Wiki source code of Neuro Critical Care

Last modified by Hussein Abdallah on 2024/04/01 19:18
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1 {{box cssClass="floatinginfobox" title=" "}}
2 [[image:https://pulmonarypracticeassociates.com/wp-content/uploads/2018/11/CriticalCareMedicine-img.jpg||alt="Critical Care Medicine – Pulmonary Practice" height="159" width="227"]]
3
4 **Contents**
5
6 {{toc/}}
7 {{/box}}
8
9 (% class="wikigeneratedid" %)
10 [[See pharmacy orientation presentation>>https://upmchs-my.sharepoint.com/:p:/r/personal/lukeml_upmc_edu/Documents/Lukehart/Boot%20Camp/2023-2024%20Presentations/McGinnis,%20Cory.pptx?d=w7d58f2d037194c2887820ad1e4b09606&csf=1&web=1&e=DnT8Wy]]
11
12 = **NICU TRAC** =
13
14
15
16 (% style="width:691px" %)
17 |(% style="width:332px" %)(((
18 **SUMMARY STATEMENT**
19 )))|(% style="width:356px" %)(((
20 **SERVICE NOTE / MEMO **
21 )))
22 |(% style="width:332px" %)(((
23 Dx:
24
25
26
27 Lines:
28
29 Code:
30
31 Goals:
32 )))|(% style="width:356px" %)(((
33 Neuro exam:
34
35
36 ICU timeline 3 days:
37
38
39 Follow-ups;
40 )))
41
42 [[image:1711448285590-966.png]]
43
44 = **Ventilation** =
45
46 (% class="box" %)
47 (((
48 **~ What is an SBT?**
49 )))
50
51 (% class="box" %)
52 (((
53 **Generally speaking, the factors predicting successful extubation are: **
54
55 1. Passing an SBT
56 1. [[Rapid shallow breathing test (RSBT)>>https://www.mdcalc.com/calc/3999/rapid-shallow-breathing-index-rsbi]]
57 1. reason for intubation was reversed
58 1. secretions are
59 1. neck flexion strength
60 1. GCS / strength of cough
61
62 In neuro patients, the factors are
63
64 1. degree of secretions 
65 1. ability to swallow (raise palate)
66 1. 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)
67 )))
68
69 (% class="wikigeneratedid" %)
70 "desynchronous with the vent"
71
72
73 (% class="wikigeneratedid" %)
74 Upload: Respiratory Therapy Ventilator Workshop (pdf)
75
76
77
78 (% style="width:691px" %)
79 |(% style="width:332px" %) |(% style="width:356px" %)
80 |(% style="width:332px" %) |(% style="width:356px" %)
81
82 = **HYPO-Natremia** =
83
84 Remember tonicity is determined by 2 x Na+ + glucose / BUN so practically speaking you think about Na+ / glucose / BUN
85
86 __Order first__:
87
88 * Random electrolytes, urine
89 * Urine osmolality
90 * Serum osmolarity (kinda useless but just get it)
91
92 (% class="table-bordered" style="width:1487px" %)
93 |(% style="width:1042px" %)**HYPO-**tonic (Serum Osm LOW)|(% style="width:232px" %)**ISO-**tonic (Serum Osm wnl)|(% style="width:210px" %)**Hyper-**tonic (Serum Osm HIGH)
94 |(% style="width:1042px" %)(((
95 most applicable practically
96
97
98 |(% style="width:87px" %) |(% style="width:307px" %)**HYPO**-volemic|(% style="width:350px" %)**EU**-volemic|(% style="width:280px" %)**HYPER**-volemic
99 |(% style="width:87px" %)physical exam|(% style="width:307px" %)(((
100 physical exam useless
101 )))|(% style="width:350px" %)(((
102 physical exam useless
103
104 path:
105 )))|(% style="width:280px" %)(((
106 physical exam can help
107
108 path:
109 )))
