Tim Rausch, FNP-BCUPMC Presbyterian Hospital

Pittsburgh, PA

I have no financial interest in any of the products contained in this lecture nor am I receiving any financial compensation from any company either public or private. Additionally, it should be understood that the descriptions in this lecture are generalized and therapy should be based on individual assessments.

1. Identify patients at risk for acute neurologic changes

2. Review assessment of patients with acute neurologic changes

3. Help you advance your knowledge of management of patients with acute neurologic changes

4. Update on reversal of designer anticoagulants

Head injuries◦ TBI

◦ Stroke

◦ Seizures

◦ Infection

Spinal Cord Injuries◦ Trauma

◦ Infection

Traumatic Brain Injuries◦ Subdural Hematomas

◦ Epidural hematomas

◦ Intraparenchymal hematomas

◦ Diffuse Axonal Injuries

◦ Anoxic Brain Injuries

neurosurgery.ufl.edu

Strokes◦ Hemorrrhagic

◦ Ishcemic

Thromotic

Plaque

Fat

Spinal Cord Injuries◦ Traumatic

Vertebral fractures

Distraction Injuries

Hemorrhagic

◦ Infectious

Meningitis

Abscess

1. Stroke- thrombotic, hemorrhagic, spasm

2. ICH- SDH, SAH, EDH, IPH

3. Seizure- Clinical, non-clinical

4. Altered gas exchange- hypoxia, hypercarbia

5. Hypotension- hypovolemia, arrhythmia

6. Spinal cord compression-hematoma, infection

ABC’s

CTh

CXR

EEG

EKG

LABS

Physical Exam

ABC’s◦ Airway

Intact, debris, altered anatomy, medical devices

◦ Breathing

Depth, rate, accessory muscles

◦ Circulation

Peripheral, central

CTh◦ Initial CT scan

Noncontrast CTh to establish baseline or need for intervention

CTA to evaluate for stroke

◦ Follow-up CT scan

Short term CTh at 4-8 hrs if stable

Immediate CTh if change in assessment

CXR◦ Pneumothorax

◦ Pneumonia

Infection

Aspiration

EEG◦ Continuous v. single

Continuous

Allows for evaluation over 24+ hr period

Can capture non-convulsive seizures

Allows for dissipation of previously administered AED’s

Requires 24 hour monitoring/ expensive

Single

Useful for snap shot view of altered states

Cost effective

EKG◦ MI

◦ Hypoperfusing arrhythmia

Labs◦ Glucose

◦ H+H, PLT, PT/PTT/INR

◦ Electrolytes, especially Na+ , Ca++

◦ Renal functions

◦ Hepatic functions, NH4

◦ Drug screen; withdrawal, anticholinergics, TCA’s, alcohol, SSRI’s, benzo’s, Barbs

◦ ABG, PE

◦ Lumbar puncture???

Physical Exam◦ Neurological

LOC

Pupillary assessment

Anisocoria: Contralateral cerebral pressure

Focal signs

Seizures

◦ Change in vital signs Cushing’s response (Elevated ICP, HTN, bradycardia)

Change in respiratory pattern

Kussmaul’s: Elevated ICP -> attempt to decrease PaCO2

Cheyne –Stokes: Brainstem pressure 2/2 delayed response to hypoxia

Biot’s: Mudulliary pressure 2/2 uncal/tentorial herniation

Physical Exam◦ Hemodynamic

Change in vital signs

Cushing’s response (HTN, bradycardia, elevated ICP)

Change in respiratory pattern

Kussmaul’s: Elevated ICP -> attempt to decrease PaCO2

Cheyne –Stokes: Brainstem pressure 2/2 delayed response to hypoxia

Biot’s: Mudulliary pressure 2/2 uncal/tentorial herniation

Apneustic: damage to the pons or upper medulla

1. Blown pupil

2. Intracranial hemorrhage

3. Seizures

4. Elevated ICP

5. Altered Gas Exchange

6. Blood Pressure Management

7. Fibrinolytics

8. Reversing Anticoagulants

9. Transport

1. Blown pupil◦ Hypertonic solution

Mannitol-10g/kg

23.4% saline- 30 ml

3% saline

2. Intracranial hemorrhage◦ SDH

Surgical: craniotomy, burr holes

◦ SAH

Craniotomy

◦ IVH

EVD

◦ IPH

Manage medically

3. Seizure◦ Benzodiazepines

Lorazepam: IV, IM

0.1 mg/kg

Diazepam: IV, PR

0.2 mg/kg

Midazolam: IV,IM

0.2 mg/kg, then 0.05-2 mg/kg/hr

3. Seizures◦ Antiepileptics

Phenytoin: 20mg/kg, then 100mg q8 hrs

Fosphenytoin: 20 PE/kg, then 100 mg q8 hrs

Levetiracetam: 1-1.5 g bid

Propofol: 2-5 mg/kg, then 20-100mcg/kg/min

Valproic Acid: 15-20 mg/kg

Phenobarbital: up to 20 mg/kg

Pentobarbital: 5-15 mg/kg, then 0.5 -10 mg/kg/hr

4. Elevated ICP Goal: ICP<15 and CPP>65 and PbO2>20

Elevate HOB

Loosen C-Collar

Minimize PEEP 5cm H2O

Avoid IJ Catheters

Drive up MAP

Mannitol, 200 mg/kg

Midazolam infusion

Hypertonic Saline

Na + goal 145-155◦ Na+ < 137 -> 250 cc bolus1, then 40cc/hr

◦ Na+ 137-140 -> 150 cc bolus1, then 35cc/hr

◦ Na+ > 140 -> 35 ml/hr

Check Na+ and Osmoloality Q-6 hrs◦ <135- increase by 10cc/hr; if 70cc/hr, give 250 cc bolus1

