Neuro

Question 1

Most effective interventions in reducing ICP

Answer 1

1. Temp control (parenchyma volume and blood volume)
2. PaCO2 control (intracranial blood volume)
3. HOB 30 degrees (intracranial blood volume)
4. Loosen tube ties/cervical collar/in-line neck positioning (intracranial blood volume)
5. EVD (intracranial CSF volume)

Question 2

initial bundle of care for brain injury

Answer 2

MAP > 80 mmHg, SBP < 110-160 mmHg
Normal temp (avoid hyperthermia)
PaCO2 35-40 mmHg (target normal)
PaO2 80-120 mmHg (target normal)
Hgb > 90 g/L
HOB 30°, loosen collars/ties
Optimize platelets/INR
Propofol/ketamine to RASS -4

Question 3

BP goal for an unsecured aneurysmal SAH

Answer 3

SBP <140

Question 4

BP goals for ischemic CVA

Answer 4

Pre lysis (r-TPA): SBP < 185 mmHg DBP <110 mmHg
post lysis (r-TPA): SBP < 180 mmHg DBP <105 mmHg
No lysis: SBP <220 mmHg DBP <120 mmHg

Question 5

BP goals for acute hemorrhagic CVA

Answer 5

SBP <140

Question 6

first, second, third line, 4th line options for status epilepticus (explain the seizure clock!! ⏰ ⏰ )

Answer 6

Benzodiazepines (5 min, 10 min) ⏰
Anti-epileptics: Phenytoin, Keppra, valproic acid (15 min) ⏰
Infusion therapy: Propofol, Midazolam, Ketamine (30 min) ⏰
Rescue therapy: Deep barbiturate coma, Immunomodulatory therapy (anti-N-methyl-D-aspartate (NMDA) receptor encephalitis), Inhalational anesthetics (Isoflurane and desflurane) (45 min) ⏰

Question 7

neuro insults where the target SBP should be <140

Answer 7

Subarachnoid bleed
Epidural bleed
Internal capsule bleed
Ischemic stroke with hemorrhagic transformation

Question 8

neuro insults where the target SBP should be <160 and MAP should be 80-90

Answer 8

Undifferentiated TBI (SBP >110 <160, MAP >80)
Subdural bleed (venous)
Traumatic subarachnoid bleed
DAI
SCI (MAP 85-90 for cord perfusion)
IVH

Question 9

Aneurysmal Subarachnoid Hemorrhage treatment goals

Answer 9

securing the airway as needed
blood pressure control (goal SBP <140 mm Hg)
reversal of anticoagulation
management of ICP

Question 10

Aneurysmal Subarachnoid Hemorrhage treatment pathway

Answer 10

IV/O2/Monitor
Preliminary neuro exam
secure the airway if req’d
Art line/blood pressure control (goal SBP <140 mm Hg, labetalol, hydralazine, propofol, fentaNYL)
reversal of anticoagulation (VitK/FFP/PCC/Plt/TXA)
management of ICP (mannitol/HTS)
prevent secondary brain injury (optimize venous drainage, treat pain/fever/electrolytes/glucose, Consider seizure prophylaxis, optimize BP/PaO2/pCO2)

Question 11

Intracerebral haemorrhage treatment goals

(deep parenchymal venous bleed)

Answer 11

1. securing the airway as needed
2. blood pressure control (goal SBP <160 mmHg, MAP 80-90)
3. reversal of anticoagulation
4. management of ICP

Question 12

Neurogenic shock treatment

Answer 12

1. Fluid replacement
2. Levophed
3. Epi if profoundly bradycardic