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Neurological emergencies

Neurological emergencies. Head injury. 32 year old man Assaulted Unconscious Management?. Image  Kathy Mak. Neurological injury. Primary injury Secondary injury. Secondary brain injury. Inadequate cerebral oxygen delivery Systemic Shock Respiratory failure Intracranial

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Neurological emergencies

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  1. Neurological emergencies

  2. Head injury • 32 year old man • Assaulted • UnconsciousManagement? Image  Kathy Mak

  3. Neurological injury • Primary injury • Secondary injury

  4. Secondary brain injury • Inadequate cerebral oxygen delivery • Systemic • Shock • Respiratory failure • Intracranial •  cerebral perfusion pressure • Herniation

  5. Severe blunt head injury • 3 main priorities: • Resuscitation • Ensure adequate cerebral oxygenation • Prevent herniation • Rapid diagnosis of brain lesion

  6. Airway Modified jaw thrust Images  Kathy Mak

  7. Resuscitation Breathing • Priority is oxygenation and carbon dioxide removal • High flow oxygen • Bag mask ventilation • Although most comatose patients require intubation, this should be carried out by experienced practitioners

  8. Resuscitation • Circulation • Aim for MAP > 80-90 mm Hg in an attempt to maintain adequate cerebral perfusion pressure • Shock is rarely a direct result of a head injury

  9. Following resuscitation • BP 140/80 • SpO2 100% • pH 7.4 • PaCO2 4.5 kPa (34 mmHg) • PaO2 30 kPa (225 mmHg) Image  Kathy Mak

  10. GCS 6 prior to sedation and paralysis for intubation and was moving all limbsWhat next? • CT brain? • Mannitol? • Hyperventilation? • Continue sedation & paralysis? Image  Kathy Mak

  11. Treatment of ICP • Mannitol • Should not be given prior to evacuation of haematoma unless there are signs of deterioration unrelated to systemic deterioration • Only give after volume resuscitation • Hyperventilation • Hyperventilation to PaCO2 <35 mmHg should not be carried out routinely

  12. Sedation & neuromuscular blockade • Sedation reduces cerebral oxygen demand • Neuromuscular blockade prevents coughing (coughing  ICP) • Interfere with neurological examination • agent • no evidence regarding superiority of any particular sedative • use short acting agents

  13. What now? Image  Kathy Mak

  14. Intracranial pressure Volume of space occupying lesion

  15. Haematoma Brain tissue Cerebrospinal fluid Circulating blood

  16. Treatment of herniation • Mannitol • Hyperventilation

  17. What next?

  18. On admision to ICU • Haematoma evacuated • Pupils equal, reactive • MAP 80 • ICP 26What next? Image  Kathy Mak

  19. Management • Ensure adequate cerebral oxygen delivery • Oxygen saturation • Cerebral blood flow • Determined by cerebral perfusion pressureCPP=MAP-ICP • Reduce cerebral oxygen demand • Prevent herniation

  20. Management • Intracranial pressure • Treatment threshold 20-25 mmHg • Cerebral perfusion pressure • Target >60 mmHg

  21. Reduce ICP • Drain CSF • Osmotherapy • PaCO2 ~35 mmHg • Improve venous drainage • Nurse head up (30°) • Position head and neck to ensure venous drainage is not obstructed Image  Kathy Mak

  22. Decrease cerebral oxygen demand • Analgesia and sedation • Control temperature (and treat cause of pyrexia) • Prevent/treat fits Image  Kathy Mak

  23. Other treatment • stress ulcer & mechanical DVT prophylaxis • physiotherapy • look for and treat coagulopathy • not uncommon • prevent hyperglycaemia Image  Kathy Mak

  24. Head injury • Any questions?

  25. Status epilepticus

  26. Status epilepticus Treat hypoglycaemia, take blood,give O2, left lateral position Yes Aborted? 30 minutes Lorazepam 0.1 mg/kg Look for causeRegularanticonvulsant Yes Aborted? Phenytoin if notalready given Yes Aborted? Treat as refractory SE

  27. Status epilepticus Treat hypoglycaemia, take blood,give O2, left lateral position Yes Aborted? Lorazepam 0.1 mg/kg Look for causeRegularanticonvulsant Yes Aborted?

  28. Status epilepticus Treat hypoglycaemia, take blood,give O2, left lateral position Yes Aborted? Diazepam 0.2 mg/kg Lorazepam 0.1 mg/kg Look for causeRegularanticonvulsant Yes Aborted? Phenytoin 15-20 mg/kg

  29. Status epilepticus Treat hypoglycaemia, take blood,give O2, left lateral position Yes Aborted? Diazepam 0.2 mg/kg Lorazepam 0.1 mg/kg Look for causeRegularanticonvulsant Yes Aborted? Phenytoin 15-20 mg/kg Phenytoin if notalready given Yes Aborted? Treat as refractory SE

  30. Refractory status epilepticus • Rapid sequence induction • Thiopentone/propofol • Suxamethonium/rocuronium • (NB risk of K due to rhabdomyolysis) • Intubate and ventilate Image  Janet Fong

  31. Refractory SE • Treatment options • Midazolam • Propofol • Thiopentone • Target • Abolition of clinical and electrical seizure activity

  32. Midazolam • Dose • 0.2 mg/kg loading • 0.1-0.2 mg/kg/h • Tachyphylaxis • Requires significant dose increase after 24-48 h to maintain seizure control

  33. Propofol • Dose • Loading dose 3-5 mg/kg • Infusion 30-100 µg/kg/min • Propofol infusion syndrome • Severe metabolic acidosis • Rhabdomyolysis • Cardiovascular collapse

  34. Key points • Head injury • Resuscitate first • Maintain CPP >60 mmHg • Reduce ICP with evacuation of SOL, drainage of CSF, mannitol and ventilation to PaCO2 4-4.5kPa • Sedate, nurse head up, prevent fits & fever, prevent hyperglycaemia

  35. Key points • Status epilepticus • True emergency • Treat hypoglycaemia • Lorazepam 0.1 mg/kg • Sedate, intubate and ventilate • Thiopentone/propofol/midazolam infusion

  36. Any questions?

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