What are the initial management and admission orders for a patient with a cerebrovascular accident (CVA)?

From the Guidelines

Admission to a stroke unit or ICU is crucial for patients with cerebrovascular accident (CVA), as it allows for continuous cardiac monitoring, vital sign checks, and neurological assessments using the NIH Stroke Scale every 4-8 hours, as recommended by the most recent guidelines 1. The initial management of a patient with CVA requires prompt stabilization, assessment, and targeted interventions.

• The patient should be admitted to a stroke unit or ICU with continuous cardiac monitoring, vital sign checks every 4 hours, and neurological assessments using the NIH Stroke Scale every 4-8 hours.
• Maintain the airway with head elevation at 30 degrees and oxygen therapy to keep saturation above 94% 1.
• Order NPO status initially with IV fluids (0.9% normal saline at 75-100 mL/hr) until swallow evaluation.
• For ischemic stroke within the treatment window, consider IV alteplase (0.9 mg/kg, maximum 90 mg, with 10% as bolus and remainder over 60 minutes) if no contraindications exist, or endovascular thrombectomy for large vessel occlusions.
• For hemorrhagic stroke, reverse anticoagulation if applicable and consult neurosurgery.
• Control blood pressure with IV labetalol (10-20 mg) or nicardipine (5 mg/hr) for targets of <185/110 mmHg in ischemic stroke candidates for thrombolysis and <160/90 mmHg in hemorrhagic stroke, as recommended by the guidelines 1.
• Order baseline labs (CBC, coagulation studies, electrolytes, renal function), neuroimaging (CT/MRI), and cardiac workup (ECG, cardiac enzymes).
• Initiate DVT prophylaxis with intermittent pneumatic compression initially, transitioning to subcutaneous heparin (5000 units every 8-12 hours) after 24-48 hours if hemorrhage is excluded.
• Start aspirin 325 mg within 24-48 hours for ischemic stroke if thrombolysis is not given, as recommended by the guidelines 1. These measures aim to stabilize the patient, prevent complications, and minimize neurological damage during the critical early phase of stroke care. The most recent guidelines emphasize the importance of a multidisciplinary team approach, including physicians, nurses, occupational therapists, physiotherapists, speech-language pathologists, social workers, and clinical nutritionists, to provide comprehensive care for patients with CVA 1. The patient's management plan should be formulated within 48 hours of admission, using standardized, valid assessment tools to evaluate the patient's stroke-related impairments and functional status, as recommended by the guidelines 1.

From the Research

Initial Management and Admission Orders for CVA

The initial management and admission orders for a patient with a cerebrovascular accident (CVA) involve several key considerations, including:

• Prompt assessment and diagnosis to determine the type of CVA (ischemic or hemorrhagic) 2
• Administration of intravenous tissue plasminogen activator (tPA) if treatment is initiated within 3 hours of clearly defined symptom onset for ischemic stroke 2
• Early aspirin therapy for patients with acute ischemic stroke who are not receiving thrombolysis 2
• Prophylactic low-dose subcutaneous heparin or low molecular weight heparins for patients with restricted mobility 2

Diagnostic Considerations

Diagnosing CVA in the prehospital setting can be challenging, with a study finding that the prehospital diagnosis of CVA was correct in only 63% of cases 3

• The most common mimics of CVA include vertigo, electrolyte and metabolic disturbances, seizures, cardiovascular disorders, and brain tumors 3
• The use of stroke screening scales may be beneficial in improving the accuracy of prehospital diagnosis 3

Patient Characteristics and Comorbidities

Certain patient characteristics and comorbidities are associated with an increased risk of CVA, including:

• Congestive heart failure (CHF) 4
• Age over 65 4
• Atrial fibrillation 4
• Peripheral vascular disease (PVD) 4
• Female gender 4

Hemodynamic Management

The hemodynamic management of patients with acute brain injury caused by cerebrovascular diseases is not well established, with a survey finding significant variability in practice among healthcare professionals 5

• The use of routine echocardiography, cardiac output monitoring, and advanced hemodynamic monitoring varies widely 5
• Norepinephrine is the most common drug used to increase arterial blood pressure, and normal saline is the most common fluid used 5

Rehabilitation and Occupational Therapy

Occupational therapy interventions, such as the Occupational Adaptation frame of reference, may be beneficial in improving functional independence and discharge outcomes for patients with CVA 6