Critical Care of Aneurysm Patients Flashcards
Initial management concerns after aneurysmal SAH (aSAH) include rebleeding, hydrocephalus, delayed cerebral ischemia, hyponatremia with hypovolemia, DVT and pulmonary embolism seizures, and reduced cerebral oxygen delivery. What are the initial management steps that are needed to reduce these risks after aSAH?
● A. Administration of oral nimodipine
● B. Maintaining euvolemia and normal circulating blood volume
● C. Control of blood pressure by keeping the systolic blood pressure below 160 mmHg
● D. Optimizing cerebral blood flow and keeping normal ICP
● E. All of the above
E. All of the above
Methods that may be used to augment cerebral oxygen delivery includes all of the following except?
● A. Optimizing cerebral blood flow by avoiding induced hypertension, avoiding hypotension, and maintaining euvolemia and normal ICP
● B. Elevating oxygen saturation with the goal of 100% saturation in all patients at risk of delayed cerebral ischemia
● C. Maintaining optimal hemoglobin with the goal of 8 to 10 Hgb
● D. Intra-arterial verapamil by endovascular interventionist to improve blood rheology and keep cerebral vascular resistance low
● E. Causing prophylactic hypervolemia
E. Causing prophylactic hypervolemia
Arrythmias may occur after aneurysmal subarachnoid hemorrhage. What is the most important monitoring for this risk factor?
● A. Arterial line
● B. Airway monitoring and management with intubation
● C. Maintaining euvolemia
● D. Cardiac monitoring
● E. Intraventricular catheter
D. Cardiac monitoring
What are the admitting orders for a patient with aneurysmal SAH (aSAH)?
● A. Admit in ICU with VS and neuro check every 1 hour
● B. Elevating head of bed to 30 degrees with low level of external stimulation, restricted visitation, and no loud noises
● C. Nursing care including strict I’s and O’s monitoring, daily weights, TED stocking with pneumatic compression boots and indwelling Foley catheter if lethargic
● D. Early aggressive fluid therapy to head off cerebral salt wasting which include NS + 20 mEq KCL/L at 2 mL/kg/h (140–150 mL/h)
● E. Medication, oxygenation, and temperature regulation
● F. All of the above
D. Early aggressive fluid therapy to head off cerebral salt wasting which include NS + 20 mEq KCL/L at 2 mL/kg/h (140–150 mL/h)
Which of the following statements is correct regarding medication of a patient admitted in hospital after aneurysmal subarachnoid hemorrhage?
● A. Prophylactic antiseizure medications are given
● B. Analgesics are given along with dexamethasone which may help with headache and neck pain
● C. There is no role of calcium channel blockers in these patients
● D. Stool softener and antiemetics are given
● E. H2 blockers and proton pump inhibitors are given as well
C. There is no role of calcium channel blockers in these patients
Risk factors for hyponatremia after SAH include diabetes, CHF, cirrhosis, adrenal insufficiency, or the use of any of the drugs like NSAIDs, acetaminophen, narcotics, and thiazide diuretics. Hyponatremic patients with SAH have incidence of delayed cerebral infarction how much times as compared to normonatremic patients?
● A. Two times
● B. Three times
● C. Four times
● D. Five times
● E. Six times
B. Three times
Literature review shows that 4 to 26% of SAH patients had onset seizures, 1 to 28% had early seizures (within 2 weeks), and 1 to 35% had late seizures (after 2 weeks). Following are the risk factors for post-SAH seizure except?
● A. Increasing age (more than 65 years)
● B. MCA aneurysm or associated intracerebral or subdural hematoma
● C. Good neurologic grade
● D. Volume of subarachnoid hematoma or rebleeding
● E. Cerebral infarction or vasospasm or hyponatremia
C. Good neurologic grade
About 15 to 20% of rebleed in SAH patients occur within 14 days, 50% will rebleed within 6 months; thereafter the risk is 3%/year with a mortality rate of 2%/year. The maximal frequency of rebleed is on which day after SAH (1/3 of these rebleed occur within 3 hours in that day or 1/2 within 6 hours)?
● A. 1st day
● B. 2nd day
● C. 3rd day
● D. 4th day
● E. 5th day
A. 1st day
Which of the following statements is correct regarding correlation of delayed ischemic neurologic deficit (DIND) development with Hunt and Hess grade?
● A. In grade 1, there is 22% chances of DIND
● B. In grade 2, there is 33% chances of DIND
● C. In grade 3, there is 52% chances of DIND
● D. In grade 4, there is 53% chances of DIND
● E. In grade 5, there is 74% chances of DIND
● F. All of the above
F. All of the above
Which of the following statements is incorrect regarding modified grading system of Fisher (correlation between the amount of blood on CT and the risk of vasospasm)?
● A. Grade 0 is no SAH or IVH
● B. Grade 1 is focal or diffuse thin SAH, no IVH with 24% symptomatic vasospasm
● C. Grade 2 is focal or diffuse thin SAH with IVH and has 33% symptomatic vasospasm
● D. Grade 3 is focal or diffuse thick SAH, with no IVH and has 33% chance of vasospasm
● E. Grade 4 is focal or diffuse thick SAH with no IVH and has 40% chance of vasospasm
E. Grade 4 is focal or diffuse thick SAH with no IVH and has 40% chance of vasospasm
Which of the following is not a risk factor for re-bleeding?
● A. Male gender
● B. High-grade SAH
● C. Large aneurysm
● D. SBP > 175 mmHg
● E. Lumbar spinal drainage
A. Male gender
Which method should not be used to augment cerebral oxygen delivery (DO2)?
● A. Optimizing CBF
● B. Maintaining euvolemia
● C. Nimodipine
● D. Elevate O2 saturation
● E. Induced hypertension
E. Induced hypertension
A patient with aneurysmal SAH was referred for ICU care. How frequently should the neurological check be performed as a part of initial critical care?
● A. 1 hourly
● B. 2 hourly
● C. 4 hourly
● D. 6 hourly
● E. Twice daily
A. 1 hourly
A patient with SAH is brought to your ICU. The family is worried about the risk of other such event. After initial hemorrhage, during which time period there is maximal risk of rebleed?
● A. Within 3 hours
● B. Within 6 hours
● C. Within 8 hours
● D. Within 12 hours
● E. Within 24 hours
E. Within 24 hours
ECG of a patient with SAH show inverted T waves, prolonged QT interval, ST elevation, and U waves. The BP of the patient is 100/90. The initial management for neurogenic stress cardiomyopathy in this case includes which of the following?
● A. Dopamine
● B. Dobutamine
● C. Norpine
● D. Milrinone
● E. Potassium
D. Milrinone
