Neuro Critical Care
Contents
- NICU TRAC
- Ventilation
- HYPO-Natremia
- AKI
- Generalized Convulsing Status Epilepticus
- Paralytic Reversal
- Anticoagulation and Reversal
- Vasospasm
- HYPERTENSION
- IV Fluids
- Tube Feeds
- Transcranial Dopplers
- Managing Elevated ICP
- Neuro exam - stroke patients
- Storming
- Neuro-stim
- Neuro exam - ICU / comatose
- Stroke
- ICU Sign-out Template
See pharmacy orientation presentation
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
| 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)
+/- 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
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 |
| 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) |
| Protamine based on last dose of heparin, call pharmacy for dosing |
|
| 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
HYPERTENSION
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
Stroke
How to interpret a CT perfusion summary:
red = dead brain tissue
green = penumbra
if core < 50-70 and ratio > 1.8, then thrombectomy candidate
Candidates for DHC
- Generally NOT anyone over 65 (BAG)
- Generally NOT anyone with two territory infarct e.g. ACA and MCA is out (Hafeez)
ICU Sign-out Template
See Intern encyclopedia for general sign-out rules. The perfect sign-out from the perfect resident consists of the following.
