4. CVA Thrombolysis
   5. CVA Blood Pressure Control
2. Protocol: Step 1 Prehospital Assessment
   1. Activate EMS system in all potential CVA patients
   2. Prehospital evaluation of patient
      1. Cincinnati Prehospital Stroke Scale
      2. Los Angeles Prehospital Stroke Scale
   3. Transport to hospital with Stroke Team
3. Protocol: Step 2 Immediate General Assessment (<10 minutes)
   1. ABC Management
   2. Obtain full vital signs including Oxygen Saturation
   3. Deliver Oxygen by Nasal cannula
   4. Obtain Intravenous Access
   5. Electrocardiogram, telemetry and Troponin I (or other Serum Cardiac Marker)
   6. Obtain bedside Serum Glucose (63 mg/dl used as cut-off for Hypoglycemia as stroke mimic)
   7. Labs to obtain in all patients
      1. Complete Blood Count (CBC) with Platelet Count
      2. Basic metabolic profile (e.g. Chem8)
      3. ProTime (PT)
      4. Partial Thromboplastin Time (PTT)
   8. Labs and other diagnostics to obtain in selected patients
      1. Liver Function Tests
      2. Urine toxicology screen
      3. Blood Alcohol level
      4. Pregnancy Test
      5. Arterial Blood Gas
      6. Chest XRay
4. Protocol: Step 3 Immediate Neurologic Assessment (<25 minutes)
   1. Alert Stroke Team of possible Thrombolytic candidate
   2. Obtain patient history
   3. Determine onset of CVA symptoms
      1. Consider Thrombolytics within 3 hours of onset
   4. Physical Examination
   5. Neurologic Examination
      1. Assess Level of Consciousness (Glasgow Coma Scale)
      2. Assess Stroke Severity
         1. NIH Stroke Scale
         2. Hunat and Hess Scale
5. Protocol: Step 4 Rule-out Hemorrhagic CVA
   1. Imaging
      1. Obtain urgent noncontrast Head CT (<25 minutes)
         1. MRI Brain is as sensitive for hemorrhage and may be substituted if no delay
         2. However CT Head is the preferred study over MRI
         3. Fiebach (2004) Stroke 35(2): 502-6
      2. Head CT read by radiologist (<45 minutes)
      3. Lateral Neck XRay Indications
         1. Altered Level of Consciousness
         2. Trauma
   2. Head CT suggests intracranial bleeding
      1. See Hemorrhagic CVA
      2. Immediate angiography (e.g. CT Angiogram, MR Angiogram) to evaluate for aneurysm
      3. Neurosurgery consultation
      4. Reverse anticoagulants or Bleeding Disorder
      5. Manage Hypertension appropriately
   3. Head CT negative despite high suspicion for SAH
      1. Lumbar Puncture contraindicates Thrombolytics
      2. Obtain Lumbar Puncture to assess for subarachnoid blood
         1. Recommended at 12 hours after onset of symptoms
         2. Send cell count (although blood cells can be seen also with traumatic LP)
         3. Send specimen for spectrophotometry for Bilirubin (only produced in vivo)
   4. Head CT negative suggesting Ischemic CVA
      1. Consider Thrombolytic Therapy below
6. Protocol: Step 5 Thrombolytic Therapy (if indicated)
   1. Review Thrombolytic Contraindications
   2. Review risks and benefits of Thrombolytic therapy
   3. Review indications for Thrombolytic therapy
      1. Persistent neurologic deficits
      2. CVA Symptom onset <3 hours prior
   4. Precaution
      1. Do not delay Thrombolysis for lab results unless high suspicion of abnormality
   5. Management
      1. See CVA Thrombolysis
7. Protocol: Step 6 General Measures
   1. Admit all stroke patients for 24-48 hours
      1. Cardiac monitoring (telemetry)
      2. Frequent neurologic checks (every 2-3 hours is a common interval)
         1. Speech
         2. Extremity motor strength
         3. Facial symmetry
   2. Keep patient NPO acutely to lower risk of aspiration
      1. Swallowing assessment for aspiration risk
   3. Gentle intravenous fluid hydration only (avoid D5W)
      1. Normal saline or lactated ringers at 50 cc/hour
   4. Maintain body temperature <97.5
      1. Acetaminophen (Tylenol)
      2. Cooling blankets
   5. Continue Oxygen by Nasal cannula to keep O2 Sat >92%
   6. Consider Thiamine in Alcoholics and malnourishment
8. Protocol: Step 7 Observe for and treat complications
   1. Blood Sugar Monitoring
      1. Treat Hypoglycemia: Bolus D50W (do not over correct)
      2. Treat Hyperglycemia (>300 mg/dl)
   2. CVA Blood Pressure Control
      1. Avoid lowering Blood Pressure too low in first 24 hours
      2. Typically initiate acute Blood Pressure management if >220/120 mmHg
      3. Anticipate spontaneous resolution over days
   3. Seizures
      1. Evaluate with Glucose and Serum Sodium
      2. Treat with Diazepam and Phenytoin
   4. Cerebral edema (peaks on day 3-5, duration 10 days)
      1. Intubate and hyperventilate to pCO2 of 35 mmHg
      2. Mannitol
      3. Neurosurgery consultation for decompression
      4. Corticosteroids are not indicated
   5. Delirium
      1. Avoid medications that cause Altered Level of Consciousness (e.g. sedatives, anticholinergics)
      2. Preserve normal sleep-wake cycle by avoiding disturbing night-time sleep
      3. Maintain orientation by maximizing sensory input (adequate lighting, eliminate background noise)
   6. Pressure Sores (Decubitus Ulcer)
      1. Early mobilization and frequent turning
      2. Frequent skin examination
      3. Alternating pressure mattresses
      4. Maintain adequate nutrition (see below)
   7. Malnutrition
      1. Assess albumin, Prealbumin, and Cholesterol as markers of malnutrition
   8. Fever
      1. Associated with worse outcome in Ischemic Stroke
      2. Thoroughly investigate for fever cause
      3. Lower fever with antipyretics
   9. Pneumonia
      1. Early mobilization
      2. Incentive Spirometry hourly
      3. Decrease Aspiration Pneumonia risk
         1. Avoid medications that cause Altered Level of Consciousness
         2. Assess swollowing study
   10. Urinary Tract Infections
       1. Avoid indwelling catheters as much as possible
   11. Other common complications
       1. Serum Inappropriate ADH Syndrome
       2. Pulmonary Embolism
9. Protocol: Step 8 Adjunctive Therapy
   1. See Prevention of Ischemic Stroke
      1. Includes Anticoagulation in Ischemic Stroke
   2. Avoid Heparin
   3. Start Aspirin 325 mg qd
   4. See Dysphagia after Cerebrovascular Accident
   5. Early rehabilitation
      1. Speech Therapy
      2. Physical Therapy
      3. Occupational Therapy
10. Prognosis
    1. Indicators of poor outcome
       1. Hyperglycemia
       2. Fever
       3. Hypertension
    2. Factors with positive impact on functional recovery
       1. Family Support has significant positive impact
11. References
    1. (2000) Circulation 102(suppl I):I-204 to I-216
    2. Lewandowski (2001) Ann Emerg Med 37:202-21
    3. Tsouna-Hadjis (2000) Arch Phys Med Rehabil 81:881-7
    4. Beauchamp (1999) Radiology 212(2):307-24
    5. Adams (2007) Stroke 38(5): 1655-711