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Breathing for the Head

Breathing for the Head. John Peterson, DO KU School of Medicine - Wichita. Disclosures. I’ve known Alan and Jeff for a while……. Objectives. Neurological injuries Physiological effects Airway management Ventilator management. Neurological injuries. Disturbances in consciousness

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Breathing for the Head

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  1. Breathing for the Head John Peterson, DO KU School of Medicine - Wichita

  2. Disclosures • I’ve known Alan and Jeff for a while……

  3. Objectives • Neurological injuries • Physiological effects • Airway management • Ventilator management

  4. Neurological injuries • Disturbances in consciousness • Encephalopathy • Traumatic brain injury • Acute Myelopathy • Ischemic stroke • Intracerebral hemorrhage • Subarachnoid hemorrhage • Brain tumors • Status epilepticus • Venous thrombosis • Cerebral Sinus • DVT/PE Bhardway, Anish, et. al., ed, Handbook of Neurocritical Care, 2nd ed. Springer, 2011. pp xi - xiii

  5. Disturbances in Consciousness • Drowsy • Stupor • Minimally conscious state • Vegetative state • Restored sleep/wake cycle • Locked – in syndrome • Coma • Brain death

  6. Encephalopathy • Vascular • Trauma • Neoplasm • Seizure • Organ Failure • Metabolic • Endocrine • Pharmacologic • CNS infection • Systemic infection • Inflammatory and immune – mediated encephalitis Bhardway, Anish, et. al., ed, Handbook of Neurocritical Care, 2nd ed. Springer, 2011, p 289

  7. Traumatic Brain Injury • Primary injury • Secondary injury • May be more injurious • Hypoxia and hypoperfusion most likely are the most critical factors in secondary injury Bhardway, Anish, et. al., ed, Handbook of Neurocritical Care, 2nd ed. Springer, 2011, p 308

  8. Acute Myelopathy • Traumatic • Degenerative spine • Neoplastic • Inflammatory • Systemic disease • Bacterial and viral infections • Vascular • Toxic/Metabolic

  9. Stroke • Defined • Focal neurological deficit that has an arterial distribution that correlates with specific region of the brain

  10. Normal Brain

  11. Ischemic stroke • Focal neurological deficit corresponding to arterial territory • Transient ischemic attack (TIA) • Symptoms resolve in less than 24 hrs • Typically less than 1 hr • Reversible Ischemic Neurologic Deficit (RIND) • Symptoms lasting 24 – 72 hrs Bhardway, Anish, et. al., ed, Handbook of Neurocritical Care, 2nd ed. Springer, 2011, p 341

  12. Ischemic Stroke

  13. Ischemic stroke • Embolic • Cardiac • Artery to artery embolus • Paradoxical embolus • Thrombotic • Intracranial atherosclerosis • Lipohyalinosis • Arterial dissection • Arteritis • Fibromuscular dysplasia • Vasospasm • Hypercoaguable states Bhardway, Anish, et. al., ed, Handbook of Neurocritical Care, 2nd ed. Springer, 2011, p 342

  14. Ischemic Stroke • Modifiable • Diabetes mellitus • Hypertension • Smoking • Hypercholesterolemia • Coronary artery disease • Non-modifiable • Age • Male • Family history Bhardway, Anish, et. al., ed, Handbook of Neurocritical Care, 2nd ed. Springer, 2011, p 342

  15. Intracerebral Hemorrhage

  16. Intracerebral Hemorrhage • 10 – 15% of all strokes • 30 day mortality: 35 – 52% • Only 20% are independent functional at 6 months • Etiology • Primary • Secondary to hypertension • Secondary • Aneurysmal, AVM, Tumor, Amyloidangiopathy, Coagulopathies, Trauma

  17. Intraventricular Hemorrhage

  18. Subarachnoid Hemorrhage • Trauma • Most common cause • Spontaneous • 80% Aneurysmal • 10 – 15% Perimesencephalicnonaneurysmal hemorrhage • 5% Nonaneurysmal • 2 – 5% of all strokes

