Tag Archives: crit care

Manual Inline Stabilization

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Demonstration of MILS or Manual In-Line Stabilization.

– maintain head in neutral position

– assistant to intubation stands by patient as shown above, with hand on either side of head between mastoid process and the occipital

– assistant holds head steady while opposing the applied forces of airway manipulation (gently)

This technique is used for patients with suspected cervical spine injuries. A jaw-thrust maneuver should be used instead of head-tilt/chin lift maneuver. Do not use cricoid pressure. Use of video laryngoscopes may be necessary.

 

Reference:

Rajajee, V., Riggs, B. and Seder, D. (2017). Emergency Neurological Life Support: Airway, Ventilation, and Sedation. Neurocritical Care, 27(S1), pp.4-28.

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PATCH Trial

Platelet transfusion versus standard care after acute stroke due to spontaneous cerebral haemorrhage associated with antiplatelet therapy (PATCH)

Research Question:  Will platelet transfusion compared to standard of care reduce death or dependence in patients who present with ICH who took antiplatelet drugs within 7 days?

NOTES:

  • multicenter, open-label, randomized trial
  • 60 hospitals in Netherlands, UK and france
  • Inclusion: supratentorial ICH, antiplatelets for 7 days, GCS at least 8
  • standard of care vs standard of care + platelet transfusion within 90 minutes of CT scan
  • primary outcome: shift towards death or dependence on mRS at 3 months

Results:

  • 190 participants (97 treatment, 93% standard of care)
  • death or dependence at 3 months:  adjusted OR 2.05 95% CI 1.18-3.56; p=0.0114
  • serious adverse event:  42% vs 29%
  • deaths during hospital stay:  29% vs 24%

 

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Subgroup analysis:

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Reference:

Baharoglu, M Irem et al. “Platelet Transfusion Versus Standard Care After Acute Stroke Due To Spontaneous Cerebral Haemorrhage Associated With Antiplatelet Therapy (PATCH): A Randomised, Open-Label, Phase 3 Trial”. The Lancet 387.10038 (2016): 2605-2613.

Anticoagulation in Patients with Brain Metastases

Treatment:

  • Anticoagulate in patients with brain tumors and VTE except if risk of ICH is high: i.e.
    • melanoma mets
    • renal cell carcinoma mets
    • choriocarcinoma mets
    • thyroid carcinoma mets
  • treat x 3-6 months; long term if malignant gliomas
  • LMWH recommended versus warfarin
  • If risk of ICH high:
    • IVC filter if significant residual brain mets
    • if mets already removed / treated effectively and medical condition too unstable – anticoagulate

DVT Prophylaxis:

  • do not anticoagulate except in post-operative period
  • use SCDs with post-op LMWH or UFH 12-24 hours after surgery
  • cotninue prophylaxis until ambulation resumed

 

REFERENCE:

Uptodate. “Anticoagulant and antiplatelet therapy in patients with brain tumors.” Accessed 08/12/2016.

Lyman GH, Khorana AA, Falanga A, et al. American Society of Clinical Oncology guideline: recommendations for venous thromboembolism prophylaxis and treatment in patients with cancer. J Clin Oncol 2007; 25:5490.

 

Protected: Lenox Hill Antibiogram

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SETScore for Early Tracheostomy in Stroke

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**APS acute physiology score, LIS lung injury score

 

  • initially an in-house screening tool for tracheostomy prediction
  • performed within 1st 24 hours after admission – use worst value in the first 24 hours
  • Dysphagia either
    • reported from a transferring neurological department or
    • observed by clinical signs on admission
      • non-successful swallowing test
      • impaired saliva handling
      • loss/reduction of gag reflex
    • if already intubated on admission, scored with “0”
  • (Neuro)surgical intervention
    • decompressive surgery, hematoma removal, non-cranial major surgery
    • NOTE EVD or probe placement, thrombectomy, angioplasty for vasospasm or coiling
  • Diffuse lesion = a multilocular or widespread affection of brain (i.e. SAH, brain edema, multiple infarcts, hematomas)
  • hydrocephalus = distension of ventricles requiring EVD
  • total sum ranges between 3 and 37

Previously used (with score of >10) to screen for eligibility to be included in pilot trial of SETPOINT study for early tracheostomy (within 3 days) to standard regimen (late tracheostomy between day7 and day14).

 

 

Reference

Schönenberger, Silvia et al. “The Setscore To Predict Tracheostomy Need In Cerebrovascular Neurocritical Care Patients”. Neurocritical Care 25.1 (2016): 94-104.

 

Organ Donor Protocol

VS parameters:

  • SBP >100mm Hg and/or MAP >70mm Hg
  • HR 60-140 bpm
  • Temp 36-38 Celcius

Electrolytes parameters:

  • pH 7.35-7.45    PCO2 35-45    PO2 >100
  • Bicarb 24-30    BE 00 +/- 2
  • Na+ 135-145 mg/dL
  • K+ 3.5-4.5 mg/dL
  • Ca++ >8.7 mg/dL
  • Mg++ >1.5 mg/dL
  • Phosphate >2.5 mg/dL
  • Glucose <200 mg/dL

Corrections:

