NEUROLOGICAL EMERGENCIES IN THE ICU...Neurological Emergencies in the ICU J. Gordon Boyd, MD, PhD,...
Transcript of NEUROLOGICAL EMERGENCIES IN THE ICU...Neurological Emergencies in the ICU J. Gordon Boyd, MD, PhD,...
NEUROLOGICAL EMERGENCIES
IN THE ICU
J. GORDON BOYD, MD, PHD, FRCPC
ASSOCIATE PROFESSOR
DEPTS. OF MEDICINE (NEUROLOGY) AND CRITICAL CARE MEDICINE
QUEEN’S UNIVERSITY
@JGORDONBOYD
Canadian Critical Care Forum-November 2019
Disclosures
◻ I receive a stipend from the Trillium Gift of Life
Network for my role as a Regional Medical Lead
◻ I receive research funding from Queen’s, IFPOC
Outline
◻ Use a case-based format to discuss 3 neurological
emergencies that may be encountered in the ICU,
including:
Intraparenchymal Hemorrhage
Subarachnoid Hemorrhage
Neuromuscular respiratory failure
Intraparenchymal Hemorrhage
◻ Clinical vignette 1: The neurology service calls you to assess this 67M with a history of hypertension who came to the emergency department as an acute stroke protocol 45 minutes ago
2 hours ago, he developed sudden onset left sided weakness
A few moments ago, he vomited and became sleepy, and they are worried about his ability to protect his airway
Intraparenchymal Hemorrhage
◻ Initial assessment:
◻ BP 215/130, HR 85, RR 12
◻ GCS 11 [E2 (to pain), M5
(localizes), V4 (confused, slurred)]
◻ Dense left hemiplegia
◻ Cardiac, respiratory, and
abdominal exams grossly normal
◻ WHAT IS OUR PLAN?
Intraparenchymal Hemorrhage
◻ ABCs
◻ A and B are OK so far, so what
about C? What do you do about
the BP of 215/130?
◻ A. Do not adjust the BP, his brain is
likely used to seeing the high pressures.
◻ B. Don’t lower it >25% or you’ll
worsen the ischemia around the
hematoma
◻ C. Use labetolol to bring the
BP<160/80
◻ D. Use GTN drip to lower the blood
pressure to <180 systolic
Intraparenchymal Hemorrhage
◻ ABCs
◻ A and B are OK so far, so what
about C? What do you do about
the BP of 215/130?
◻ A. Do not adjust the BP, his brain is
likely used to seeing the high pressures.
◻ B. Don’t lower it >25% or you’ll
worsen the ischemia around the
hematoma
◻ C. Use labetolol to bring the
BP<160/80
◻ D. Use GTN drip to lower the blood
pressure to <180 systolic
Intraparenchymal Hemorrhage
◻ ICH guidelines
“probably safe” to lower blood pressure to 140/80
Based largely on INTERACT 2 trial, showing a trend towards better functional recovery in patients with aggressive blood pressure control (<140/80) compared with conventional targets (<180/110)
However, ATACH-II trial called this into question
Individual patient data meta-analysis, favour lowering BP, not >60mmHg, and try to avoid fluctuations
Choice of agent is debated, labetolol, enalaprilat, nicardipine are all reasonable choices; avoid GTN as it causes cerebral vasodilation and increases ICP
ATACH-
II
Intraparenchymal Hemorrhage
◻ Back to your patient
You patient has remained
clinically stable. 24 hours after
admission, your team’s
pharmacist asks “what about DVT
prophylaxis?”
What do you say?
A. Yes
B. No
C. Maybe
Intraparenchymal Hemorrhage
◻ Back to your patient
You patient has remained clinically stable. 24 hours after admission, your team’s pharmacist asks “what about DVT prophylaxis?”
What do you say?
A. Yes
B. No
C. Maybe
◻ According to the 2015 ASA guidelines, it is recommended that all patients with ICH receive DVT prophylaxis (heparin or LMWH),
Intraparenchymal Hemorrhage
◻ Back to your patient
◻ Is there any role for
neurosurgical intervention?
