Tim Rausch, FNP-BC UPMC Presbyterian Hospital Pittsburgh, PA
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1 Tim Rausch, FNP-BC UPMC Presbyterian Hospital Pittsburgh, PA
2 I have no financial interest in any of the products contained in this lecture nor am I receiving any financial compensation from any company either public or private. Additionally, it should be understood that the descriptions in this lecture are generalized and therapy should be based on individual assessments.
3 1. Identify patients at risk for acute neurologic changes 2. Review assessment of patients with acute neurologic changes 3. Help you advance your knowledge of management of patients with acute neurologic changes 4. Update on reversal of designer anticoagulants
4 Head injuries TBI Stroke Seizures Infection Spinal Cord Injuries Trauma Infection
5 Traumatic Brain Injuries Subdural Hematomas Epidural hematomas Intraparenchymal hematomas Diffuse Axonal Injuries Anoxic Brain Injuries
6 neurosurgery.ufl.edu
7 Strokes Hemorrrhagic Ishcemic Thromotic Plaque Fat
8 Spinal Cord Injuries Traumatic Vertebral fractures Distraction Injuries Hemorrhagic Infectious Meningitis Abscess
9 1. Stroke- thrombotic, hemorrhagic, spasm 2. ICH- SDH, SAH, EDH, IPH 3. Seizure- Clinical, non-clinical 4. Altered gas exchange- hypoxia, hypercarbia 5. Hypotension- hypovolemia, arrhythmia 6. Spinal cord compression-hematoma, infection
10 ABC s CTh CXR EEG EKG LABS Physical Exam
11 ABC s Airway Intact, debris, altered anatomy, medical devices Breathing Depth, rate, accessory muscles Circulation Peripheral, central
12 CTh Initial CT scan Noncontrast CTh to establish baseline or need for intervention CTA to evaluate for stroke Follow-up CT scan Short term CTh at 4-8 hrs if stable Immediate CTh if change in assessment
13 CXR Pneumothorax Pneumonia Infection Aspiration
14 EEG Continuous v. single Continuous Allows for evaluation over 24+ hr period Can capture non-convulsive seizures Allows for dissipation of previously administered AED s Requires 24 hour monitoring/ expensive Single Useful for snap shot view of altered states Cost effective
15 EKG MI Hypoperfusing arrhythmia
16 Labs Glucose H+H, PLT, PT/PTT/INR Electrolytes, especially Na +, Ca ++ Renal functions Hepatic functions, NH4 Drug screen; withdrawal, anticholinergics, TCA s, alcohol, SSRI s, benzo s, Barbs ABG, PE Lumbar puncture???
17 Physical Exam Neurological LOC Pupillary assessment Anisocoria: Contralateral cerebral pressure Focal signs Seizures Change in vital signs Cushing s response (Elevated ICP, HTN, bradycardia) Change in respiratory pattern Kussmaul s: Elevated ICP -> attempt to decrease PaCO2 Cheyne Stokes: Brainstem pressure 2/2 delayed response to hypoxia Biot s: Mudulliary pressure 2/2 uncal/tentorial herniation
18 Physical Exam Hemodynamic Change in vital signs Cushing s response (HTN, bradycardia, elevated ICP) Change in respiratory pattern Kussmaul s: Elevated ICP -> attempt to decrease PaCO2 Cheyne Stokes: Brainstem pressure 2/2 delayed response to hypoxia Biot s: Mudulliary pressure 2/2 uncal/tentorial herniation Apneustic: damage to the pons or upper medulla
19 1. Blown pupil 2. Intracranial hemorrhage 3. Seizures 4. Elevated ICP 5. Altered Gas Exchange 6. Blood Pressure Management 7. Fibrinolytics 8. Reversing Anticoagulants 9. Transport
20 1. Blown pupil Hypertonic solution Mannitol-10g/kg 23.4% saline- 30 ml 3% saline
21 2. Intracranial hemorrhage SDH Surgical: craniotomy, burr holes SAH Craniotomy IVH EVD IPH Manage medically
22 3. Seizure Benzodiazepines Lorazepam: IV, IM 0.1 mg/kg Diazepam: IV, PR 0.2 mg/kg Midazolam: IV,IM 0.2 mg/kg, then mg/kg/hr
