Differential Diagnosis
Checklist:
Reference:
Andersen, Lars W. et al. “Etiology And Therapeutic Approach To Elevated Lactate Levels”. Mayo Clinic Proceedings 88.10 (2013): 1127-1140.
for neurocritical care experts
Differential Diagnosis
Checklist:
Andersen, Lars W. et al. “Etiology And Therapeutic Approach To Elevated Lactate Levels”. Mayo Clinic Proceedings 88.10 (2013): 1127-1140.
*clinical practice, uncertain of evidence – will have to investigate further.
Prior to Epidural Blood Patch:
FIRST 24 HOURS:
SECOND 24 HOURS:
THIRD 24 HOURS:
Schematic section through the vertebral column, showing the cauda equina and its covering membranes with the dural leakage site before (A) and after (B) application of the epidural blood patch.
Post-blood patch orders:
If blood patch not an option: oral or IV caffeine 300-500mg OD or BID (therapeutic doses have been associated with CNS toxicity and atrial fibrillation
“Brain Sag”. Peripheral Brain. N.p., 2016. Web. 24 June 2016.
R Oedit et al. Efficacy of the epidural blood patch for the treatment of post lumbar puncture headache BLOPP: A randomised, observer-blind, controlled clinical trial. BMC Neurology 20055:12 DOI: 10.1186/1471-2377-5-12.
bedside clinical score for prediction of endocarditis in enterococcal bacteremia
NOVA:
cutoff score <4 points suggested a very low risk for enterococcal IE
useful for avoiding unnecessary TEE in enterococcal bacteremia
Uptodate. http://www.uptodate.com/contents/treatment-of-enterococcal-infections?source=search_result&search=ENTEROCOCCUS+FAECALIS%5C&selectedTitle=1~37#H10055572. Accessed 06/22/2016
Treatment dose: amantadine 100 mg BID x 14 days; then 150 mg BID at week 3; then 200 mg BID at week 4; after week 4, taper over 2 to 3 days
Giacino, Joseph T. et al. “Placebo-Controlled Trial Of Amantadine For Severe Traumatic Brain Injury”.New England Journal of Medicine 366.9 (2012): 819-826.
CT perfusion (CTP)
Parameters of CTP:
Tissue at risk:
The CTP Time-Density Curve:
Time−density curve on computed tomography perfusion.
Kurz, K. D. et al. “Radiological Imaging In Acute Ischaemic Stroke”. Eur J Neurol 23 (2015): 8-17.
This blog describes the technique of FDG-PET in measuring brain metabolism in patients in the inter-ictal continuum..
Renard, D. et al. “Teaching Neuroimages: FDG-PET In Progressive Supranuclear Palsy”. Neurology74.14 (2010): e60-e60.
Struck, Aaron F. et al. “Metabolic Correlates Of The Ictal-Interictal Continuum: FDG-PET During Continuous EEG”. Neurocritical Care 24.3 (2016): 324-331.
Transtentorial herniation: acute unresponsiveness, decline in GCS >=2 pts with uni- or bilateral pupillary dilatation and loss of reactivity to light, and increase in ICP >20mmHg in acomatose patient x 5 mints +/- change in pupillary sie and reactivity.
Intervention:
– well-tolerated in renal failure, no observed pulmonary edema or overload despite high incidence of cardiovascular dysfunction in this population (small study)
Proposed Mechanism of Action: hypertonic saline causes osmolar gradient –> to fluid shifts, reduces brain mass, without significant diuresis
Potential complications:
*mechanism for hypotension: ?not clarified yet, small animal study suggests may be mediated by sympathetic neural reflex and not a diuretic effect; others suggest may be due to vasodilatory effect; or maybe due to resolution of Cushing response
Hirsch, Karen G. et al. “Treatment Of Elevated Intracranial Pressure With Hyperosmolar Therapy In Patients With Renal Failure”. Neurocritical Care 17.3 (2012): 388-394.
Thyroid function tests should not be measured on critically ill patients, unless thyroid dysfunction is suspected. When thyroid dysfunction is suspected, TSH is inadequate and all methods of assessing free T4 are unreliable in severe critical illness.
Patients who are critically ill with low T3 and T4 and no other clinical signs of hypothyroidism should not be treated with thyroid hormone replacement. Start thyroid replacement if there is evidence of hypothyroidism; in the absence of myxedema coma, start at half the expected full replacement dose.
“Thyroid Function In Nonthyroidal Illness”. Uptodate.com. N.p., 2016. 14 June 2016.
Hepatitis B surface antigen (HBsAg):
Hepatitis B surface antibody (anti-HBs)
Anti-HBc
2016. Web. https://www.cdc.gov/hepatitis/hbv/pdfs/serologicchartv8.pdf 11 June 2016.