When should a patient with a suspected cerebral vascular accident (CVA) be intubated?

Indications for Intubation in Patients with Suspected CVA

Patients with suspected cerebrovascular accident (CVA) should be intubated if they have a Glasgow Coma Scale (GCS) score ≤ 8, significantly deteriorating consciousness, loss of protective laryngeal reflexes, respiratory failure, or seizures. 1

Primary Indications for Intubation in CVA Patients

• GCS score ≤ 8, which indicates severe impairment of consciousness and inability to protect the airway 1, 2
• Significantly deteriorating level of consciousness, defined as a fall in GCS of two or more points, or a fall in motor score of one or more points 1
• Loss of protective laryngeal reflexes, which increases risk of aspiration 1, 2
• Respiratory failure, including:
  • Failure to achieve PaO₂ ≥ 13 kPa (though a lower target with peripheral oxygen saturation ≥ 95% is acceptable in acute ischemic stroke) 1, 2
  • Hypercarbia (PaCO₂ > 6 kPa) 1
  • Spontaneous hyperventilation (PaCO₂ < 4.0 kPa) 1
• Active seizures that compromise airway protection 1, 2
• Anatomical issues affecting airway patency:
  • Bilateral fractured mandible 1
  • Copious bleeding into the mouth (e.g., from skull base fracture) 1

Intubation Technique for CVA Patients

When intubation is indicated, the following approach is recommended:

• Use rapid sequence induction with appropriate hemodynamic management 1, 2
• Monitor blood pressure closely during intubation, with targets specific to stroke type:
  • Acute ischemic stroke: SBP > 110 mmHg and < 185 mmHg (if candidate for/received thrombolysis) or < 220 mmHg (if thrombolysis contraindicated) 1
  • Hemorrhagic stroke: SBP > 140 mmHg 1
  • Spontaneous subarachnoid hemorrhage: SBP < 160 mmHg 1
• Recommended drug regimen for induction:
  • High-dose fentanyl (3-5 μg/kg), alfentanil (10-20 μg/kg), or remifentanil TCI (Cpt ≥ 3 ng/ml) 1
  • Induction agent dosed to maintain adequate mean arterial pressure; ketamine 1-2 mg/kg may be useful in hemodynamically unstable patients 1
  • Neuromuscular blockade with suxamethonium 1.5 mg/kg or rocuronium 1 mg/kg 1
• Have vasoconstrictors (e.g., ephedrine or metaraminol) immediately available to treat hypotension 1

Important Considerations and Caveats

• Recent evidence suggests that routine intubation based solely on GCS score may not always be beneficial, particularly in patients with GCS 7-8 who are otherwise stable 3, 4
• Intubation carries significant risks, with mortality rates of approximately 50% within 30 days in intubated stroke patients 2
• Maintain normocapnia (PaCO₂ 4.5-5.0 kPa) after intubation; brief periods of mild hyperventilation (PaCO₂ 4.0-4.5 kPa) should only be used if there are signs of impending uncal herniation 1
• Avoid hyperoxia as it may worsen outcomes; target PaO₂ ≥ 13 kPa or SpO₂ ≥ 95% 1, 2
• Early intubation before neurological or respiratory deterioration becomes severe may improve outcomes 5
• Patients who remain hypotensive despite resuscitation should be stabilized before transport 1

Special Considerations for Extubation

• Higher GCS scores, particularly better eye response components, may predict successful extubation in MCA stroke patients 6
• Consider extubation when the patient demonstrates adequate airway protection, stable respiratory parameters, and improved neurological status 6