Neuro Critical Care

Last modified by Hussein Abdallah on 2024/04/01 19:18

NICU TRAC

SUMMARY STATEMENT	SERVICE NOTE / MEMO
Dx: Lines: Code: Goals:	Neuro exam: ICU timeline 3 days: Follow-ups;

Ventilation

What is an SBT?

Generally speaking, the factors predicting successful extubation are:

Passing an SBT
Rapid shallow breathing test (RSBT)
reason for intubation was reversed
secretions are
neck flexion strength
GCS / strength of cough

In neuro patients, the factors are

degree of secretions
ability to swallow (raise palate)
predicted ability to handle secretions based on anatomy of lesion (e.g. someone with a frontal lobe lesion much more promising than a cerebellar / 4th ventricular lesion)

"desynchronous with the vent"

Upload: Respiratory Therapy Ventilator Workshop (pdf)

HYPO-Natremia

Remember tonicity is determined by 2 x Na+ + glucose / BUN so practically speaking you think about Na+ / glucose / BUN

Order first:

Random electrolytes, urine
Urine osmolality
Serum osmolarity (kinda useless but just get it)

HYPO-tonic (Serum Osm LOW)

ISO-tonic (Serum Osm wnl)

Hyper-tonic (Serum Osm HIGH)

most applicable practically

	HYPO-volemic	EU-volemic	HYPER-volemic
physical exam	physical exam useless	physical exam useless path:	physical exam can help path:
Path	ineffective intra-arterial blood volume --> RAAS --> H2O/Na+ absorption
Practical examples		SIADH, AI, Hypothyroidism, tea and toast diet, beer potomania	cirrhotic, CHF
Uosm	HIGH	HIGH	HIGH
UNa	LOW	HIGH	LOW
Treatment

very rare, not generally applicable (e.g. MM)

Hyperglyemia

NORMAL RANGES OF RANDOM URINE LYTES

Urine osmolality: 300 – 900 mOsm/kg
Urine sodium (Na+): 40 – 260 mmol/24h
Urine potassium (K+): 25 – 125 mmol/24h
Urine urea: 250-125 mmol/24h

Step-up treatment of hyponatremia

Fluid restriction
salt tabs
1.5%
3% - given as 250 cc bolus
23% - given as a 10 minute push

CSW vs. SIADH

Risks of overcorrecting

Generally a safe rate of correction is

"From low to high, your pons will die" (osmotic demyelination syndrome)

AKI

Calculat FENa

Pre-renal	intrinsic
FENa	FENa
Treat = IVF	Treat = diuretic?

Generalized Convulsing Status Epilepticus

1. Determine access

LOADING SHORT-ACTING TREATMENT TO BREAK CONVULSIONS

2a. If access: 2-4 mg IV ativan (repeat as needed w/ escalating doses until convulses STOP q5min 4, 8, 10, no limit until break, all while calling condition C if not already called)

2b. If no access: 10mg IM versed (repeat as needed 10mg IM q5 min also until convulses STOP)

+/- LOADING LONG-ACTING TREATMENT TO BREAK CONVULSIONS: if had to give a second round of benzo in step 2, then will need to also load with ONE of these options (orange bag should be called by this point)

LONG-ACTING AED LOADS	Reasons to Use / Not to Use
3a. Keppra 60 mg/kg (max 4.5g) OR brivaracetam 100mg once	Keppra General #1 choice; Brivaracetam unusual choice outside of 4F/5F (expensive to go home on)
3b. Fosphenytoin 20 mg/kg (max ____)	Reason NOT to use: will decrease GCS 1-2 points likely and cause bradycardia
3c. VPA 40 mg/kg (max _____)	Reason NOT to use: hepatic dysfunction i.e. known cirrhosis
3d. Lacosamide (Vimpat) 200-400mg once	Reason NOT to use: bradycardia/heart block risk

If still seizing after first-load of LONG-ACTING above, then go ahead and choose another row in the table on top of it.

If still seizing after two-loads of LONG-ACTING, intubate if not already and will need cEEG / propofol / ketamine (orange bag should be long-involved by this point)

NOTES until orange bag arrives:

- Don't hold patient down, just move harmful objects out of the way

- Get suction available STAT

- Put non-rebreather on their face even while convulsing (they WILL all desat while seizing) unless they start vomiting

LOADING SHORT-ACTING TREATMENT TO BREAK CONVULSIONS

2a. If access: 2-4 mg IV ativan (repeat as needed w/ escalating doses until convulses STOP q5min 4, 8, 10, no limit until break, all while calling condition C if not already called)

2b. If no access: 10mg IM versed (repeat as needed 10mg IM q5 min also until convulses STOP)

LONG-ACTING AED LOADS	Reasons to Use / Not to Use
3a. Keppra 60 mg/kg (max 4.5g) OR brivaracetam 100mg once	Keppra General #1 choice; Brivaracetam unusual choice outside of 4F/5F (expensive to go home on)
3b. Fosphenytoin 20 mg/kg (max ____)	Reason NOT to use: will decrease GCS 1-2 points likely and cause bradycardia
3c. VPA 40 mg/kg (max _____)	Reason NOT to use: hepatic dysfunction i.e. known cirrhosis
3d. Lacosamide (Vimpat) 200-400mg once	Reason NOT to use: bradycardia/heart block risk

If still seizing after first-load of LONG-ACTING above, then go ahead and choose another row in the table on top of it.

