NEUROLOGICAL EMERGENCIES IN THE ICU...Neurological Emergencies in the ICU J. Gordon Boyd, MD, PhD,...

NEUROLOGICAL EMERGENCIES

IN THE ICU

J. GORDON BOYD, MD, PHD, FRCPC

ASSOCIATE PROFESSOR

DEPTS. OF MEDICINE (NEUROLOGY) AND CRITICAL CARE MEDICINE

QUEEN’S UNIVERSITY

@JGORDONBOYD

Canadian Critical Care Forum-November 2019

Disclosures

◻ I receive a stipend from the Trillium Gift of Life

Network for my role as a Regional Medical Lead

◻ I receive research funding from Queen’s, IFPOC

Outline

◻ Use a case-based format to discuss 3 neurological

emergencies that may be encountered in the ICU,

including:

Intraparenchymal Hemorrhage

Subarachnoid Hemorrhage

Neuromuscular respiratory failure


◻ Clinical vignette 1: The neurology service calls you to assess this 67M with a history of hypertension who came to the emergency department as an acute stroke protocol 45 minutes ago

2 hours ago, he developed sudden onset left sided weakness

A few moments ago, he vomited and became sleepy, and they are worried about his ability to protect his airway


◻ Initial assessment:

◻ BP 215/130, HR 85, RR 12

◻ GCS 11 [E2 (to pain), M5

(localizes), V4 (confused, slurred)]

◻ Dense left hemiplegia

◻ Cardiac, respiratory, and

abdominal exams grossly normal

◻ WHAT IS OUR PLAN?


◻ ABCs

◻ A and B are OK so far, so what

about C? What do you do about

the BP of 215/130?

◻ A. Do not adjust the BP, his brain is

likely used to seeing the high pressures.

◻ B. Don’t lower it >25% or you’ll

worsen the ischemia around the

hematoma

◻ C. Use labetolol to bring the

BP<160/80

◻ D. Use GTN drip to lower the blood

pressure to <180 systolic


◻ ICH guidelines

“probably safe” to lower blood pressure to 140/80

Based largely on INTERACT 2 trial, showing a trend towards better functional recovery in patients with aggressive blood pressure control (<140/80) compared with conventional targets (<180/110)

However, ATACH-II trial called this into question

Individual patient data meta-analysis, favour lowering BP, not >60mmHg, and try to avoid fluctuations

Choice of agent is debated, labetolol, enalaprilat, nicardipine are all reasonable choices; avoid GTN as it causes cerebral vasodilation and increases ICP

ATACH-

II


◻ Back to your patient

You patient has remained

clinically stable. 24 hours after

admission, your team’s

pharmacist asks “what about DVT

prophylaxis?”

What do you say?

A. Yes

B. No

C. Maybe



You patient has remained clinically stable. 24 hours after admission, your team’s pharmacist asks “what about DVT prophylaxis?”

What do you say?

A. Yes

B. No

C. Maybe

◻ According to the 2015 ASA guidelines, it is recommended that all patients with ICH receive DVT prophylaxis (heparin or LMWH),



◻ Is there any role for

neurosurgical intervention?



◻ Is there any role for

neurosurgical intervention?

◻ 2 main indications for surgery

1. Cerebellar hematoma >3 cm in

diameter with neurological

deterioration

2. Lobar hematoma <1 cm from

the cortical surface in a patient

with neurological deterioration


◻ Summary: 3 things to remember about ICH:

1. Be really aggressive in BP control (but not too aggressive, eg

>60 mmHg drop in SBP)

2. DVT prophylaxis is OK 24 hours after the bleed, as long as the

patient is clinically stable and has stopped bleeding

3. There are two indications for neurosurgical intervention,

cerebellar hematomas and lobar hemorrhages within 1 cm of the

cortical surface

Subarachnoid hemorrhage

◻ Clinical vignette 2: You are called to the emergency department to assess a 20F who

collapsed shortly after complaining of the “worst headache of her life”

The CT scan shows the following…


What do you see?

Name 4 possible etiologies for

these findings.

1.

2.

3.

4.


What do you see?

Name 4 possible etiologies for

these findings.

1. Aneurysm

2. AVM

3. Sympathomimetic drugs

4. Vasculitis (e.g. SLE)


Name 3 neurological

complications of SAH. How

are these

prevented/treated?


Name 3 neurological

complications of SAH. How

are these

prevented/treated?

