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Tim Rausch, FNP-BCUPMC Presbyterian Hospital
Pittsburgh, PA
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.
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
Head injuries◦ TBI
◦ Stroke
◦ Seizures
◦ Infection
Spinal Cord Injuries◦ Trauma
◦ Infection
Traumatic Brain Injuries◦ Subdural Hematomas
◦ Epidural hematomas
◦ Intraparenchymal hematomas
◦ Diffuse Axonal Injuries
◦ Anoxic Brain Injuries
Strokes◦ Hemorrrhagic
◦ Ishcemic
Thromotic
Plaque
Fat
Spinal Cord Injuries◦ Traumatic
Vertebral fractures
Distraction Injuries
Hemorrhagic
◦ Infectious
Meningitis
Abscess
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
ABC’s
CTh
CXR
EEG
EKG
LABS
Physical Exam
ABC’s◦ Airway
Intact, debris, altered anatomy, medical devices
◦ Breathing
Depth, rate, accessory muscles
◦ Circulation
Peripheral, central
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
CXR◦ Pneumothorax
◦ Pneumonia
Infection
Aspiration
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
EKG◦ MI
◦ Hypoperfusing arrhythmia
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???
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
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
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
1. Blown pupil◦ Hypertonic solution
Mannitol-10g/kg
23.4% saline- 30 ml
3% saline
2. Intracranial hemorrhage◦ SDH
Surgical: craniotomy, burr holes
◦ SAH
Craniotomy
◦ IVH
EVD
◦ IPH
Manage medically
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 0.05-2 mg/kg/hr
3. Seizures◦ Antiepileptics
Phenytoin: 20mg/kg, then 100mg q8 hrs
Fosphenytoin: 20 PE/kg, then 100 mg q8 hrs
Levetiracetam: 1-1.5 g bid
Propofol: 2-5 mg/kg, then 20-100mcg/kg/min
Valproic Acid: 15-20 mg/kg
Phenobarbital: up to 20 mg/kg
Pentobarbital: 5-15 mg/kg, then 0.5 -10 mg/kg/hr
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
Na + goal 145-155◦ Na+ < 137 -> 250 cc bolus1, then 40cc/hr
◦ Na+ 137-140 -> 150 cc bolus1, 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 bolus1
◦ 136 to144- increase by 5cc/hr: if at 70cc/hr, give 150 cc bolus1
◦ > 152- decrease by 5cc/hr
◦ > 155- decrease by 15cc/hr
◦ > 159- hold 4 hrs, restart at 50% of rate2
◦ > 160- hold, check Na+ q4 restart at 20cc/hr when below 1562
1- Boluses given over 30 minutes
2- do not restart if Na+ increase by >1 mEq/hr
60 cc/hr or greater45 cc/hr X 8 hr, then20 cc.hr X 8 hr, then10 cc/hr X 8 hr, then stop
45 – 60 cc/hr25 cc/hr X 8 hrs, then15cc/hr X 8 hrs, then5 cc/hr X 8 hrs, then stop
30 – 45 cc/hr20 cc/hr X 8 hrs, then10 cc/hr X 8 hrs, then5 cc/hr X 8 hrs, then stop
< 30 cc/hr10 cc/hr X 8 hr, then5 cc/hr X 8 hr, then stop
5. Altered gas exchange◦ Hypoxia
Pneumothorax
Pulmonary Embolism
Mucous Plugging
Equipment (ventilator, spontaneous)
◦ Hypercarbia
Equipment, disconnected O2 supply
Hypoventilating, therapeutic misadventure
6. Blood Pressure Management◦ Hypertension
Labatalol: 10-20 mg Q 10 min
Hydralazine: 10 mg Q 10 min
Lopressor: 5-10 mg Q 10 min up to 3 doses
Nitroprusside: 0.5 – 3 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
6. Blood Pressure Management◦ Hypotension
Hypovolemia
IVF: NSS, Lactated Ringers, Plasmalyte
Arrhythmia
Normalize HR, then treat hypotension
7. Fibrinolytic Therapy < 3 hrs Exclusion: ICH, BP > 185/110,
active bleeding, PLT<100k, heparin <48hrs, INR>1.7,
Fibrinolytics
Tissue Plasminogen Activator
Heparin
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
Drug Elimination Lab Assay Reversal Agent
Apixaban(Eliquis)
Liver/kidney9-14 hrs
Anti Xa, INRProthrombin
Complex, aPCC
ArgatrobanLiver
60-90 minaPTT
None established
Bivalirudin(Angiomax)
Enzymes aPTTrFVIIa
Dialysis
Dabigatran(Pradaxa)
Kidney17-17 hrs
INR, aPTT
IdarucizumabaPCC
ProthrombinComplexDialysis
Edoxaban(Savaysa)
Liver/Kidney10-14 hrs
Noneestablished
ProthrombinComplex
aPCC
Drug Elimination Lab Assay Reversal Agent
Fondaparinux(Arixtra)
Kidney7-21 hrs
None Established
aPCC
LMWH(Lovenox,
Enoxaparin, Dalteparin)
Kidney2-8-hrs
Anti Xa?Protamine
aPCC
UnfractionatedHeparin
Liver1-2 hrs
aPTTAnti Xa?
Protamine
Rivarobaxin(Xarelto)
Liver/Kidney5-9 hrs
(13 hrs in elderly)
INRAnti Factor Xa
ProthombinComplex
aPCC
Warfarin(CoumadinJantoven)
Liver36-48 hrs
INR
ProthrombinComplex
rFVIIaVitamin K
FP
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
0.01- 0.02 mg/100u IV
heparinMax dose 50 mg
PCC 5-15 min 12-24 hrs w/vit K 12.5-50 IU/kg
rFVIIa 5-10 min4-6 hrs w/FFP +
Vit KSurg. 90mcg/kg
FVII. 15-30mcg/kg
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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