23 3. Seizures Antiepileptics Phenytoin: 20mg/kg, then 100mg q8 hrs Fosphenytoin: 20 PE/kg, then 100 mg q8 hrs Levetiracetam: g bid Propofol: 2-5 mg/kg, then mcg/kg/min Valproic Acid: mg/kg Phenobarbital: up to 20 mg/kg Pentobarbital: 5-15 mg/kg, then mg/kg/hr
24 4. Elevated ICP Goal: ICP<15 and CPP>65 and PbO2>20 Elevate HOB Loosen C-Collar Minimize PEEP 5cm H2O Avoid IJ Catheters Drive up MAP Mannitol, 200 mg/kg Midazolam infusion Hypertonic Saline
25 Na + goal Na + < 137 -> 250 cc bolus 1, then 40cc/hr Na > 150 cc bolus 1, then 35cc/hr Na + > 140 -> 35 ml/hr Check Na + and Osmoloality Q-6 hrs <135- increase by 10cc/hr; if 70cc/hr, give 250 cc bolus to144- increase by 5cc/hr: if at 70cc/hr, give 150 cc bolus 1 > 152- decrease by 5cc/hr > 155- decrease by 15cc/hr > 159- hold 4 hrs, restart at 50% of rate 2 > 160- hold, check Na+ q4 restart at 20cc/hr when below Boluses given over 30 minutes 2- do not restart if Na+ increase by >1 meq/hr
26 60 cc/hr or greater cc/hr cc/hr < 30 cc/hr 45 cc/hr X 8 hr, then 20 cc.hr X 8 hr, then 10 cc/hr X 8 hr, then stop 25 cc/hr X 8 hrs, then 15cc/hr X 8 hrs, then 5 cc/hr X 8 hrs, then stop 20 cc/hr X 8 hrs, then 10 cc/hr X 8 hrs, then 5 cc/hr X 8 hrs, then stop 10 cc/hr X 8 hr, then 5 cc/hr X 8 hr, then stop
27 5. Altered gas exchange Hypoxia Pneumothorax Pulmonary Embolism Mucous Plugging Equipment (ventilator, spontaneous) Hypercarbia Equipment, disconnected O2 supply Hypoventilating, therapeutic misadventure
28 6. Blood Pressure Management Hypertension Labatalol: mg Q 10 min Hydralazine: 10 mg Q 10 min Lopressor: 5-10 mg Q 10 min up to 3 doses Nitroprusside: mcg/kg/min Clevidipine:1-2 mg/hr up to 32 mg/hr for 24 hrs Max dose 1,000 mg/24 hrs 2/2 lipid load
29 6. Blood Pressure Management Hypotension Hypovolemia IVF: NSS, Lactated Ringers, Plasmalyte Arrhythmia Normalize HR, then treat hypotension
30 7. Fibrinolytic Therapy < 3 hrs Exclusion: ICH, BP > 185/110, active bleeding, PLT<100k, heparin <48hrs, INR>1.7, Fibrinolytics Tissue Plasminogen Activator Heparin
31 8. Reversing Anticoagulant Therapy Vitamin K antagonists Warfarin Heparins Unfractionated, Low molecular weight Factor Xa Inhibitors Apixaban, rivaroxiban, fondaparinux Direct thrombin inhibitors Argatroban, bivalirudin, dabigatran
32
33 Drug Elimination Lab Assay Reversal Agent Apixaban (Eliquis) Argatroban Bivalirudin (Angiomax) Dabigatran (Pradaxa) Edoxaban (Savaysa) Liver/kidney 9-14 hrs Liver min Enzymes Kidney hrs Liver/Kidney hrs Anti Xa, INR aptt aptt INR, aptt None established Prothrombin Complex, apcc None established rfviia Dialysis Idarucizumab apcc Prothrombin Complex Dialysis Prothrombin Complex apcc
34 Drug Elimination Lab Assay Reversal Agent Fondaparinux (Arixtra) LMWH (Lovenox, Enoxaparin, Dalteparin) Unfractionated Heparin Rivarobaxin (Xarelto) Warfarin (Coumadin Jantoven) Kidney 7-21 hrs Kidney 2-8-hrs Liver 1-2 hrs Liver/Kidney 5-9 hrs (13 hrs in elderly) Liver hrs None Established Anti Xa? aptt Anti Xa? INR Anti Factor Xa INR apcc Protamine apcc Protamine Prothombin Complex apcc Prothrombin Complex rfviia Vitamin K FP
35 Drug Onset Duration Dose apcc 5-15 min 8-12 hrs 8-25 u/kg FFP 1-4 hrs 6 hrs 5-20ml/kg Idarucizumab Immediate 24 hrs 5 gm Protamine 5 min Dose dependent mg/100u IV heparin Max dose 50 mg PCC 5-15 min hrs w/vit K IU/kg rfviia 5-10 min 4-6 hrs w/ffp + Vit K Surg. 90mcg/kg FVII mcg/kg
36 9. Transport Patient/family wishes Distance to tertiary facility Resources of transport crew Prep for transport Stabilize airway Stabilize hemodynamically Consult with receiving facility
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