SESAP - ICU Neuro

Question 1

Brain Death - Step 1

Answer 1

1. Irreversible coma - H&P with supporting catastrophic imaging
2. ILL defined period of time from admission to allow for recovery, 6-24 hours

Question 2

Brain Death - Step 2

Answer 2

Fix all metabolic and physiologic derangements
NORMOthermic. NORMOtensive. No intoxicants. D/c all meds for at least 5 half lives. all electrolytes including Na, Glc need to be corrected

Question 3

Brain Death - Step 3

Answer 3

Assess neuro status
GCS < 3
No cranial nerve reflexes
No response to painful stimuli. 
Pupils - fixed and NR to light
"doll's eye" - cervico ocular reflex  
"Cold calorics" vestibulo-ocular reflex --> eyes stay fixed in the miposition
vestibulo-ocular - . The eyes should remain NO gag
NO cough
NO corneal reflex

Spinal reflexes MAY exist

Question 4

Brain Death - Step 4

Answer 4

apnea test - HIGH paC02 should trigger resp effort.

Patient preoxgenated to 100%, ventilator is adjusted to give paC02 of 40. Then, vent disconnected. abort test if patient is unstable, desaturates or has respirations. Draw an ABG after 10 minutes and if paCO2 is > 60 = brain dead.

Question 5

Brain Death - ancillary exams

Answer 5

NOT necessary but may be performed if apnea test cannot be administered. 
Nuclear perfusion test
EEG
4 vessel angiography
transcranial doppler

Question 6

VTE in TBI-ICH

1. What agent?
2. When to start?

Answer 6

1. LWW Heparin - Lovenox - lower VTE rate, equivalent bleeding rate
2. within 72 hours after stable head scan

Question 7

Delirium - Which medications are safe?

Answer 7

Dexmedetomidine (Precedex) associated with decreased delirium, decreased ICU LOS, decreased MV time.

Question 8

Dexmedetomidine

1. MOA
2. Side effects

Answer 8

1. Alpha 2 agonist, presynaptic, in the CNS. Does not allow release of Norepi.
2. Bradycardia, Hypotension. (why; because less Norepi)

Question 9

Alcohol withdrawal management
Mainstay treatment
Side effect?
Next line?

Bonus - treatment of overdose of mainstay treatment?

Answer 9

Benzodiazepines. Lorazepam.
side effect - lactic acidosis, myocardial suprresion, shock,
Next line - management of tachycardia/hypertension - alpha 2-agonists –> clonidine, dexmedetomidine.

Aside - outpatient management - Disulfuram (to prevent recividism), chlordiazepoxide ( Long acting agent outpatient)

bonus - Flumazenil