  19. Subarachnoid Hemorrhage

  20. Vasospasm • Occurs between days 4 -12 • Lasts up to 21 days • Monitoring with transcranial doppler (TCD) • Treatment for symptomatic vasospasm • Triple H • Hypertension • Hypervolemia • Hemodilution • Angiography with balloon dilation or intra-arterial calcium – channel blocker infusion

  21. Epidural Hematoma Subdural Hematoma

  22. Post-Cardiac Arrest Brain Injury • Therapeutic hypothermia • Indicated for out-of-hospital ventricular fibrillation arrest • Possible benefit with asystole and PEA • 55% of the hypothermia group had a favorable outcome vs 39% in the normothermia group • At 6 months 41% of the hypothermia group died vs 55% of the normothermia group Bhardway, Anish, et. al., ed, Handbook of Neurocritical Care, 2nd ed. Springer, 2011, p 393

  23. Venous Thrombosis • Cerebral Sinus • Rare cause of stroke • Thrombophilia is most common cause • Systemic anticoagulation required • DVT/PE • 79% of pulmonary embolism originates from a lower extremity deep vein thrombosis • Neurological conditions predisposing to VTE • Spinal cord injury • Traumatic brain injury • Ischemic stroke • Intracerebral hemorrhage • Malignant glioma Bhardway, Anish, et. al., ed, Handbook of Neurocritical Care, 2nd ed. Springer, 2011, p 433-434, 506-507

  24. Venous Thrombosis • Deep Vein Thrombosis • Risk Factors • Venous valvular insufficiency • Right-sided heart failure • Postoperative period • Prolonged bedrest • Extremity trauma • Malignancy and cancer therapy • Pregnancy and postpartum period • Hormone therapy • Spinal cord injury • History of venous thromboembolism • Hypercoagulable state Bhardway, Anish, et. al., ed, Handbook of Neurocritical Care, 2nd ed. Springer, 2011, p 506-507

  25. Malignant Hyperthermia • Autosomal dominant condition • Triggers • Halogenated inhalational anesthetics • Succinylcholine • Extreme stress, vigorous exercise and heat exposure • Risk Factors • Myopathies Bhardway, Anish, et. al., ed, Handbook of Neurocritical Care, 2nd ed. Springer, 2011, p 437

  26. Malignant Hyperthermia • Signs and symptoms • Unexpected rise in end-tidal CO2 > 55 or PaCO2 >60 • Increased minute ventilation • Unexplained tachycardia, ventricular tachycardia or fibrillation, labile blood pressure, congestive heart failure • Metabolic acidosis with elevated serum lactate • Altered mental status (when anesthetic is stopped) • Generalized muscle rigidity, masseter rigidity (despite neuromuscular blockade), rhabdomyolysis • Acute renal failure • Hyperkalemia • Hyperthermia (Temperature can rise 1 – 2 C˚ q 5 min up to 44˚C) • This is a late finding • DIC • Especially with temp > 41˚C Bhardway, Anish, et. al., ed, Handbook of Neurocritical Care, 2nd ed. Springer, 2011, p 438

  27. Malignant Hyperthermia • Management • Stop offending agent • Admit to ICU • Increase minute ventilation to normalize PaCO2 • Body cooling • NG icy lavage, ice packs, fans, surface or invasive cooling systems • Target temp of 38.5 • Dantrolene • Continue for 3 days IV or PO dosing • Monitor for excessive muscle weakness or hepatotoxicity • Monitor for recrudescence Bhardway, Anish, et. al., ed, Handbook of Neurocritical Care, 2nd ed. Springer, 2011, p 438

  28. Neuroleptic Malignant Syndrome • Risks • Prior physical exhaustion and dehydration • Previous episode of NMS • Exposure to antipsychotic drugs • Signs and symptoms • Develop within 24hrs – 1 month after exposure to antipsychotic drugs • Regression within 1 wk – 1 month after discontinuation of drug • 10% Mortality Bhardway, Anish, et. al., ed, Handbook of Neurocritical Care, 2nd ed. Springer, 2011, p 435-436