◦ 136 to144- increase by 5cc/hr: if at 70cc/hr, give 150 cc bolus1

◦ > 152- decrease by 5cc/hr

◦ > 155- decrease by 15cc/hr

◦ > 159- hold 4 hrs, restart at 50% of rate2

◦ > 160- hold, check Na+ q4 restart at 20cc/hr when below 1562

1- Boluses given over 30 minutes

2- do not restart if Na+ increase by >1 mEq/hr

60 cc/hr or greater45 cc/hr X 8 hr, then20 cc.hr X 8 hr, then10 cc/hr X 8 hr, then stop

45 – 60 cc/hr25 cc/hr X 8 hrs, then15cc/hr X 8 hrs, then5 cc/hr X 8 hrs, then stop

30 – 45 cc/hr20 cc/hr X 8 hrs, then10 cc/hr X 8 hrs, then5 cc/hr X 8 hrs, then stop

< 30 cc/hr10 cc/hr X 8 hr, then5 cc/hr X 8 hr, then stop

5. Altered gas exchange◦ Hypoxia

Pneumothorax

Pulmonary Embolism

Mucous Plugging

Equipment (ventilator, spontaneous)

◦ Hypercarbia

Equipment, disconnected O2 supply

Hypoventilating, therapeutic misadventure

6. Blood Pressure Management◦ Hypertension

Labatalol: 10-20 mg Q 10 min

Hydralazine: 10 mg Q 10 min

Lopressor: 5-10 mg Q 10 min up to 3 doses

Nitroprusside: 0.5 – 3 mcg/kg/min

Clevidipine:1-2 mg/hr up to 32 mg/hr for 24 hrs

Max dose 1,000 mg/24 hrs 2/2 lipid load

6. Blood Pressure Management◦ Hypotension

Hypovolemia

IVF: NSS, Lactated Ringers, Plasmalyte

Arrhythmia

Normalize HR, then treat hypotension

7. Fibrinolytic Therapy < 3 hrs Exclusion: ICH, BP > 185/110,

active bleeding, PLT<100k, heparin <48hrs, INR>1.7,

Fibrinolytics

Tissue Plasminogen Activator

Heparin

8. Reversing Anticoagulant Therapy◦ Vitamin K antagonists

Warfarin

◦ Heparins

Unfractionated, Low molecular weight

◦ Factor Xa Inhibitors

Apixaban, rivaroxiban, fondaparinux

◦ Direct thrombin inhibitors

Argatroban, bivalirudin, dabigatran

Drug Elimination Lab Assay Reversal Agent

Apixaban(Eliquis)

Liver/kidney9-14 hrs

Anti Xa, INRProthrombin

Complex, aPCC

ArgatrobanLiver

60-90 minaPTT

None established

Bivalirudin(Angiomax)

Enzymes aPTTrFVIIa

Dialysis

Dabigatran(Pradaxa)

Kidney17-17 hrs

INR, aPTT

IdarucizumabaPCC

ProthrombinComplexDialysis

Edoxaban(Savaysa)

Liver/Kidney10-14 hrs

Noneestablished

ProthrombinComplex

aPCC

Drug Elimination Lab Assay Reversal Agent

Fondaparinux(Arixtra)

Kidney7-21 hrs

None Established

aPCC

LMWH(Lovenox,

Enoxaparin, Dalteparin)

Kidney2-8-hrs

Anti Xa?Protamine

aPCC

UnfractionatedHeparin

Liver1-2 hrs

aPTTAnti Xa?

Protamine

Rivarobaxin(Xarelto)

Liver/Kidney5-9 hrs

(13 hrs in elderly)

INRAnti Factor Xa

ProthombinComplex

aPCC

Warfarin(CoumadinJantoven)

Liver36-48 hrs

INR

ProthrombinComplex

rFVIIaVitamin K

FP

Drug Onset Duration Dose

aPCC 5-15 min 8-12 hrs 8-25 u/kg

FFP 1-4 hrs 6 hrs 5-20ml/kg

Idarucizumab Immediate 24 hrs 5 gm

Protamine 5 min Dose dependent

0.01- 0.02 mg/100u IV

heparinMax dose 50 mg

PCC 5-15 min 12-24 hrs w/vit K 12.5-50 IU/kg

rFVIIa 5-10 min4-6 hrs w/FFP +

Vit KSurg. 90mcg/kg

FVII. 15-30mcg/kg

9. Transport◦ Patient/family wishes

◦ Distance to tertiary facility

◦ Resources of transport crew

◦ Prep for transport

Stabilize airway

Stabilize hemodynamically

Consult with receiving facility