What is the management plan for a 32-year-old male patient who had an onsite stroke, received Cardiopulmonary Resuscitation (CPR) in the ambulance, was revived, and is currently intubated with Tissue Plasminogen Activator (TPA) administered?

Management of Young Adult with Acute Ischemic Stroke

The management of this 32-year-old male with acute ischemic stroke who required CPR and has been intubated should focus on comprehensive stroke unit care with close monitoring of neurological status, blood pressure management, temperature control, and prevention of complications.

Immediate Management Priorities

Airway and Ventilation

• Continue intubation and ventilatory support to maintain oxygen saturation ≥94% 1
• Position the patient with head of bed elevated 30° to reduce risk of aspiration and optimize cerebral perfusion
• Monitor ventilation parameters to avoid hypoxia (PaO₂ < 70 mmHg) and severe hyperoxia (PaO₂ > 300 mmHg) 1

Neurological Monitoring

• Perform neurological evaluations every 15 minutes for the first 2 hours, every 30 minutes for the next 6 hours, and hourly thereafter 2
• Use NIH Stroke Scale to document neurological status and track changes
• Monitor for signs of neurological deterioration that may indicate hemorrhagic transformation, particularly given tPA administration 1

Blood Pressure Management

• Maintain blood pressure <180/105 mmHg for the first 24 hours after tPA administration 1, 2
• Use IV antihypertensives as needed to maintain target BP
• Avoid hypotension; maintain mean arterial pressure >70 mmHg to ensure adequate cerebral perfusion 1

Temperature Management

• Implement continuous temperature monitoring 1
• Treat fever aggressively (temperature >37.5°C/99.5°F) as hyperthermia is associated with increased morbidity and mortality 1
• Consider mild-moderate hypothermia (33-36°C) if the patient experienced cardiac arrest with return of spontaneous circulation 1

Post-tPA Management

Hemorrhage Monitoring

• Perform follow-up CT scan at 24 hours post-tPA or immediately if neurological deterioration occurs 1
• Monitor for signs of symptomatic intracranial hemorrhage, which occurs in approximately 6.4% of patients treated with tPA 1
• Delay anticoagulants and antiplatelet agents for 24 hours after tPA administration 1

Laboratory Monitoring

• Continue monitoring complete blood count, coagulation parameters, and renal function
• Maintain strict glycemic control, avoiding both hyperglycemia and hypoglycemia 2

Multidisciplinary Care

Specialty Consultations

• Continue with neurology, neurosurgery, cardiology, and cardiovascular surgery consultations as planned
• The multidisciplinary approach is essential as stroke unit care significantly improves outcomes compared to general medical ward care 1

Diagnostic Workup

• Cardiac evaluation: Echocardiogram, continuous cardiac monitoring for arrhythmias
• Vascular imaging: CT angiography or MR angiography to identify potential large vessel occlusion
• Consider mechanical thrombectomy if large vessel occlusion is identified, especially since the patient has already received tPA 1

Complication Prevention

Deep Vein Thrombosis (DVT) Prevention

• Apply intermittent pneumatic compression devices immediately 1
• Consider prophylactic-dose LMWH after 24 hours post-tPA and once repeat brain imaging confirms no hemorrhagic transformation 2
• Early mobilization when clinically stable 1

Infection Prevention

• Monitor for signs of pneumonia, which is common in intubated stroke patients 1
• Elevate head of bed to reduce aspiration risk
• Consider early tracheostomy if prolonged intubation is anticipated 1

Nutrition Management

• Assess swallowing function before initiating oral feeding once extubated
• Consider early enteral nutrition via nasogastric tube if prolonged intubation is expected 1

Long-term Planning

Secondary Prevention

• Once stabilized (>24 hours post-tPA), initiate appropriate antiplatelet therapy 2
• Investigate stroke etiology to guide secondary prevention strategies
• Consider early rehabilitation consultation

Prognosis Considerations

The prognosis for this young patient depends on several factors:

• Stroke severity (initial NIHSS score)
• Time from symptom onset to tPA administration
• Response to treatment
• Presence of complications

While younger age is generally associated with better outcomes, the need for CPR and intubation suggests a severe presentation that may impact prognosis. However, early administration of tPA improves the likelihood of favorable outcomes, with approximately 31-50% of patients achieving complete or nearly complete neurological recovery 1.