  • POTASSIUM
    • >5.0 (or if UO <1 ml/kg/hr) eliminate KCl from IV fluids
    • 3.7-3.9 mg/dL – 1 run of KCl 10 mEq (premixed)
    • 3.5-3.7 mg/dL – 2 runs of KCl 10 mEq (premixed)
    • 3.3-3.5 mg/dL  – 3 runs of KCl 10 mEq (premixed)
    • 3.1-3.3 mg/dL  – 4 runs of KCl 10 mEq (premixed)
    • <3.1mg/dL         –  contact coordinator
  • GLUCOSE – check serum glucose q4h
    • >500 mg/dL 20 units Regular insulin IV
    • >400 mg/dL 15 units Regular insulin IV
    • >300 mg/dL 10 units Regular insulin IV
    • >200 mg/dL 5 units Regular insulin IV
    • >100 mg/dL 3 units Regular insulin IV
  • SODIUM
    • >160 Run D5W for primary IV
    • >150 Run D5W/0.2NS for primary IV
    • 135-150 Run 0.45NS for primary IV
    • <135 Run NS for primary IV
  • CALCIUM
    • <8.7 (if ionized Ca <4.2) Calcium chloride 1 Gm IV over 10 minutes
  • MAGNESIUM
    • <1.5 Magnesium sulfate 10% 1.5 ml/min infusion
  • PHOSPHORUS
    • <2.5 Potassium phosphate replacement (no specific dose indicated)

Infusions:

  • BLOOD PRESSURE
    • Dopamine infusion:  400mg in D5W 250ml premixed, titrate to SBP >100
    • Dobutamine infusion (if hypotensive from cardiac dysfunction):  250mg in D5W 250ml premixed, titrate to SBP >100
    • Norepinephrine infusion:  8mg in D5W 500ml, titrate to SBP >100
  • LEVOTHYROXINE protocol (if prescribed by transplant coordinator)
    • Monitor glucose and potassium levels q2h.
    • administer IV bolus of in rapid succession:
      • dextrose 50% x 1 amp (50 ml)
      • solumedrol 1 gram
      • regular insulin 20 units
      • levothyroxine 20 mcg
    • Begin Levothyroxine infusion (200 mcg in 500 ml NS) at 25 ml/hr
    • Reduce pressors as much as possible and adjust levothyroxine infusion to maintain SBP >100
  • DIABETES INSIPIDUS
    • if UO >400cc/hr x 2 hours – 5 units aqueous vasopressin (Pitressin) ffd by infusion: Vasopressin 50 units in D5W 500mL at 20 ml/hr
    • titrate to urine output 100-150cc/hr
    • bolus 5 units vasopressin q2h PRN if IV pump not available

 

Reference:

New York Organ Donor Network’s “ICU Donor Guidelines and Routine Orders”

Antibiotic-Associated Encephalopathy

What are the clinical, radiologic, and electrophysiologic features of antibiotic-associated encephalopathy (AAE)?

3 types of AAE

  1. Type 1 AAE
    • onset within days of antibiotic initiation
    • common occurrence of myoclonus or seizures, abnormal EEG, normal MRI, and resolution within days
    • seen with penicillin and cephalosporins
    • most common in setting of renal insufficiency.
  2. Type 2 AAE
    • onset within days of antibiotic initiation
    • frequent occurrence of psychosis, rare seizures, infrequently abnormal EEG (nonspecific rather than epileptic), normal MRI, and resolution within days
    • seen with procaine penicillin, sulfonamides, fluoroquinolones, and macrolides
  3. Type 3 AAE
    • seen only with metronidazole
    • onset weeks after initiation
    • frequent occurrence of cerebellar dysfunction, rare seizures, rare and nonspecific EEG abnormalities, and omnipresence of abnormal MRI
  4. Isoniazid did not fit into any of these categories
    • time to onset is weeks to months
    • psychosis is common, seizures are rare, EEG is frequently abnormal but nonspecifically

 

F2.medium

*INH does not fit into any of the subtypes.

 

Features:

  • Time of onset after antibiotic initiation – 5 days (except INH and MNZ – 3 weeks)
  • Time to resolution of encephalopathy after ABx discontinuation – 5 days (except MNZ – 13 days)
  • MRI findings
    • abnormal in all MNZ-associated encephalopathy but normal in all others
      • T2 hyperintensities in dentate nuclei of cerebellum (also ?involvement of brainstem, corpus callosum, etc)
    • Bilateral frontal subcortical T2 MRI hyperintensities in isolated case of cefditoren pivoxil toxicity
  • CT findings
    • normal in all cases except 1 case of cerebellar hypodensity with MNZ toxicity and 1 report of L thalamic hypodensity with imipenem toxicity
  • EEG findings:
    • abnormal in 70%
    • abnormal in nearly all cases of cephalosporin-associated encephalopathy
    • common with PCN (83%), cipro (83%) and INH (69%)
    • most common abnormalities: nonspecific signs of encephalopathy (slowing, generalized periodic discharges with triphasic morphology
    • epileptiform discharges / seizures seen in 28% (55% in cephalosporins, 44% in quinolones and 40% of PCN, but not in macrolides, MNZ or sulfonamides)
  • check serum and CSF trough levels of antibiotics?
    • cefepime trough 0.2 to 1.1 mg/L
    • 50% probability of neurologic toxicity at trough of 22mg/L
    • CSF level during toxicity in 2 cases with values of 2.4 mg/L and 18 mg/L

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A – FLAIR hyperintensities bilatearl deep cerebellar nuclei
B – DWI showing restricted diffusion in splenium with MNZ toxicity
C – ADC sequences

 

 

 

 

Reference

Bhattacharyya, Shamik et al. “Antibiotic-Associated Encephalopathy”. Neurology 86.10 (2016): 963-971.