  29. Brain Tumors • Second most common cause of death from intracranial disease • 33% overall 5 year survival • 33% of all tumors are gliomas • 67% are high grade • Metastatic tumors are the most common brain neoplasm • Lung (18 – 64%) • Breast (2 – 21%) • Melanoma (4 – 16%) • Colorectal tumors (2 – 12%) • Renal cell carcinoma (1 – 8%) • Lymphoma (< 10%) • Unknown origin (1 – 18%) Bhardway, Anish, et. al., ed, Handbook of Neurocritical Care, 2nd ed. Springer, 2011, p 445-446

  30. Brain Tumors

  31. Brain Tumor

  32. Brain Tumors • Headache • Seizure • Progressive focal neurological deficits • Visual defects • Altered mental status • Intracerebral hemorrhage • Intracranial pressure elevation

  33. Hydrocephalus • Caused by impaired cerebrospinal fluid flow, reabsorption or excessive production • Cerebrospinal fluid • Forms at 0.3mL/min • 20mL/hr • 500mL/day • Total volume ~150mL • 75mL in cranial vault • Normal pressure ~10mmHg Bhardway, Anish, et. al., ed, Handbook of Neurocritical Care, 2nd ed. Springer, 2011, p 469. 471

  34. Hydrocephalus

  35. Hydrocephalus

  36. Neuromuscular Disorders • Acute generalized weakness • CNS • Bilateral hemispheric • Brainstem • Spinal cord • Motor neuron • West Nile infection • Poliomyelitis • Enterovirus infection • Neuromuscular junction • Myasthenia gravis • Lambert-Eaton myasthenic syndrome • Organophosphate poisoning • Botulism • Tick Paralysis • Hypermagnesemia • Snake/insect/marine toxins Bhardway, Anish, et. al., ed, Handbook of Neurocritical Care, 2nd ed. Springer, 2011, p 478

  37. Neuromuscular Disorders • Acute generalized weakness causes cont. • Neuropathies • Guillain – Barré syndromes • Critical illness polyneuropathy • Chronic idiopathic demyelinatingpolyneuropathy • Toxic neuropathies • Vasculitic neuropathy • Porphyric neuropathy • Diptheria • Lymphoma • Carcinomatous meningitis • Acute uremic polyneuropathy • Eosinophilia-myalgia syndrome Bhardway, Anish, et. al., ed, Handbook of Neurocritical Care, 2nd ed. Springer, 2011, p 478

  38. Neuromuscular Disorders • Acute generalized weakness causes cont. • Myopathies • Critical illness myopathy • Dermatomyositis • Polymyositis • Periodic paralysis/hypokalemicmyopathy • Myotonic dystrophy • Acid maltase deficiency • Muscular dystrophies • Mitochondrial myopathies • Corticosteroid-induced myopathy Bhardway, Anish, et. al., ed, Handbook of Neurocritical Care, 2nd ed. Springer, 2011, p 478

  39. Neuromuscular Disorders • Causes of acute respiratory muscle weakness • CNS • Diseases of high cervical cord or medulla • Motor neuron disease • Neuromuscular junction • Myasthenia gravis • Lambert-Eaton myasthenic syndrome • Neuropathies • Idiopathic bilateral phrenic nerve paresis • Guillain-Barré syndrome (rare) • Neuralgic amyotrophy • Large artery vasculitis • Multifocal motor neuropathy • Myopathies • Acid maltase deficiency Bhardway, Anish, et. al., ed, Handbook of Neurocritical Care, 2nd ed. Springer, 2011, p 478

  40. Neuromuscular Disorders • Causes of acute predominantly bulbar weakness • CNS • Brainstem diseases • Bilateral white matter diseases • Syrinx • Motor neuron • Amyotrophic lateral sclerosis • Kennedy disease • Neuromuscular junction • Myasthenic gravis • Lambert-Eaton myasthenic syndrome • Botulism • Neuropathies • Guillan-Barré syndrome (rare) • Carcinomatous meningitis • Skull base tumor or metastases • Miller-Fisher disease • Sarcoidosis • Basilar meningitis • Myopathies • Dermatomyositis • Polymyositis • Oculopharyngeal muscular dystrophy • Myotonic dystrophy • Distal myopathy with vocal cord paralysis Bhardway, Anish, et. al., ed, Handbook of Neurocritical Care, 2nd ed. Springer, 2011, p 479