If still seizing after two-loads of LONG-ACTING, intubate if not already and will need cEEG / propofol / ketamine (orange bag should be long-involved by this point)

NOTES until orange bag arrives:

- Don't hold patient down, just move harmful objects out of the way

- Get suction available STAT

- Put non-rebreather on their face even while convulsing (they WILL all desat while seizing) unless they start vomiting

Paralytic Reversal

Paralytic	Reversal agent (dose)
ROC	Suggamadex OR Neostigmine + glycopyrrolate
Succinylcholine	No reversal, will wear off in ~5 minutes

Anticoagulation and Reversal

For all DOACs/Heparin especially, make sure you know last dose.

ANTICOAGULATNT	Agent and dose	NOTES
VIT K ANTAGONIST (WARFARIN) APIXABAN EDOXABAN RIVAROXABAN	OPTION 1a ACUTE EMERGENCIES: 4F-PCC (KCentra) INR based for Warfarin (if attg cares) INR 2-4: 25 units/kg INR 4-6: 35 units/kg INR 6+ or head bleed: 50 units/kg DOAC / non-INR based for Warfarin (if attg doesn't care) 25 units/kg for life-threatening bleed other than ICH 50 units/kg for life-threatening bleed = ICH OPTION 1b ACUTE EMERGENCIES: FFP (If K-centra is not available) 10-15 mL/kg FFP, ordered in units (200-250 mL / unit, will probably have to call blood bank)	order and call pharmacy for K-central, generally should be efficient and accessible at all times at PUH Ignore INR for non-Warfarin (DOACs)
HEPARIN LOVENOX	Protamine based on last dose of heparin, call pharmacy for dosing	can theoretically reverse SQH / SQL but pretty useless, this is generally only for IV heparin / lovenox. c/i in shellfish allergy w/ anaphylaxis
Dabigatran (Pradaxa)	Idaricizumab (Praxbind) 5 grams over 10 minutes	super expensive
Aspirin / Clopidogrel (Plavix)	Platelets or DDAVP	0.4 mcg/kg DDAVP
Hemophilia A	major head bleed: Factor 8 50 units /kg	FYI this is still given even if no bleed in head (you will not be called about these people)

Vasospasm

Drugs to NOT use with vasospasm
- PHB deactivates nimotop
- Statins & vasospasm _____
- SSRI & vasospasm _____
How these patients will present practically:
- Spasm window is generally day 14-21

Treatment How to order Notes
Milrinone
Verapamil

HYPERTENSION

Treatment	How to order	Notes
Clevidipine
Nicardipine

See attached ppt. on clevipidine / nicardipine formulary review

March 2024 update:

System P and T has reviewed the formulary status of clevidipine and nicardipine. We have found that the current evidence does not show that clevidipine is superior to nicardipine. There is also an approximately $750k savings to be achieved by standardizing to nicardipine. As such, we will be making clevidipine non-formulary. We will be moving to a premixed formulation of nicardipine that will be stocked in the accudoses and ORs, so there is no wait to have it come up from pharmacy.

This has been discussed with the CTICU, CCU and Neuro ICU medical directors as well as presby neuro anesthesia leadership and they are in agreement. Shaheryar has also discussed this with Mike Lang and Brad Gross and they are on board. We wanted to make sure that you are aware as well.

It will likely be a few months before we have made the appropriate EHR and operational changes to go-live with this. We will make sure to notify you when we have a go-live date. Please review the deck and let us know if you have any questions.

Chenell Donadee, MD, MBA

Senior Medical Director, UPMC ICU Service Center

Associate Director, UPMC Pharmacy Service Center

Medical Advisor, Supply Chain, UPMC

Associate Professor, Department of Critical Care Medicine

University of Pittsburgh School of Medicine

Cell: 614-893-0994

IV Fluids

TBA

Tube Feeds

Duo-tube vs. OGT tube

Transcranial Dopplers

TBA

Managing Elevated ICP

Medications


Hypertonic Saline
Mannitol

Neuro exam - stroke patients

Eye deviation

Eyes deviate ipsilateral to ACA/MCA temporal lobe strokes (not PCA)
Eyes deviate contrlateral to seizures

Storming

TBA

Neuro-stim

TBA

Neuro exam - ICU / comatose

Use TOF to make sure paralytics are actually reversed.

How to use TOF:

NPI with pupillomoeter:

Point of using this over just pupil size is that it's unaffected by many ICU meds and intoxicants including opioids, NMBAs, sedatives
see attached pamphlet