Intraparenchymal Hemorrhage
◻ Back to your patient
◻ Is there any role for
neurosurgical intervention?
◻ 2 main indications for surgery
1. Cerebellar hematoma >3 cm in
diameter with neurological
deterioration
2. Lobar hematoma <1 cm from
the cortical surface in a patient
with neurological deterioration
Intraparenchymal Hemorrhage
◻ Summary: 3 things to remember about ICH:
1. Be really aggressive in BP control (but not too aggressive, eg
>60 mmHg drop in SBP)
2. DVT prophylaxis is OK 24 hours after the bleed, as long as the
patient is clinically stable and has stopped bleeding
3. There are two indications for neurosurgical intervention,
cerebellar hematomas and lobar hemorrhages within 1 cm of the
cortical surface
Subarachnoid hemorrhage
◻ Clinical vignette 2: You are called to the emergency department to assess a 20F who
collapsed shortly after complaining of the “worst headache of her life”
The CT scan shows the following…
Subarachnoid hemorrhage
What do you see?
Name 4 possible etiologies for
these findings.
1.
2.
3.
4.
Subarachnoid hemorrhage
What do you see?
Name 4 possible etiologies for
these findings.
1. Aneurysm
2. AVM
3. Sympathomimetic drugs
4. Vasculitis (e.g. SLE)
Subarachnoid hemorrhage
Name 3 neurological
complications of SAH. How
are these
prevented/treated?
Subarachnoid hemorrhage
Name 3 neurological
complications of SAH. How
are these
prevented/treated?
1. Obstructive hydrocephalus
2. Seizures
3. Vasospasm/delayed
ischemic insults
Subarachnoid hemorrhage
◻ Neurological complications of SAH
◻ Obstructive hydrocephalus
call you friendly neighborhood neurosurgeon for an EVD
◻ Seizures
No role for seizure prophylaxis
■ if clinical seizures occur, treat them
■ Continuous EEG monitoring is recommended, and if subclinical seizures are detected, then treatment is recommended
◻ Delayed ischemic events
Usually begin 4-7 days after the bleed, monitor with transcranial doppler/CTA/clinical exam/EEG
Moving away from “triple H therapy” (hypertension, hypervolemia, hemodilution) to focus more on induced hypertension +/- milrinone
nimodipine (doesn’t prevent vasospasm, but improves mortality and decreases ischemic events)
Subarachnoid hemorrhage
◻ Summary: 3 things to remember about SAH:
1. The bleed is just the beginning of the patients’ problems,
significant morbidity and mortality is caused by the complications
of SAH, particularly ischemia and hydrocephalus
2. Look hard for the cause of SAH, it’s not all due to aneurysms
3. There is no role for prophylactic anti-convulsants
Neuromuscular respiratory failure
◻ Clinical vignette 3: You are asked to see a 19 year old nursing student admitted to the
neurology service with a diagnosis of Guillain-Barre syndrome
She presented 3 days ago with ascending weakness, now she is nearly
quadriparetic, and the neurologists are concerned about impending
respiratory failure
What is your approach to this consult?
Neuromuscular respiratory failure
◻ Clinical examHealthy appearing young woman in no distress
BP 120/80, HR 125, SaO2 100% RA, RR 24
Chest sounds clear, normal heart sounds
Neurological exam demonstrates flaccid paralysis of the lower extremities,
grade 3/5 weakness in upper extremities and neck flexors, cranial nerves
are normal
Discussion points:
■ Is this patient OK?
■ How do you monitor a patient for impending respiratory failure?
■ How do you know when a patient is in trouble?
■ How do you treat respiratory failure in GBS? Is it different from other forms of
neuromuscular respiratory failure (e.g. MG, inflammatory myopathies?)