110 |(% style="width:87px" %)Path|(% style="width:307px" %)ineffective intra-arterial blood volume ~-~-> RAAS ~-~-> H2O/Na+ absorption|(% style="width:350px" %) |(% style="width:280px" %)
111 |(% style="width:87px" %)Practical examples|(% style="width:307px" %) |(% style="width:350px" %)SIADH, AI, Hypothyroidism, tea and toast diet, beer potomania|(% style="width:280px" %)cirrhotic, CHF
112 |(% style="width:87px" %)Uosm|(% style="width:307px" %)HIGH|(% style="width:350px" %)HIGH|(% style="width:280px" %)HIGH
113 |(% style="width:87px" %)UNa|(% style="width:307px" %)LOW |(% style="width:350px" %)HIGH|(% style="width:280px" %)LOW
114 |(% style="width:87px" %)Treatment|(% style="width:307px" %) |(% style="width:350px" %) |(% style="width:280px" %)
115 )))|(% style="width:232px" %)very rare, not generally applicable (e.g. MM)|(% style="width:210px" %)Hyperglyemia
116
117
118
119 __**NORMAL RANGES OF RANDOM URINE LYTES**__
120
121 * Urine osmolality: 300 – 900 mOsm/kg
122 * Urine sodium (Na+): 40 – 260 mmol/24h
123 * Urine potassium (K+): 25 – 125 mmol/24h
124 * Urine urea: 250-125 mmol/24h
125
126 (% class="wikigeneratedid" %)
127
128
129 (% class="wikigeneratedid" %)
130 **Step-up treatment of hyponatremia**
131
132 * Fluid restriction
133 * salt tabs
134 * 1.5%
135 * 3%  - given as 250 cc bolus
136 * 23% - given as a 10 minute push
137
138 (% class="wikigeneratedid" %)
139 **CSW vs. SIADH**
140
141
142 (% class="wikigeneratedid" %)
143 **Risks of overcorrecting**
144
145 (% class="wikigeneratedid" %)
146 Generally a safe rate of correction is
147
148 (% class="wikigeneratedid" %)
149 "From low to high, your pons will die" (**osmotic demyelination syndrome**)
150
151 = **AKI** =
152
153 (% class="wikigeneratedid" %)
154 Calculat FENa
155
156 |Pre-renal|intrinsic
157 |FENa |FENa
158 |Treat = IVF |Treat = diuretic?
159
160 = **Generalized Convulsing Status Epilepticus** =
161
162 ~1. Determine access
163
164 __LOADING SHORT-ACTING TREATMENT TO BREAK CONVULSIONS__
165
166 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)
167
168 2b. If no access: **10mg IM versed** (repeat as needed 10mg IM q5 min also until convulses STOP)
169
170 __+/- 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)//
171
172 (% style="width:833px" %)
173 |(% style="width:444px" %)**LONG-ACTING AED LOADS**|(% style="width:385px" %)**Reasons to Use / Not to Use**
174 |(% style="width:444px" %)3a. **Keppra 60 mg/kg (max 4.5g) **OR **brivaracetam 100mg **once |(% style="width:385px" %)Keppra General #1 choice; Brivaracetam unusual choice outside of 4F/5F (expensive to go home on)
175 |(% style="width:444px" %)3b. **Fosphenytoin 20 mg/kg **(max ~_~_~_~_)|(% style="width:385px" %)__Reason NOT to use__: will decrease GCS 1-2 points likely and cause bradycardia
176 |(% style="width:444px" %)3c. **VPA 40 mg/kg** (max ~_~_~_~__) |(% style="width:385px" %)__Reason NOT to use__: hepatic dysfunction i.e. known cirrhosis
177 |(% style="width:444px" %)3d. **Lacosamide (Vimpat) 200-400mg **once|(% style="width:385px" %)__Reason NOT to use__: bradycardia/heart block risk
178
179 If still seizing after first-load of LONG-ACTING above, then go ahead and choose another row in the table on top of it.
