Monthly Archives: July 2018

Algorithm for Treatment of Cerebral Venous Thrombosis (CVT)

An algorithm for the diagnosis and management of CVT:

Capture.JPG

CTV, CT venography; CVT, cerebral venous thrombosis; ICH, intracerebral
hemorrhage; LMWH, low molecular weight heparin; MRV, magnetic resonance venography; PRES, posterior reversible encephalopathy syndrome; UHF,
unfractionated heparin.

 

Table 1 Major risk factors and conditions associated with CVT
Infection

  • INFECTION:
    • Paranasal sinusitis
    • Intracranial infections: abscess, meningitis
    • Trauma Head trauma, neurosurgical operations
    • Internal jugular catheter
  • MEDICAL / SURGICAL CONDITIONS
    • Dehydration
    • Pregnancy and puerperium
    • Coagulation disorders: factor V Leiden, protein C / S deficiency, antithrombin III deficiency, hyperhomocysteinemia, APAS
    • Hematologic disorders: polycythemia, sickle cell disease, TTP, polycythemia, PNH
    • Malignancies, inflammatory bowel disease, nephrotic syndrome, liver cirrhosis, collagen vascular disease including SLE, Wegener’s granulomatosis and Behçet syndrome
    • Previous surgical procedures
  • MEDICATION
    • Oral contraceptives, hormone replacement therapy,  L-asparagenase, corticosteroid

 

Table 3 Clinical presentations of CVT:

  • Symptoms
    • Headache
    • Double or blurred vision
    • Altered consciousness
    • Seizure
    • Behavioral symptoms (delirium, amnesia, mutism)
  • Signs
    • Papilledema
    • Focal neurologic deficit
    • Cranial nerve palsy
    • Nystagmus

 

Society of Neurointerventional Surgery (SNIS) Recommendations:

Imaging
► A combination of MRI/MRV or CT/CTV studies should be performed in patients with suspected CVT (class I; level of evidence C).
► DSA as a diagnostic modality is indicated in cases of suspected CVT when the diagnosis of CVT cannot be reliabl established with non-invasive imaging alone (class IIa; level of evidence C).

Medical and surgical treatment
► Anticoagulation with unfractionated heparin or low molecular weight heparin is reasonable in patients with CVT (class IIa; level of evidence C).
► Decompressive craniectomy may be considered in patients with large parenchymal lesions causing herniation or intractable intracranial hypertension (class IIb; level of evidence C).

Endovascular therapy
► Endovascular therapy may be considered in patients with clinical deterioration despite anticoagulation, or with severe neurological deficits or coma (class IIb; level of evidence C). The duration of anticoagulation therapy before declaring it to be a ‘failure’ and proceeding with endovascular therapy is unknown.
► There is insufficient evidence to determine which endovascular approach and device provides the optimal restoration of venous outflow in CVT. In many cases, a variety of treatment approaches is required to establish sinus patency.

 

Radiologic Findings in CVT:

  1.  noncontrast CT – hyperdensity of occluded sinuses + cerebral edema +/- ICH
  2. contrast CT – empty delta sign, HU>70% highly specific for acute CVT
  3. MRI – T2 hypointensity in acute CVT, T1 and T2 hyperintensity in subacute CVT

 

 

References

Lee, S., Mokin, M., Hetts, S., Fifi, J., Bousser, M. and Fraser, J. (2018). Current endovascular strategies for cerebral venous thrombosis: report of the SNIS Standards and Guidelines Committee. Journal of NeuroInterventional Surgery, 10(8), pp.803-810.

 

Advertisements

Survival After Mechanical Intubation

From “Prognosis After Emergency Department Intubation to Inform Shared Decision-Making,” published by the Journal of American Geriatric Society;

Posterior Fossa ASPECT Score

Early Mobilization Program Algorithm

Assessment of the patient to begin early mobility protocol:

  1. Awaken:  Assessment of Sedatives
  2. Breathing: Assess for patients readiness to terminate mechanical vent
  3. Coordinate:   After assessment of sedatives and breathing combined: Awakening & Breathing Controlled Trial
  4. Delirium:  Is the RASS high 2* to agitation? Is the patient delirious? Assess for Delirium CAM-ICU
  5. Exercise/Early Mobility: Generate a PT/OT/SLP therapy order (see consult generating sheet)

*Remember that mobility is not just ambulating someone on the vent; it is mobilizing the mind and body to reconnect to personal goals one step at a time. Mobility starts today!

 

Critial Care Early Mobilization Protocol for the ICU Patient:

  1. The Intensivist and Nurse-in-Charge every evening should identify those patients who may be candidates for Early Mobilization the following AM.
  2. The patients identified for Early Mobilization should refer to the Early Mobilization Protocol3. Appropriate therapy consultations will be made

4. The candidates for Early Mobilization will be provided during Hands-off-Communication amongst the nursing and physician staff during change of shift.

5. The AM Intensivist will confirm, based on their clinical assessment and bio-physiologic data, the patient can be mobilized by the Team (the team may include but is not limited to. Physical Therapy, Occupational Therapy, Patient Care Assistant and Critical Care Nurse).

6. The Early Mobilization Team will round in their respective units to get confirmation from the Nurse-in-Charge when confirmed by the Intensivist.

 

Critical care Earlv Mobilization protocol for the Mechanically ventilated patient:

1. The Intensivist and Nurse-in-Charge every evening should identify the mechanically ventilated patients who may be candidates for Early Mobilization the following AM.

2. The patients identified for Early Mobilization should refer to the ABCDE protocol

3. The evening Critical Care staff’s responsibility is to confirm the Awakening Trial (See algorithm above).  Breathing trial and the Coordination Evaluation is implemented.

4. To provide adequate cooperation for mobilization a Delirium Assessment must be performed on each patient who may be potentially enrolled.

5. Appropriate therapy consultations will be made.

6. The candidates for Early Mobilization will be provided during Hands-off-Communication amongst the nursing and physician staff during change of shift.

7. The AM Intensivist will confirm, based on their clinical assessment and bio-physiologic data, the patient can be mobilized by the Team (the team may include but is not limited to Respiratory Therapy, Physical Therapy, Occupational Therapy, Patient Care Assistant and Critical Care Nurse).

8. The Early Mobilization Team will round in their respective units to get confirmation from the Nurse-in-Charge when confirmed by the Intensivist.

**Note if the patient is to be weaned a few hours before mobilization is to occur, mobilization will be held as to assure the patient adequate energy to successfully wean.

**Note this protocol does not exclude those patients who are orally intubated.

 

 

Procedure for RASS Assessment

1. Observe patient a. Patient is alert, restless, or agitated, (score 0 to +4)

2. If not alert, state patient’s name and say to open eyes and look at speaker.

b. Patient awakens with sustained eye opening and eye contact. (score -1)

c. Patient awakens with eye opening and eye contact, but not sustained, (score -2)

d. Patient has any movement in response to voice but no eye contact, (score -3)

3. When no response to verbal stimulation, physically stimulate patient by shaking shoulder and/or rubbing stemum.

e. Patient has any movement to physical stimulation. (score -4)

f. Patient has no response to any stimulation. (score -5)

 

<download PDF file>

REFERENCE:

NSUH Early Mobilization Protocol.