A: Neuro

Question 1

MDSO: Stroke:

Answer 1

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)

Question 2

MDSO / Flowchart : Stroke: - BP Targets for Ischemic, ICH, SAH

Answer 2

ICH = 140
SAH = 140-160
ISCH = 160-180 if tPA ; < 220 if no tPA

Question 3

MDSO/Flowchart: Stroke: ETCO2 Target for Herniation

Answer 3

30-35 ETCO2 / VBG 35-40 / ABG 32-35

Question 4

MDSO/Flowchart: Stroke: “Brain Protective Measures” (5 H’s)

Answer 4

Hypo/Hyper - glycemia
Hypo/Hyper - oxemia
Hypo tension
Hypercapnea
Hyperthermia

Question 5

MDSO/Flowchart: Stroke: Onset to tPA window (time?)

Answer 5

< 4.5 hrs

Question 6

MDSO / Flowchart ? STROKE: How do you manage Seizures ? Related to Stroke ?

Answer 6

If already had a seizure, Patch to consider prophylactic seizure medication (ie Midaz infusion ? , Keppra ? Dilantin ?)

If actively seizing - GO TO Seizure MDSO

Question 7

CPG: Stroke: If Ischemic and BP > 220/120 - - how fast to reduce BP?

Answer 7

15-25% > 24 hrs

Question 8

CPG: Stroke: dosing for tPA

Answer 8

0.9 mg/kg tPA; 10% (0.09 mg/kg) > 1 min….then 90% (0.81mg/kg) > 1 hour

Question 9

CPG: Stroke: Window for EVT (Endovascular Therapy) - time window ?

Answer 9

6-12 hrs

Question 10

CPG: Stroke: Who should get ASA ?

Answer 10

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

Question 11

CPG: Stroke: Anticoag Reversal.

Answer 11

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

Question 12

Other: ENLS Tiers - for ICP / Hernatiation

Answer 12

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

Question 13

MDSO / Flochart: Stroke: Signs of Herniation.

Answer 13

GCS < 9 and…..
- Abnormal Pupils (fixed/dilated, non-reactive)
-Abnormal Motor Exam (flaccid or posturing)
-Cushing’s Reflex

Question 14

MDSO: Seizure - Meds

Answer 14

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

Question 15

MDSO / Flowchart - SEIZURE - What must you rule out off the bat ?

Answer 15

Remember to Check / Fix BS

Question 16

MDSO / Flowchart - SEIZURE: On the flowchart, what is the other option for infusion at the step of considering intubation ?

Answer 16

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

Question 17

MDSO / Flowchart: SEIZURE - not related to Stroke, TBI - - - BUT if 3rd trimester / post-partum. What do you give and how do you give it ?

Answer 17

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)

Question 18

MDSO : Pre-Eclampsia / Eclampsia Seizures - When to do you give MgSO4 ?

Answer 18

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

Question 19

MDSO: Pre-Eclampsia: What are S/S of Mg Toxicity and What is the treatment ?

Answer 19

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)

Question 20

MDSO: Pre-Eclampsia : T or F : Eclamptic Seizures are almost always self-limiting ?

Answer 20

T - usual duration 60-75 seconds

Question 21

MDSO: TBI: MEDS

Answer 21

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)

Question 22

MDSO: TBI: Flowchart: Initial Management Priorities /Targets (not meds)

Answer 22

Sat 94-98
Temp - keep normothermia
Get BS
SMR/Collar
Potential Intubation

Question 23

MDSO / Flowchart : TBI : after initial management priorities you find the BP to be low? Treatment ? Target ?

Answer 23

If Hypotensive - Target > 80

*Fluid @ 10 cc/kg
*Look for / Treat Other Bleeds (Pelvis , Abdo ???) - get bloods
*Still refractory - NE 0-0.5

Question 24

MDSO / Flowchart : ETCO2 targets

Answer 24

TBI - aim for 33-38

If signs of herniation then 30-35

Question 25

MDSO / Flowchart : TBI - when do you start warming ?

Answer 25

If Temp < 35

In all trauma you want to avoid Hypothermia

Question 26

MDSO / Flowchart : TBI: What if they have seizure , secondary to TBI ?

Answer 26

GO TO : SEIZURE MDSO: ie Midaz, Dilantin, Propofol