  41. Neuromuscular Disorders • Acute failure of the autonomic nervous system • CNS • Diseases affecting the hypothalamus, brainstem, medulla, high cervical cord • R insular stroke • Neuromuscular junction • Lambert-Eaton myasthenic syndrome • Botulism • Neuropathies • Diabetic autonomic neuropathy • Amyloid neuropathy • Guillain-Barré with predominant dysautonomia • Paraneoplasticdysautonomia • Connective tissue disorders • Sjogrens • Systemic lupus erythematosus • Infectious • Chagas • HIV • Leprosy • Diptheria Bhardway, Anish, et. al., ed, Handbook of Neurocritical Care, 2nd ed. Springer, 2011, p 479

  42. Neuromuscular Disorders • Indications for ICU admission • Respiratory weakness • FVC < 40ml/kg • NIF < - 40 cmH2O • > 30% decline in FVC or NIF in 24 hrs • Signs of fatigue or dyspnea • Significant neck flexor weakness or poor cough • CXR • Infiltrates, atelectasis or pleural effusion • Dysphagia/inability to protect airway • Increased aspiration risk • Bulbar dysfunction/bilateral facial weakness • Failed swallow evaluation • Autonomic instability • Dysrhythmia • Blood pressure lability • Profound sensitivity to sedatives • Planned interventions • Plasma exchange • Frequent vital checks or intensive nursing care • Rapid onset of symptoms (< 7 days) Bhardway, Anish, et. al., ed, Handbook of Neurocritical Care, 2nd ed. Springer, 2011, p 480

  43. Neuromuscular Disorders • Intubation indications • Consider early intubation • May reduce pulmonary complications • FVC < 20 mL/kg • NIF < - 30 cmH2O • PaO2 < 70 (decrease by > 50% in 24 hrs) on room air • Hypoventilation (PaCO2 > 45) • Dysphagia Bhardway, Anish, et. al., ed, Handbook of Neurocritical Care, 2nd ed. Springer, 2011, p 480

  44. Neuromuscular disorders • Extubation criteria • Pressure support of 5 with PEEP 5 for > 2hrs (prolonged SBT) • Some evidence for PS of 0 with PEEP of 5 or T-piece predicts more successful extubation • Successful secretion management Bhardway, Anish, et. al., ed, Handbook of Neurocritical Care, 2nd ed. Springer, 2011, p 481

  45. Status Epilepticus • A seizure that persists a sufficient length of time or is repeated frequently enough to produce a fixed and enduring epileptic condition • Historically, is defined by a seizure lasting 30 min and should be considered for seizures lasting 5 – 10 min • Nonconvulsant status epilepticus should be considered with coma patients with unclear etiology • May occur in as many as 8 -34% of critically ill patients Bhardway, Anish, et. al., ed, Handbook of Neurocritical Care, 2nd ed. Springer, 2011, p 489

  46. Status Epilepticus • Etiologies • Neurovascular • Tumor • CNS Infection • Inflammatory disease • Traumatic brain injury • Primary epilepsy • Hypoxia/ischemia • Drug/substance toxicity or withdrawl • Fever • Metabolic abnormalities Bhardway, Anish, et. al., ed, Handbook of Neurocritical Care, 2nd ed. Springer, 2011, p 491

  47. Status Epilepticus • Medical treatment • May require inducing a coma • Neuromuscular blockade • Will not stop the seizure, only the motor manifestation • Airway and ventilator management • May not be required for nonstatus seizure • Will be required for induced coma Bhardway, Anish, et. al., ed, Handbook of Neurocritical Care, 2nd ed. Springer, 2011, p 499

  48. Spinal Cord Injury • Trauma is the most common cause • ~ 50% are motor vehicle related • 24% related to falls • 9% sports injury • 11% assault • > 50% involve the cervical spine Bhardway, Anish, et. al., ed, Handbook of Neurocritical Care, 2nd ed. Springer, 2011, p 325

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