Neurologic Emergency Initial Management

Susan Yeager MS, RN, CCRN, ACNP, FNCSLead Neurocritical Care Nurse Practitioner

The Ohio State University Wexner Medical Center

Columbus, Ohio USA

Neurocritical Care Society Board of Director

Objectives

Overview initial evaluation of the neurologic patient

Overview initial management of common neurologic diagnosisTraumatic Brain InjuryStroke

Exam

AirwayBreathingCirculation

Cranial Nerves

CN I OlfactoryCN II OpticCN III OculomotorCN IV TrochlearCN V Trigeminal CN VI AbducensCN VII Facial

CN VIII Vestibulocochlear

CN IX Glossopharyngeal

CN X VagusCN XI Spinal

AccessoryCN XII Hypoglossal

CN 1 Olfactory

PatencySoap, OJ, Coffee

CN II OpticVisual acuity

Pocket SnellenClock,

calendar, newspaper

Visual FieldsCover eyeFour angles per

sideblink to threat

CN III Oculomotor

Eyelid and eye movement

Pupillary constriction

CN III-Oculomotor

Direct and consensual light reaction

EOM-”H”Down and outDilated pupilPtosis

CN IV Trochlear

EOM’s

Abducens CN VI

Lateral eye movement

CN V-Trigeminal

Masseter-biteSharp/dullCorneal reflex

Facial CN VII

EyebrowsSmilePuff cheeksEye closeTaste anterior

tongue

CN VIII Auditory

HearingEquilibrium sensationFinger click

CN IX Glossopharyngeal

SwallowSay “ah”

CN X Vagus

Aortic Blood pressureHeart rateDigestionTasteGag reflex

tongue depressortonsil tip

CN XI Spinal Accessory

SternocleidomastoidTrapeziusShoulder shrugHead side to side

CN XII-Hypoglossal

Stick out tongueSide to side cheek

EvaluationBolek, B. (2006). Facing cranial nerve assessment. American Nurse Today, Nov: pg 21-22.

Traumatic Brain Injury

Incidence Worldwide, TBI is a major cause of death, disability

and economic cost to society 1.4 Million TBI victims are treated per year 235, 000 of require inpatient care 50,000 die annually, 44,000 occur at the scene

or ED Etiology: Falls: 28%, MVC: 20%, Hits: 19%,

Assaults: 11%, Other: 12% Age Groups: age < 5, ages 15-24, age > 70 Drug/alcohol use and non-use of safety/protective

equipment increases the risk

Airway Cervical Spine Immobilization Maintain patent airway

Intubation-GCS < 8 level II Oral gastric tube

Maintain PaO2 > 60 mmHg and O2 sat > 90% - level III Continuous pulse oximetry Establish eucapnia

Avoid hyperventilation within the first 24 hours – level III

Prophylactic hyperventilation (PaCO2 < 25 mmHg) is not recommended – level II

May use hyperventilation to temporarily reduce ICP – level III

Cardiovascular Stability Coagulopathy Reversal INR < 1.4

Coumadin Fresh Frozen Plasma Vitamin K

Prothrombin Complex Dialysis Platelets > 75

Establish euvolemia or mild hypervolemia Systolic > 90 mmHg - level II MAP > 80 mmHg Restore volume-0.9 NS or Lactate Ringers

Intracranial Hypertension Avoidance HOB

Pain Control

Avoid Venous compression

15 mm Hg is considered upper limit of normal

Most consider treating sustained elevations of 20 - 25mm Maintain Cerebral Perfusion Pressure

Avoid CPP > 70 < 50 mmHg – level ll/lll Hematocrit 30%; hemoglobin 10 g/dL

Decrease Cerebral Edema

Osmotic Diuretics Mannitol: 0.25 – 1 gm/kg -

level II Osmolarity < 320

mOsm/kg 3% Saline or 23.4% saline

Level III evidence. Questions still with optimal dosage, method of administration, and timing and duration of therapy

Insert urinary catheter Steroids are not

recommended to treat ICP and may increase mortality – level I

Maintain Normothermia No evidence to support

prophylactic hypothermia Regulate body temperature

For every 1 º C change in temperature there is a 5-7% change in cerebral metabolism

Prevent shivering Increases metabolic

demands

Prevent Seizures AED prophylaxis is

recommended (within first 7 days) - level II Fosphenytoin 18 mg/kg Dilantin 18 mg/kg

Aggressively treat acute seizures

AEDs are not indicated for long term prophylaxis – level II

Stroke

Ischemic

Hemorrhagic

Incidence-Ischemic 4th leading cause of death in the United

States Stroke affects more than 795,000

individuals per year: Approximately 600,000 of these are first attacks, and 185,000 are recurrent strokes

The risk of ischemic stroke in current smokers is about double that of nonsmokers after adjustment for other risk factors

Atrial fibrillation (AF) is an independent risk factor for stroke, increasing risk about five-fold

