Procedure

Advanced Airway Management after CVA

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Advanced Airway Management after CVA, Cerebrovascular Accident Associated Intubation, Endotracheal Intubation Precautions after Stroke

  • See Also
  1. CVA Management
  2. Advanced Airway
  3. Rapid Sequence Intubation
  4. Endotracheal Intubation Preparation
  5. Endotracheal Tube
  6. Endotracheal Intubation Preoxygenation (and Apneic Oxygenation)
  7. Direct Laryngoscope
  8. Video Laryngoscope
  9. Endotracheal Intubation
  10. Extraglottic Device (e.g. Laryngeal Mask Airway or LMA)
  1. See Advanced Airway
  2. Aspiration risk
  3. Decreased Level of Consciousness
  4. High NIH Stroke Scale
    1. High risk for hemorrhagic conversion and decompensation
  5. Posterior stroke
    1. Consider Endotracheal Intubation if neurointervention planned
  6. Interfacility Transfer
    1. Consider before transport, allowing for stabilization and decreased risk for decompensation during transport
  • Management
  1. Use Rapid Sequence Intubation (RSI)
  2. Intubate with head of bed at 30 degrees
  3. Maintain Blood Pressure in range in the intubation and peri-intubation period
    1. See Blood Pressure Control after Cerebrovascular Accident
    2. Target systolic Blood Pressure (SBP): 140 to 180 mmHg
    3. Target mean arterial pressure (MAP): 70 to 90 mmHg
    4. Hypotension
      1. Consider starting Vasopressors before intubation, targeting SBP 160 mmHg
      2. Avoid IV fluids to maintain Blood Pressure in adequately hydrated patients
    5. Hypertension (most CVA patients)
      1. Systolic Blood Pressure >180 mmHg is at increased risk of hemorrhagic conversion
  4. RSI Medication Selection
    1. Sedation
      1. Etomidate or
      2. Ketaphol (Ketamine with Propofol 1:1)
    2. Paralysis
      1. Rocuronium 1.2 to 1.5 mg/kg (preferred)
      2. Succinylcholine may be preferred by neurointensivists
  5. Post-Intubation
    1. Nasogastric or Orogastric Tube
    2. Sedation
      1. Combination of Propofol and Fentanyl
      2. Start Norepinephrine for Hypotension on sedation (see Blood Pressure targets as above)
    3. Maintain normocapnea
      1. Target End-Tidal CO2: 35-45 mmHg
      2. Avoid Hyperventilation
        1. Risk of vasonstriction and associated with worse outcomes
    4. Avoid hyperoxia
      1. Maintain Oxygen Saturation 95-98%
  • References
  1. Swaminathan and Weingart (2026) Stroke Airway, EM:Rap, 2/23/2026