Immediate management of CVA

1. What is the first step in acute CVA management?
2. What are the indications for emergent CT?
3. Why should hypotonic fluids be avoided?
4. What are the cutoffs for BP treatment in a nonthrombolytic candidate? A thrombolytic candidate? Hemorrhagic CVA?
5. How are post-CVA seizures treated?
6. How is cerebral perfusion calculated? What is the goal value?
7. What are methods used to decrease ICP?

Answers:
1. ABCs.
2. To determine if patient is candidate for emergent thrombolytic therapy, impaired consciousness, coagulopathy present, fever.
3. Possibility of worsening brain edema.
4. Treat for SBP>220, DBP>120 in nonthrombolytic candidate. Treat for SBP>185, DBP>110 in thrombolytic candidate, before giving treatment. Treat for SBP>180, DBP>105 in hemorrhagic CVA, usually with labetalol (which does not cause cerebral vasodilation).
5. Benzos. If not effective, can use phenytoin.
6. Cerebral perfusion = MAP - ICP. Goal is >60mmHg.
7. ICP is managed by correcting contributing factors (hypercarbia, hypoxia, hyperthermia, acidosis, hypotension, hypovolemia), elevating HOB, avoid jugular compression, hyperventilation, hyperosmolar therapy (mannitol), Lasix, barbiturates, fluid restriction, surgical decompression.