A: Neuro Flashcards
MDSO: Stroke:
1) Labetalol
10-20 mg Slow IVP - PRN ; 0.5 - 2 mg/min (HR>60) - MP
2) 3%
3mL/kg (max 20 mL/min = 1200 ml/hr - we have max 800 mL/hr)
3) Mannitol
1g /kg bolus (MAP > 80 ; have foley in place)
MDSO / Flowchart : Stroke: - BP Targets for Ischemic, ICH, SAH
ICH = 140
SAH = 140-160
ISCH = 160-180 if tPA ; < 220 if no tPA
MDSO/Flowchart: Stroke: ETCO2 Target for Herniation
30-35 ETCO2 / VBG 35-40 / ABG 32-35
MDSO/Flowchart: Stroke: “Brain Protective Measures” (5 H’s)
Hypo/Hyper - glycemia
Hypo/Hyper - oxemia
Hypo tension
Hypercapnea
Hyperthermia
MDSO/Flowchart: Stroke: Onset to tPA window (time?)
< 4.5 hrs
MDSO / Flowchart ? STROKE: How do you manage Seizures ? Related to Stroke ?
If already had a seizure, Patch to consider prophylactic seizure medication (ie Midaz infusion ? , Keppra ? Dilantin ?)
If actively seizing - GO TO Seizure MDSO
CPG: Stroke: If Ischemic and BP > 220/120 - - how fast to reduce BP?
15-25% > 24 hrs
CPG: Stroke: dosing for tPA
0.9 mg/kg tPA; 10% (0.09 mg/kg) > 1 min….then 90% (0.81mg/kg) > 1 hour
CPG: Stroke: Window for EVT (Endovascular Therapy) - time window ?
6-12 hrs
CPG: Stroke: Who should get ASA ?
Ischemic, if NOT already on an antiplatelet, AND not receiving tPA, AFTER ruling out bleed with CT
If got tPA, then consider after 24 hours of tPA, and new CT
If already on home ASA - can consider Clopidogrel
CPG: Stroke: Anticoag Reversal.
Warfarin: Vitamin K - 10mg > 10 min (before/same time as ) PCC 2000 IU
If < 90 kg < 3.0 INR - give 1000 IU
**
Rivaroxaban (Xarelto) / Apixaban (Eliquis) —> PCC 2000 IU + TXA 1g > 10 min, repeat in 1 hr
**
Dabigatran (PRADAXA) - PRAXABIND
Other: ENLS Tiers - for ICP / Hernatiation
REVIEW CT / ASSESS Na+
HOB 30
NECK MIDLINE / LOOSEN COLLAR
MINIMIZE STIMULI
ANALGESIA / SEDATION (reduce BP)
NORMOTHERMIA
Avoid Hypo Na+
HERNIATION ? - 3% ; target ETCO2 of 30-35
MDSO / Flochart: Stroke: Signs of Herniation.
GCS < 9 and…..
- Abnormal Pupils (fixed/dilated, non-reactive)
-Abnormal Motor Exam (flaccid or posturing)
-Cushing’s Reflex
MDSO: Seizure - Meds
1) MIDAZ - IP
5mg IV q 5 min PRN (Max 0.2 mg/kg )
note, no issue with 2 doses even at 50 kg
OR - - - 10 mg IM
2) Phenytoin (Dilantin) - MP
20 mg/kg in 250 NS only, with 0.2 micron filter - max rate 25mg /min (**flow rate varies, as concentration will change based on weight)
3) Propofol - MP
**MAP > 70
50 mg IVP q 5 min
Prepare to Intubate
Infusion: usual dose: 0-5 mg/kg/hr
MDSO / Flowchart - SEIZURE - What must you rule out off the bat ?
Remember to Check / Fix BS
MDSO / Flowchart - SEIZURE: On the flowchart, what is the other option for infusion at the step of considering intubation ?
MDSO is: Propofol Infusion (MAP > 70) - at usual dose (0-5 mg/kg/hr)
Other Option: MIDAZ at 0.05- 0.15 mg/kg/hr
MDSO / Flowchart: SEIZURE - not related to Stroke, TBI - - - BUT if 3rd trimester / post-partum. What do you give and how do you give it ?
It says to refer to Pre-Eclampsia / Eclampsia MDSO:
For Seizures, 1st line is MgSO4
MgSO4 4 g > 27 min (<150 mg/min) LOADING DOSE, then 1 g /hr.
**NOTE: Mixing Table: 5g/250 mL (NS or D5W) = 20 mg/mL.
**On Pump, use Mag (Bolus) : 250mL, 5000 mg, set at 150 mg/min, Volume at 200 (to only get 4 g)
MDSO : Pre-Eclampsia / Eclampsia Seizures - When to do you give MgSO4 ?
Signs of Severe Pre-Eclampsia (ie pre seizure, think HELLP, Visual Disturbances, Nausea)
4g @ 150mg/min (5 in 250, deliver 200), then infusion 1 g/hr (last 50 mL over an hour)
If they subsequently go into seizure:
If above already given - go to Midaz at 5 mg IV
If MgSO4 not already given, can give Midaz and MgSO4 concurrently
MDSO: Pre-Eclampsia: What are S/S of Mg Toxicity and What is the treatment ?
S/S - Hypotension, Resp Depression, Muscle Weakness
TX: Calcium:
CaCl @ 20mg/kg q 5 min (Max 1g) PRN x 2> 20 min
**note @ 50 kg = 1 g max
**So, 1 g > 20 min PRN x 2 (can do > 5 min if CVL)
MDSO: Pre-Eclampsia : T or F : Eclamptic Seizures are almost always self-limiting ?
T - usual duration 60-75 seconds
MDSO: TBI: MEDS
1) NE 0-0.5 mcg/kg/min (target MAP > 80) - IP
If signs of Herniation Patch for #2 or #3
2) 3% 3mL/kg (Max 20 mL/min = 1200 mL/hr, pump max 800 mL/hr) (MP)- - -or
3) Mannitol 1g/kg (MAP > 80) (MP)
MDSO: TBI: Flowchart: Initial Management Priorities /Targets (not meds)
Sat 94-98
Temp - keep normothermia
Get BS
SMR/Collar
Potential Intubation
MDSO / Flowchart : TBI : after initial management priorities you find the BP to be low? Treatment ? Target ?
If Hypotensive - Target > 80
*Fluid @ 10 cc/kg
*Look for / Treat Other Bleeds (Pelvis , Abdo ???) - get bloods
*Still refractory - NE 0-0.5
MDSO / Flowchart : ETCO2 targets
TBI - aim for 33-38
If signs of herniation then 30-35
MDSO / Flowchart : TBI - when do you start warming ?
If Temp < 35
In all trauma you want to avoid Hypothermia
MDSO / Flowchart : TBI: What if they have seizure , secondary to TBI ?
GO TO : SEIZURE MDSO: ie Midaz, Dilantin, Propofol
