CEREBROVASCULAR ACCIDENT (CVA)

Transcription

1 Manual: LifeLine Patient Care Protocols Section: Adult/Pediatrics Protocol #: AP5-002 Approval Date: 12/01/2017 Effective Date: 12/01/2017 Revision Due Date: 12/01/2018 CEREBROVASCULAR ACCIDENT (CVA) PURPOSE A. To provide consistent, optimal care for patients > 16 years of age experiencing a CVA SCOPE A. All current Lifeline employees DEFINITIONS A. None GUIDELINES A. Continuous vital monitoring and EtCO2 via continuous waveform capnography B. Perform rapid Cincinnati Prehospital Stroke Scale (CPSS), GCS, verbal function, and any focal neurological deficits in a critically ill patient requiring time-dependent intervention. Whenever possible, but not to interfere with other critical tasks requiring the crew s immediate attention (scene/transport safety, airway/breathing/circulation issues, herniation syndromes, etc.) the evaluation should include NIH Stroke scale. a. All patients require the following information to be documented/obtained at the minimum: i. Cincinnati prehospital stroke scale ii. A blood glucose iii. The time the patient was last known to be at their neurological baseline b. If the patient has a positive CPSS, the provider may then opt to perform a large vessel occlusion stroke scale (for example: RACE, FAST-ED, or C-STAT) c. Document this initial assessment, and repeated neurologic assessments throughout transport. i. Document GCS, strength, pupils and verbal function 1. For hours 1-2, document every 15 min 2. For hours 3-8, document every 30 min ii. Document hourly C. If tpa has been given to the patient, document the time the therapy was started and finished

2 D. Head should be maintained in midline position. Patients with cleared lumbar spines may be transported with HOB elevated 30 or placed in reverse trendelenberg (Head of bed elevated degrees above feet) E. Avoid sedation if possible or unless control of airway is required. F. For signs of increasing intracranial pressure (ICP) (with hemorrhagic CVAs) 1. Maintain ventilation with 100% O2 to maintain EtCO2 between mm Hg. Do NOT hyperventilate patient. 2. Signs of increased ICP or impending herniation a. Decreased GCS by >2 points b. Spontaneous periorbital bruising c. Cushing s triad: Hypertension, bradycardia, respiratory depression d. Cranial nerve VI palsy: inability to abduct eye e. Unilateral dilated pupil with contralateral hemiparesis 3. Administer 3% Normal saline bolus 250 ml over 30 minutes (no repeat dosing) if any of the following criteria are met: a. Posturing (flexor or extensory posturing) b. One or two blown pupils c. GCS less than or equal to 5 in a non-sedated/non-intubated patient d. GCS decrease of 2 or greater from initial crew assessment in a patient with an initial GCS of less than 10 e. Notes: i. Effects from a hypertonic saline bolus will typically last approximately 4 hours. ii. DO NOT REDOSE OR OVERDOSE THE PATIENT. Excessive use of hypertonic saline can lead to osmotic demyelination syndrome and cause significant patient harm. Blood Pressure Guidelines A. Attempt to maintain patient parameters within normal ranges without causing severe alterations in the patient s hemodynamics. Intervene only when indicated. a. Attempt to treat pain and discomfort as this may be precipitating the elevated blood pressure B. Hypotension and hypovolemia should be corrected to maintain systemic perfusion levels necessary to support organ function (generally a MAP of 65mmHg or greater). C. In ischemic stroke patients, it is reasonable to carefully titrate elevated systolic blood pressure to less than 185 mmhg and diastolic is less than 110mg prior to administration of tpa

3 D. In hemorrhagic stroke patients, it is reasonable to carefully titrate elevated systolic blood pressure to less than 140 mmhg a. Nicardipine is the agent of choice in patients with persistently elevated blood pressure with a hemorrhagic stroke. Medications A. Nicardipine (Cardene ) per AP1-010 IV Vasoactive Drug Administration Required Documentation: A. Time last known normal B. Blood glucose C. CPSS and/or NIH Stroke Scale number D. Initial and repeated neurological assessments throughout transport Citations/References: 2018 Guidelines for the Early Management of Patients With Acute Ischemic Stroke: A Guideline for Healthcare Professionals From the American Heart Association/American Stroke Association William J. Powers, Alejandro A. Rabinstein, Teri Ackerson, Opeolu M. Adeoye, Nicholas C. Bambakidis, Kyra Becker, José Biller, Michael Brown, Bart M. Demaerschalk, Brian Hoh, Edward C. Jauch, Chelsea S. Kidwell, Thabele M. Leslie-Mazwi, Bruce Ovbiagele, Phillip A. Scott, Kevin N. Sheth, Andrew M. Southerland, Deborah V. Summers, David L. Tirschwell and on behalf of the American Heart Association Stroke Council Stroke. 2018;STR , originally published January 24, Top

4 Pt Treated with: IV tpa Time treatment given: Patient s Name/ Rm #: Scale Used Standard Time On Admission/ Immediately post tx Pt s Scale Used Standard 8 hours :15 9 hours 10 hours :45 11 hours Time Pt s 1 hour 12 hours :15 13 hours 14 hours :45 15 hours 2 hours 16 hours 17 hours 3 hours 18 hours 19 hours 4 hours 20 hours 21 hours 5 hours 22 hours 23 hours 6 hours 24 hours Q Shift 7 hours On DC COMPLETE VITAL SIGNS & NEUROVASCULAR CHECKS (NV check items located in SHEATH band) AT THE SAME FREQUENCY Top

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