180
181 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)
182
183
184 __NOTES until orange bag arrives__:
185
186 - Don't hold patient down, just move harmful objects out of the way
187
188 - Get suction available STAT
189
190 - Put non-rebreather on their face even while convulsing (they WILL all desat while seizing) unless they start vomiting
191
192 = [[image:https://www.uptodate.com/services/app/contents/graphic/view/NEURO/74649/TxCSEadults.gif||alt="Image" height="1018" width="1200"]] =
193
194 __LOADING SHORT-ACTING TREATMENT TO BREAK CONVULSIONS__
195
196 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)
197
198 2b. If no access: **10mg IM versed** (repeat as needed 10mg IM q5 min also until convulses STOP)
199
200 __+/- 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)//
201
202 (% style="width:833px" %)
203 |(% style="width:444px" %)**LONG-ACTING AED LOADS**|(% style="width:385px" %)**Reasons to Use / Not to Use**
204 |(% style="width:444px" %)3a. **Keppra 60 mg/kg (max 4.5g) **OR **brivaracetam 100mg **once |(% style="width:385px" %)Keppra General #1 choice; Brivaracetam unusual choice outside of 4F/5F (expensive to go home on)
205 |(% style="width:444px" %)3b. **Fosphenytoin 20 mg/kg **(max ~_~_~_~_)|(% style="width:385px" %)__Reason NOT to use__: will decrease GCS 1-2 points likely and cause bradycardia
206 |(% style="width:444px" %)3c. **VPA 40 mg/kg** (max ~_~_~_~__) |(% style="width:385px" %)__Reason NOT to use__: hepatic dysfunction i.e. known cirrhosis
207 |(% style="width:444px" %)3d. **Lacosamide (Vimpat) 200-400mg **once|(% style="width:385px" %)__Reason NOT to use__: bradycardia/heart block risk
208
209 If still seizing after first-load of LONG-ACTING above, then go ahead and choose another row in the table on top of it.
210
211 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)
212
213
214 __NOTES until orange bag arrives__:
215
216 - Don't hold patient down, just move harmful objects out of the way
217
218 - Get suction available STAT
219
220 - Put non-rebreather on their face even while convulsing (they WILL all desat while seizing) unless they start vomiting
221
222 = [[image:https://www.uptodate.com/services/app/contents/graphic/view/NEURO/74649/TxCSEadults.gif||alt="Image" height="1018" width="1200"]] =
223
224 = **Paralytic Reversal** =
225
226
227
228 (% style="width:532px" %)
229 |(% style="width:195px" %)**Paralytic**|(% style="width:333px" %)**Reversal agent (dose)**
230 |(% style="width:195px" %)ROC|(% style="width:333px" %)Suggamadex OR Neostigmine + glycopyrrolate
231 |(% style="width:195px" %)Succinylcholine|(% style="width:333px" %)No reversal, will wear off in ~~5 minutes
232
233 = **Anticoagulation and Reversal** =
234
235 // For all DOACs/Heparin especially, make sure you know last dose. //
236
237 (% style="width:995px" %)
238 |(% style="width:264px" %)**ANTICOAGULATNT**|(% style="width:432px" %)**Agent and dose**|(% style="width:297px" %)**NOTES**
239 |(% style="width:264px" %)(((
240
241
242 * **VIT K ANTAGONIST (WARFARIN)**
243 * **APIXABAN**
244 * **EDOXABAN**
245 * **RIVAROXABAN**
246
247
248 )))|(% style="width:432px" %)(((
249 **__OPTION 1a ACUTE EMERGENCIES:__ 4F-PCC (KCentra)**
250
251 //__INR based for Warfarin (if attg cares)__//
252
253 INR 2-4: **25 units/kg**
254
255 INR 4-6: **35 units/kg**
256
257 INR 6+ or head bleed: **50 units/kg**
258
259 //__DOAC / non-INR based for Warfarin (if attg doesn't care)__//
260
261 **25 units/kg for **life-threatening bleed other than ICH
262
263 **50 units/kg for **life-threatening bleed = ICH
264
265
266
267 **__OPTION 1b ACUTE EMERGENCIES:__ FFP (If K-centra is not available)**
268
269 **10-15 mL/kg FFP, ordered in units **(200-250 mL / unit, will probably have to call blood bank)
270 )))|(% style="width:297px" %)(((
271 order and call pharmacy for K-central, generally should be efficient and accessible at all times at PUH
272
273
274
275 Ignore INR for non-Warfarin (DOACs)
276 )))
277 |(% style="width:264px" %)(((
278 * **HEPARIN**
279 * **LOVENOX **
280 )))|(% style="width:432px" %)**Protamine **based on last dose of heparin, call pharmacy for dosing|(% style="width:297px" %)(((
281 * can theoretically reverse SQH / SQL but pretty useless, this is generally only for IV heparin / lovenox. 
