What are the immediate admission orders for a patient suspected of having a Cerebrovascular Accident (CVA)?

Admission Orders for Suspected CVA

All patients with suspected acute stroke require immediate brain imaging with non-contrast CT within 30 minutes of hospital admission, urgent neurological evaluation, continuous cardiac monitoring, and frequent vital sign assessments while being kept NPO until swallowing is assessed. 1

Immediate Diagnostic Workup

Neuroimaging (Priority #1)

• Non-contrast CT head must be completed within 30 minutes of hospital admission to distinguish ischemic from hemorrhagic stroke 1
• If patient arrives within 6 hours and potentially eligible for endovascular thrombectomy, add CT angiography (CTA) from arch-to-vertex without delay 1
• MRI with diffusion-weighted imaging (DWI) is an acceptable alternative to CT if available and doesn't delay treatment 1

Neurological Assessment

• Neurological evaluation by stroke-experienced physician within 30 minutes of admission, available 24/7 1
• NIH Stroke Scale (NIHSS) assessment performed immediately and repeated multiple times daily to detect clinical deterioration 1
• For thrombolysis candidates: neurological checks and vital signs every 15 minutes for 2 hours, then every 30 minutes for 6 hours, then hourly for 16 hours 1
• For non-thrombolysis patients: neurological checks and vital signs every hour in ICU, or minimum every 4 hours in non-ICU settings 1

Laboratory Studies (Results within 20 minutes for thrombolysis candidates)

• Complete blood count with platelets 1
• Comprehensive metabolic panel (electrolytes, renal function, glucose) 1
• Coagulation studies: PT/INR, aPTT 1
• Troponin (3% of acute stroke patients have concurrent MI) 1
• Hemoglobin A1C and fasting lipid panel 1
• For patients >50 years: ESR and CRP to screen for giant cell arteritis 1

Cardiac Evaluation

• 12-lead ECG immediately without delaying stroke treatment 1
• Continuous cardiac monitoring for 24-72 hours to detect atrial fibrillation and arrhythmias 1
• Echocardiography (at least transthoracic) within 24 hours if no cardiac source identified 1

Vascular Imaging

• Doppler ultrasound of carotid/vertebral arteries within 24 hours 1
• CTA or MRA of cervical vessels for patients with suspected large vessel disease 1

Vital Sign Monitoring and Management

Blood Pressure

• For thrombolysis candidates: maintain BP <185/110 mmHg before treatment, then <180/105 mmHg for 24 hours post-treatment 1
• For non-thrombolysis ischemic stroke: avoid aggressive BP lowering unless >220/120 mmHg 1
• For hemorrhagic stroke presenting within 6 hours: target systolic BP 140 mmHg (avoid <110 mmHg) 1
• Avoid precipitous BP drops; choose agents carefully 1

Temperature

• Monitor temperature every 4 hours for first 48 hours 1
• Treat fever >37.5°C (99.6°F) with acetaminophen and investigate for infection (pneumonia, UTI) 1

Oxygen

• Maintain oxygen saturation ≥92-94% with supplemental oxygen 2-3 L/min via nasal cannula as needed 1

Supportive Care Orders

NPO Status and Positioning

• Keep patient NPO (including oral medications) until swallowing assessment completed 1
• Head of bed positioning: 25-30° if increased intracranial pressure suspected; ≥30° if aspiration risk; head-flat position may maximize cerebral blood flow if no contraindications 1

IV Access and Fluids

• Normal saline at 75-100 mL/hour 1
• Maintain adequate hydration 1

Bed Rest and Mobilization

• Initial bed rest 1
• Rehabilitation assessment within 48 hours of admission 1
• Begin frequent, brief out-of-bed activity (sitting, standing, walking) within 24 hours if no contraindications 1

Antithrombotic Management

For Ischemic Stroke

• If thrombolysis given: NO heparin, warfarin, aspirin, clopidogrel, or dipyridamole for 24 hours 1
• If no thrombolysis: start antithrombotics within first 24 hours of admission (typically aspirin 160-325 mg) 1

For Hemorrhagic Stroke

• Immediately discontinue anticoagulation and arrange reversal 1

VTE Prophylaxis

• Intermittent pneumatic compression (IPC) devices bilaterally starting within 24 hours and continuing until independently mobile, discharge, or 30 days 1
• Low-molecular-weight heparin (enoxaparin) for high VTE risk patients; unfractionated heparin if renal failure 1
• Do NOT use anti-embolism stockings alone 1
• Assess skin integrity daily with IPC 1

Seizure Management

• Treat acute seizures with short-acting medications (lorazepam IV) if not self-limiting 1
• Do NOT start prophylactic anticonvulsants 1
• Single self-limiting seizure at onset does not require long-term anticonvulsants 1

Critical Pitfalls to Avoid

• Never give aspirin or antithrombotics before brain imaging rules out hemorrhage 1
• Never delay imaging for laboratory results (except coagulation studies for thrombolysis candidates) 1
• Never aggressively lower BP in ischemic stroke unless patient is thrombolysis candidate or BP >220/120 mmHg 1
• Never use contrast-enhanced CT initially as it may obscure hemorrhage 1
• Never delay door-to-needle time beyond 60 minutes (target ≤30 minutes) 1

Additional Considerations

• Transesophageal echocardiography if transthoracic non-diagnostic and will change management 1
• Consider ICU admission for patients requiring ventilatory support, frequent neurological monitoring, or hemodynamic instability 1
• Neurosurgical consultation for hemorrhagic stroke with hydrocephalus or mass effect 1