Neuromuscular respiratory failure
◻ Monitoring of respiratory status in neuromuscular
respiratory failureOrder q6h (minimum) vital capacity (best evidence), negative inspiratory force/maximal inspiratory pressure, maximum expiratory
pressure
Consider monitoring VBG q6h as well
20/30/40 rule for intubation
Neuromuscular respiratory failure
◻ Back to your patient
She still seems reasonably comfortable■ VC = 20 cc/kg, MIF = -35 cc H2O, MEP = 45 cc H2O
■ VBG pH 7.32 pCO2 46 p02 45 HCO3- 24
What should you do?■ A) intubate semi-electively to prevent emergent intubation later
tonight
■ B) consider non-invasive ventilation (e.g. BIPAP)
■ C) percutaneous tracheostomy
■ D) do nothing, she’s fine for now, continue to monitor
Neuromuscular respiratory failure
◻ Back to your patient
She still seems reasonably comfortable■ VC = 20 cc/kg, MIF = -35 cc H2O, MEP = 45 cc H2O
■ VBG pH 7.32 pCO2 46 p02 45 HCO3- 24
What should you do?■ A) intubate semi-electively to prevent emergent intubation later tonight
■ B) consider non-invasive ventilation (e.g. BIPAP)
■ C) percutaneous tracheostomy
■ D) do nothing, she’s fine for now, continue to monitor
Neuromuscular respiratory failure
◻ Back to your patient
She still seems reasonably comfortable■ VC = 20 cc/kg, MIF = -35 cc H2O, MEP = 45 cc H2O
■ VBG pH 7.32 pCO2 46 p02 45 HCO3- 24
What should you do?■ A) intubate semi-electively to prevent emergent intubation later tonight
■ B) consider non-invasive ventilation (e.g. BIPAP)
■ C) percutaneous tracheostomy
■ D) do nothing, she’s fine for now, continue to monitor
Remember, RR was 24
Neuromuscular respiratory failure
◻ Back to your patient
She still seems reasonably comfortable■ VC = 20 cc/kg, MIF = -35 cc H2O, MEP = 45 cc H2O
■ VBG pH 7.32 pCO2 46 p02 45 HCO3- 24
What should you do?■ A) intubate semi-electively to prevent emergent intubation later tonight
■ B) consider non-invasive ventilation (e.g. BIPAP)
■ C) percutaneous tracheostomy
■ D) do nothing, she’s fine for now, continue to monitor
BIPAP may not work for GBS (too much bulbar weakness, can’t handle secretions,
diaphragm paresis), but this is based on very little data. However, BiPAP is very
effective for other forms of neuromuscular respiratory weakness (MG, inflammatory
myopathies).
Neuromuscular respiratory failure
◻ Summary: 3 things to remember about neuromuscular respiratory weakness
Patients might look well, but they crash very quickly
20/30/40 rule and VBG q6h (minimum) for monitoring respiratory status
Do NOT use NIV for Guillain-Barre syndrome, but it is acceptable for other forms of neuromuscular respiratory failure
OVERALL REVIEW
Intraparenchymal Hemorrhage
◻ Summary: 3 things to remember about ICH:
1. Be really aggressive in BP control (but not too aggressive)
2. DVT prophylaxis is OK 24 hours after the bleed, as long as the patient is clinically stable and has stopped bleeding
3. There are two indications for neurosurgical intervention, cerebellar hematomas and lobar hemorrhages within 1 cm of the cortical surface
Subarachnoid hemorrhage
◻ Summary: 3 things to remember about SAH:
1. The bleed is just the beginning of the patients’ problems, significant morbidity and mortality is caused by the complications of SAH, particularly ischemia and hydrocephalus
2. Look hard for the cause of SAH, it’s not all due to aneurysms
3. There is no role for prophylactic anti-convulsants
Neuromuscular respiratory failure
◻ Summary: 3 things to remember about neuromuscular respiratory weakness
Patients might look well, but they crash very quickly
20/30/40 rule and VBG q6h (minimum) for monitoring respiratory status
Do NOT use NIV for Guillain-Barre syndrome, but it is acceptable for other forms of neuromuscular respiratory failure
THE END