282 ** c/i in shellfish allergy w/ anaphylaxis
283 )))
284 |(% style="width:264px" %)**Dabigatran (Pradaxa)**|(% style="width:432px" %)**Idaricizumab (Praxbind)** 5 grams over 10 minutes|(% style="width:297px" %)super expensive
285 |(% style="width:264px" %)**Aspirin / Clopidogrel (Plavix)**|(% style="width:432px" %)**Platelets **or **DDAVP**|(% style="width:297px" %)0.4 mcg/kg DDAVP 
286 |(% style="width:264px" %)**Hemophilia A**|(% style="width:432px" %)major head bleed: **Factor 8 50 units /kg**|(% style="width:297px" %)//FYI this is still given even if no bleed in head (you will not be called about these people)//
287
288 = =
289
290 = **Vasospasm** =
291
292 * Drugs to NOT use with vasospasm
293 ** PHB deactivates nimotop
294 ** Statins & vasospasm ~_~_~_~__
295 ** SSRI & vasospasm ~_~_~_~__
296 * How these patients will present practically:
297 ** Spasm window is generally day 14-21
298
299 * (% class="box errormessage" %)
300 (((
301 |**Treatment**|**How to order**|**Notes**
302 |Milrinone| |
303 |Verapamil| |
304 )))
305
306 = **HYPERTENSION** =
307
308 = =
309
310 (% class="box errormessage" %)
311 (((
312 |**Treatment**|**How to order**|**Notes**
313 |Clevidipine| |
314 |Nicardipine| |
315 )))
316
317
318 [[image:1711428823856-735.png||height="392" width="743"]]
319
320 See attached ppt. on clevipidine / nicardipine formulary review
321
322
323 (% class="box" %)
324 (((
325 //March 2024 update: //
326
327 //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. //
328
329 //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. //
330
331 //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. //
332
333
334 **Chenell Donadee, MD, MBA**
335
336 Senior Medical Director, UPMC ICU Service Center
337
338 Associate Director, UPMC Pharmacy Service Center
339
340 Medical Advisor, Supply Chain, UPMC
341
342 Associate Professor, Department of Critical Care Medicine
343
344 University of Pittsburgh School of Medicine
345
346 Cell: 614-893-0994
347 )))
348
349
350
351
352 = **IV Fluids** =
353
354 = =
355
356 TBA
357
358 = **Tube Feeds** =
359
360 Duo-tube vs. OGT tube 
361
362 = **Transcranial Dopplers** =
363
364 TBA
365
366 = **Managing Elevated ICP** =
367
368 **Medications**
369
370 (% style="width:1184px" %)
371 |(% style="width:343px" %) |(% style="width:424px" %) |(% style="width:414px" %)
372 |(% style="width:343px" %)Hypertonic Saline|(% style="width:424px" %) |(% style="width:414px" %)
373 |(% style="width:343px" %)Mannitol|(% style="width:424px" %) |(% style="width:414px" %)
374
375 = **Neuro exam - stroke patients** =
376
377 Eye deviation
378
379 * Eyes deviate **ipsilateral** to ACA/MCA temporal lobe strokes (not PCA)
380 * Eyes deviate **contrlateral** to seizures
381
382 ----
383
384 = **Storming** =
385
386 TBA
387
388
389 = =
390
391 = **Neuro-stim** =
392
393 TBA
394
395
396 = **Neuro exam - ICU / comatose** =
397
398 **Use TOF to make sure paralytics are actually reversed. **
399
400 //How to use TOF~://
401
402 **NPI with pupillomoeter**:
403
404 * Point of using this over just pupil size is that it's unaffected by many ICU meds and intoxicants including opioids, NMBAs, sedatives
405 * see attached pamphlet
406
407 [[image:1711426726722-829.png||height="204" width="570"]]
408
409 [[image:1711426807128-940.png||height="559" width="619"]]
410
411 [[attach:NPI pamphlet.pdf||target="_blank"]]
412
413 = **Stroke** =
414
415 __**How to interpret a CT perfusion summary**__:
416
417 red = dead brain tissue
418
419 green = penumbra
420
421 if core < 50-70 and ratio > 1.8, then thrombectomy candidate
422
423
424 __**Candidates for DHC**__
425
426 * Generally NOT anyone over 65 (BAG)
427 * Generally NOT anyone with two territory infarct e.g. ACA and MCA is out (Hafeez)
428
429 = (% id="cke_bm_8415S" style="display:none" %)** **(%%)**ICU Sign-out Template** =
430
431 See Intern encyclopedia for general sign-out rules. The perfect sign-out from the perfect resident consists of the following.
432
433 [[image:1711425216774-578.png||height="339" width="576"]]
434
435 [[image:1711425237808-181.png||height="345" width="558"]]
436
437 [[image:1711425268356-239.png||height="277" width="522"]]