High blood pressure is the most important risk factor for stroke

Pathophysiology

Time is Brain

DiagnosticsCBCChemistry with

spot glucose, HbA1C

CoagsToxicologyEEGEKG/Troponin,

LipidCTH or MRI w/I

25 min of arrival

TreatmentABC

SpO2 > 94%BP: >220 and DBP >120 lower meds if no TPA

15% first 24 hrTPA/Intervention: 0.9 mg/kg IV infused over 1

hour, administer 10% of total dose as initial bolus over 1 minute; not to exceed total dose of 90 mg BP < 180 and 105Last Known Well 0 - 4.5 hours

Randomized double blind placebo controlled multi-center studyEfficacy of IV t-PA given within 3 hours of stroke onset

TPA Exclusion CriteriaExclusion:

Prior stroke within past 3 months

Major surgery within past 14 days

Serious head trauma within last 3 months

History of ICH

Systolic BP > 185 mm Hg or diastolic BP > 110 mm Hg

Rapidly improving or minor symptoms

Symptoms suggestive of SAH

GI or GU bleeding within last 3 weeks

Arterial puncture at non-compressible site within last 7 days

Seizure at time of onset

Anticoagulants and heparin within last 48 hours or elevated PT > 15 sec

Platelet count < 100,000 /ml

Blood glucose < 50 mg/dl or above 400 mg/dl

Hemorrhagic Stroke

Accounts of 16% of strokes

75% intraparenchymal hematomas

25% subarachnoid bleeds ICH causes 10-15% first ever strokes

1 yr mortality ~50% 50% deaths occur first 2

days

2007 AHA/ASA Guidelines for management of Intracerebral Hemorrhage in Adults

Pathophysiology Primary

Chronic injury to small cerebral vessels from sustained HTN

Abnormal protein deposits

Secondary

AVM

Aneurysms

Bleed into preexisting infarct, brain tumor, infectious foci

Drug abuse

Coagulation disorders

Limiting Hemorrhagic Expansion and Regional HypoperfusionWhat blood pressure is best for my patient?Does it matter?

Hemostasis

BP/Local Perfusion

Platelet Function

Coagulation Factors

Ideal BP range unknown Balance perfusion Hematoma expansion

ICH BP managementstroke.ahajournals.org

Management-ICHBroderick et al 2007 AHA/ASA Guideline: ICH

Class IAdmit to ICUSeizure management Fever controlEarly mobilization if

clinically stable

Class IIControl ICPBS controlBP controlCoagulopathy reversal

Statistics-SAH

30,000/yr in USMean age 55 yearsGender 1.6/1 women50% don’t survive initial injury If survive initial injury, 30-

50% of those die d/t rebleed, cerebral edema, IICP, vasospasm

AANN Clinical Practice Guideline Series (2007). Care of patient with aneurysmal subarachnoid hemorrhage.

Bederson, et al (2009). Guidelines for the management of aneurysmal SAH…Stroke.

Subarachnoid Hemorrhage

TraumaticAVMAneurysmVenousUnknownNontraumatic 4th

most frequently occurring CV disorder

Anatomy

Arterial Venous Malformation

Aneurysm location

Evaluation-Labs/studies

CBC Electrolytes Coags, fibrinogen Toxicology/pregnancy EKG CXR CTH/CTA-3 mm/MRI/MRA/Angio

Pretreatment ManagementBederson, J. 2009 stroke AANN guidelines

Airway/breathing Circulation BP control (Class I, B)

Magnitude decrease TBD SBP<160 mmHg and MAP < 110 mmHg(IIa, C)

Meds Symptom control: pain, nausea, seizure,

constipation, agitation, fever Labs Bedrest (Class IIb, B)

SAH Post Treatment RecommendationsBenderson, Stroke. 2009; 40: 994-1025 Stroke June 2012 vol. 43 no. 6 1711-1737

Class I

Oral nimodipine 60 mg q 4 hr, 30 mg q 2

Early fixation

Class 2-3

Euvolemia

prophylatic hypervolemia not recommended III, B

Hb

The use of packed red blood cell transfusion to treat anemia might be reasonable in patients with aSAH who are at risk of cerebral ischemia. The optimal hemoglobin goal is still to be determined. IIb, B

BP control

TCD/neuromonitoring

Reasonable neuromonitoring IIa, B

Tako-Tsubo’s Cardiomyopathy

25-80% patients

•BB

•ASA

•ACE at Discharge

•If CHF diuresis

Catecholamine induced

Nonspecific ST changes

Troponin/CK elevation

Cardiac cath nl

Echo multiple segmental abnormalities EF ~30%

2014 Comprehensive Stroke and Neurocritical Care Update Presented by The Ohio State University October 16-17, 2014 Wexner Medical Center & Mount Carmel

Neurogenic Pulmonary Edema Fluid balance Diuretic ARDSNet 6 ml/kg

2014 Comprehensive Stroke and Neurocritical Care Update Presented by The Ohio State University October 16-17, 2014 Wexner Medical Center & Mount Carmel

http://enlsprotocols.org Public Domain

ENLS – Current & Future Status

Protocols are currently online http://enlsprotocols.org

Online training site open http://enls.neurocriticalcare.org

Spanish translation of ENLS 1.0 (translation of about half of slides so far)

Different pricing structure for

Physicians and nurses

Discount for World Bank Group A & B Countries

Discount for group pricing (25 or more)

Online or in-person course

Questions?

Thank you for your time!!!!susan.yeager@osumc.edu