1. Obstructive hydrocephalus

2. Seizures

3. Vasospasm/delayed

ischemic insults


◻ Neurological complications of SAH

◻ Obstructive hydrocephalus

call you friendly neighborhood neurosurgeon for an EVD

◻ Seizures

No role for seizure prophylaxis

■ if clinical seizures occur, treat them

■ Continuous EEG monitoring is recommended, and if subclinical seizures are detected, then treatment is recommended

◻ Delayed ischemic events

Usually begin 4-7 days after the bleed, monitor with transcranial doppler/CTA/clinical exam/EEG

Moving away from “triple H therapy” (hypertension, hypervolemia, hemodilution) to focus more on induced hypertension +/- milrinone

nimodipine (doesn’t prevent vasospasm, but improves mortality and decreases ischemic events)


◻ Summary: 3 things to remember about SAH:

1. The bleed is just the beginning of the patients’ problems,

significant morbidity and mortality is caused by the complications

of SAH, particularly ischemia and hydrocephalus

2. Look hard for the cause of SAH, it’s not all due to aneurysms

3. There is no role for prophylactic anti-convulsants


◻ Clinical vignette 3: You are asked to see a 19 year old nursing student admitted to the

neurology service with a diagnosis of Guillain-Barre syndrome

She presented 3 days ago with ascending weakness, now she is nearly

quadriparetic, and the neurologists are concerned about impending

respiratory failure

What is your approach to this consult?


◻ Clinical examHealthy appearing young woman in no distress

BP 120/80, HR 125, SaO2 100% RA, RR 24

Chest sounds clear, normal heart sounds

Neurological exam demonstrates flaccid paralysis of the lower extremities,

grade 3/5 weakness in upper extremities and neck flexors, cranial nerves

are normal

Discussion points:

■ Is this patient OK?

■ How do you monitor a patient for impending respiratory failure?

■ How do you know when a patient is in trouble?

■ How do you treat respiratory failure in GBS? Is it different from other forms of

neuromuscular respiratory failure (e.g. MG, inflammatory myopathies?)


◻ Monitoring of respiratory status in neuromuscular

respiratory failureOrder q6h (minimum) vital capacity (best evidence), negative inspiratory force/maximal inspiratory pressure, maximum expiratory

pressure

Consider monitoring VBG q6h as well

20/30/40 rule for intubation



She still seems reasonably comfortable■ VC = 20 cc/kg, MIF = -35 cc H2O, MEP = 45 cc H2O

■ VBG pH 7.32 pCO2 46 p02 45 HCO3- 24

What should you do?■ A) intubate semi-electively to prevent emergent intubation later

tonight

■ B) consider non-invasive ventilation (e.g. BIPAP)

■ C) percutaneous tracheostomy

■ D) do nothing, she’s fine for now, continue to monitor




■ VBG pH 7.32 pCO2 46 p02 45 HCO3- 24

What should you do?■ A) intubate semi-electively to prevent emergent intubation later tonight







■ VBG pH 7.32 pCO2 46 p02 45 HCO3- 24





Remember, RR was 24




■ VBG pH 7.32 pCO2 46 p02 45 HCO3- 24





BIPAP may not work for GBS (too much bulbar weakness, can’t handle secretions,

diaphragm paresis), but this is based on very little data. However, BiPAP is very

effective for other forms of neuromuscular respiratory weakness (MG, inflammatory

myopathies).


◻ Summary: 3 things to remember about neuromuscular respiratory weakness

Patients might look well, but they crash very quickly

20/30/40 rule and VBG q6h (minimum) for monitoring respiratory status

Do NOT use NIV for Guillain-Barre syndrome, but it is acceptable for other forms of neuromuscular respiratory failure

OVERALL REVIEW


◻ Summary: 3 things to remember about ICH:

1. Be really aggressive in BP control (but not too aggressive)

2. DVT prophylaxis is OK 24 hours after the bleed, as long as the patient is clinically stable and has stopped bleeding

3. There are two indications for neurosurgical intervention, cerebellar hematomas and lobar hemorrhages within 1 cm of the cortical surface


◻ Summary: 3 things to remember about SAH:

1. The bleed is just the beginning of the patients’ problems, significant morbidity and mortality is caused by the complications of SAH, particularly ischemia and hydrocephalus

2. Look hard for the cause of SAH, it’s not all due to aneurysms

3. There is no role for prophylactic anti-convulsants


◻ Summary: 3 things to remember about neuromuscular respiratory weakness

Patients might look well, but they crash very quickly

20/30/40 rule and VBG q6h (minimum) for monitoring respiratory status

Do NOT use NIV for Guillain-Barre syndrome, but it is acceptable for other forms of neuromuscular respiratory failure

THE END

NEUROLOGICAL EMERGENCIES IN THE ICU...Neurological Emergencies in the ICU J. Gordon Boyd, MD, PhD,...

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