Cerebrovascular Accident (CVA) Bleed Management

Initial Assessment and Diagnosis

The American College of Surgeons recommends assessing the extent of bleeding using an established grading system such as the Advanced Trauma Life Support (ATLS) classification 3
Evaluate vital signs, mental status, and neurological deficits to determine severity in patients with suspected CVA bleed 1
Minimize time between symptom onset and diagnostic evaluation in patients with suspected CVA bleed 4, 5

Patients with identified source of bleeding and hemodynamic instability should undergo immediate bleeding control procedure, according to the Critical Care society 4, 7
Patients with unidentified source of bleeding should undergo immediate further investigation, as recommended by the Critical Care society 1, 2
For patients without brain injury, employ a restricted volume replacement strategy with target systolic blood pressure of 80-90 mmHg (MAP 50-60 mmHg) until major bleeding has been stopped, as suggested by the Critical Care society 1, 2

Initiate fluid therapy using 0.9% NaCl or balanced crystalloid solution in patients with CVA bleed, according to the Critical Care society 2
If erythrocyte transfusion is necessary, aim to achieve a target hemoglobin of 70-90 g/L in patients with CVA bleed, as recommended by the Critical Care society 2

Consider tranexamic acid 10-15 mg/kg followed by an infusion of 1-5 mg/kg/h in bleeding patients with CVA bleed, as suggested by the Critical Care society 4, 5
Implement early measures to reduce heat loss and warm the hypothermic patient to achieve and maintain normothermia in patients with CVA bleed, according to the Critical Care society 2

Damage-control surgery should be performed in severely injured patients presenting with hemorrhagic shock, signs of ongoing bleeding, coagulopathy, vascular injuries, hypothermia, or acidosis, as recommended by the Critical Care society 2
Apply early mechanical thromboprophylaxis with intermittent pneumatic compression while the patient is immobile and has bleeding risk, according to the Critical Care society 1