What are the immediate doctor's orders for a patient presenting with a cerebral vascular accident (CVA) bleed?

Immediate Doctor's Orders for CVA Bleed (Intracerebral Hemorrhage)

For a patient presenting with intracerebral hemorrhage, immediately stabilize blood pressure to systolic 130-150 mmHg, reverse all anticoagulation, admit to neuro-ICU or stroke unit, obtain urgent neurosurgical consultation for cerebellar hemorrhage or hydrocephalus, and stop all antiplatelet agents. 1

Immediate Stabilization (First 15 Minutes)

Airway, Breathing, Circulation

• Assess and secure airway if GCS ≤8 or signs of impaired ventilation 1
• Maintain oxygen saturation 93-98% with supplemental oxygen only if needed (do not routinely administer oxygen) 1
• Ensure adequate ventilation; avoid hyperventilation and excessive PEEP in hypovolemic patients 1

Blood Pressure Management - CRITICAL

• Target systolic blood pressure 130-150 mmHg immediately 1
• Use rapid-onset, short-duration IV agents (e.g., labetalol, nicardipine) to facilitate titration 1
• Avoid aggressive lowering below 130 mmHg systolic - this is harmful 1
• Place arterial line for continuous BP monitoring 1

Reverse Anticoagulation STAT

For patients on Warfarin (VKA):

• Administer 4-factor prothrombin complex concentrate (PCC) immediately if INR ≥2.0 1
• Give IV vitamin K immediately after PCC to prevent later INR rebound 1
• Fresh frozen plasma is second-line if PCC unavailable 1

For patients on antiplatelet agents (ASA, clopidogrel, dipyridamole):

• Stop all antiplatelet agents immediately 1
• Do NOT give platelet transfusions - RCT data shows worse outcomes 1

For patients on DOACs (dabigatran, apixaban, rivaroxaban):

• Urgent hematology consultation for reversal agent availability 1
• Stop DOAC immediately 1

Diagnostic Orders (Within 30 Minutes)

Laboratory Studies

• Complete blood count with platelets 1
• Coagulation panel: PT/INR, aPTT 1
• Basic metabolic panel including glucose 1
• Type and screen 1
• Arterial blood gas 1

Imaging

• Non-contrast head CT already obtained for diagnosis
• CT angiography if concern for underlying vascular malformation or spot sign 1

Admission and Consultation Orders

Admission Location

• Admit to stroke unit or neuro-intensive care unit 1
• Continuous cardiac monitoring 1
• Continuous blood pressure monitoring via arterial line 1

Urgent Neurosurgical Consultation - MANDATORY for:

• Any cerebellar hemorrhage, especially with altered consciousness or brainstem symptoms 1
• Acute hydrocephalus requiring external ventricular drain (EVD) 1
• Supratentorial ICH with GCS 9-12 (may benefit from early surgery) 1
• Consider for decompressive craniectomy candidates 1

Monitoring Orders

Vital Signs

• Continuous arterial blood pressure monitoring 1
• Neurological checks every 1 hour (GCS, pupil exam, focal deficits) 1
• Core temperature monitoring (bladder or esophageal probe); maintain normothermia 36-37°C 1

Seizure Management

• Do NOT give prophylactic anticonvulsants 1
• If seizure occurs: load with levetiracetam 1g IV or phenytoin 20 mg/kg IV (max 2g) 1

Supportive Care Orders

Glucose Management

• Check blood glucose every 4 hours
• Target glucose 6-10 mmol/L (108-180 mg/dL) 1

Temperature

• Maintain normothermia; actively warm if hypothermic 1
• Avoid hyperthermia 1

DVT Prophylaxis

• Intermittent pneumatic compression devices immediately 2
• Hold pharmacologic anticoagulation until bleeding risk assessed 1

Gastric Protection

• Nasogastric tube if altered consciousness 1
• Proton pump inhibitor 1

Critical Pitfalls to Avoid

• Never give recombinant Factor VIIa outside clinical trials - increases thrombotic risk without clinical benefit 1
• Never give platelet transfusions for antiplatelet-associated ICH - worsens outcomes 1
• Never delay neurosurgical consultation for cerebellar hemorrhage - can rapidly deteriorate 1
• Defer DNR/palliative care decisions for 24-48 hours to assess response to therapy 1
• Do not restart anticoagulation acutely - requires case-by-case assessment with stroke/cardiology/hematology consultation 1

Goals of Care Discussion

• Establish goals with patient/substitute decision-maker within 24-48 hours 1
• Reassess DNR status after 24-48 hours if initially placed 1
• DNR patients should still receive all appropriate medical/surgical interventions unless explicitly indicated otherwise 1