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CVA ManagementAka: CVA Evaluation, Cerebrovascular Accident Management, Stroke Management

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  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 and obtain full vital signs
    2. Deliver Oxygen by Nasal cannula
    3. Obtain Intravenous Access
    4. Cardiac monitoring and Electrocardiogram
    5. Obtain bedside Serum Glucose
    6. Obtain labs
      1. Complete Blood Count (CBC)
      2. Serum Electrolytes (Chem7)
      3. ProTime (PT)
      4. Partial Thromboplastin Time (PTT)
  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 (Glascow 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)
      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. Neurosurgery consultation
      3. Reverse anticoagulants or Bleeding Disorder
      4. Manage Hypertension appropriately
    3. Head CT negative despite high suspicion for SAH
      1. Obtain Lumbar Puncture to assess subarachnoid blood
      2. Lumbar Puncture contraindicates Thrombolytics
    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. See CVA Thrombolysis
  7. Protocol: Step 6 General Measures
    1. Keep patient NPO acutely to lower risk of aspiration
    2. Gentle intravenous fluid hydration only (avoid D5W)
      1. Normal saline or lactated ringers at 50 cc/hour
    3. Maintain body temperature <97.5
      1. Acetaminophen (Tylenol)
      2. Cooling blankets
    4. Continue Oxygen by Nasal cannula to keep O2 Sat >92%
    5. 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
      2. 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. Other common complications
      1. Serum Inappropriate ADH Syndrome
      2. Pneumonia
      3. Urinary Tract Infection
      4. 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
  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
    2. Lewandowski (2001) Ann Emerg Med 37:202
    3. Tsouna-Hadjis (2000) Arch Phys Med Rehabil 81:881

Cerebrovascular accident (C0038454)

Definition (CSP)sudden neurologic impairment due to a cerebrovascular disorder, either an arterial occlusion or an intracranial hemorrhage.
Definition (MSH)A group of pathological conditions characterized by sudden, non-convulsive loss of neurological function due to BRAIN ISCHEMIA or INTRACRANIAL HEMORRHAGES. Stroke is classified by the type of tissue NECROSIS, such as the anatomic location, vasculature involved, etiology, age of the affected individual, and hemorrhagic vs. non-hemorrhagic nature. (From Adams et al., Principles of Neurology, 6th ed, pp777-810)
Definition (NCI)A sudden, nonconvulsive loss of neurologic function due to an ischemic or hemorrhagic intracranial vascular event. In general, cerebrovascular accidents are classified by anatomic location in the brain, vascular distribution, etiology, age of the affected individual, and hemorrhagic vs. nonhemorrhagic nature. (From Adams et al., Principles of Neurology, 6th ed, pp777-810)
ConceptsDisease or Syndrome (T047)
MSHD020521
BasqueATAKEA/EZBEHAR BASKULAR BURMUINETAKOA
DanishApopleksi/cerebrovaskulaer katastr
EnglishAccident - cerebrovascular, ACCIDENT CEREBROVASCULAR, Apoplexy, Brain Attack, Brain Vascular Accident, Brain Vascular Accidents, Cerebral apoplexy, CEREBRAL INFARCTION, Cerebral Stroke, Cerebral Strokes, cerebral vascular accident, CEREBROVASCULAR ACCIDENT, Cerebrovascular Accidents, Cerebrovascular Apoplexy, Cerebrovascular Stroke, Cerebrovascular Strokes, CVA, CVA - Cerebrovascular accident, CVA - Cerebrovascular accident unspecified, CVA unspecified, Stroke, Stroke and cerebrovascular accident unspecified, Stroke Syndrome, Stroke unspecified, Stroke/cerebrovasc accident, Stroke/cerebrovascular accident, Stroke/CVA - undefined, Strokes
FinnishAIVOHALVAUS/ AIVOVERENKIERRON HAIRIO
FrenchAccident vasculaire cerebral
Hebrewerua moxi
Hungarianagyergorcs/agyverzes
ItalianColpo/accidente cerebrovascolare
NorwegianHJERNESLAG/CEREBROVASK KATASTROFE
PortugueseAcidente/doenca cerebrovascular
SpanishAcc cerebrovascular/apoplejia, accidente cerebrovascular, ACV, apoplejia, apoplejia cerebral, stroke
SwedishHJARNSLAG/CEREBROVASKULAR SKADA
Parent ConceptsCerebrovascular Disorders (C0007820), Brain Diseases (C0006111), Arterial thrombosis (C0151942), Vascular Disorders, General and NEC (C0549519), Arterial vessel disorders (C0549603), CNS GENERAL (C0549638), VASCULAR: INTRACRANIAL (C0549642), circulatory system (C0497231), Diagnosis/Diseases Component (C0497531), Cerebrovascular accident (C0038454), Ambiguous concept (C1274012)
SourcesAOD, COSTAR, CSP, CST, DXP, ICPC, ICPCBAQ, ICPCDAN, ICPCDUT, ICPCFIN, ICPCFRE, ICPCGER, ICPCHEB, ICPCHUN, ICPCITA, ICPCNOR, ICPCPOR, ICPCSPA, ICPCSWE, LNC, MEDLINEPLUS, MSH, MTH, NCI, NDFRT, OMIM, SCTSPA, SNOMEDCT
Derived from the NIH UMLS (Unified Medical Language System)



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