What’s New In Neurology? - macep.orgs New In Neurology_ MACEP 2016.pdf · Stupor, moderate to severe hemiparesis; possible early decerebrate posturing Grade 5 Deep coma, decerebrate

What’s New In Neurology?

Evie Marcolini, Assistant ProfessorEmergency Medicine and Neurology

Medical Director, SkyHealth Critical CareYale University School of Medicine

[email protected]

Tuesday, May 10, 16

mailto:[email protected]


We make a difference

Tuesday, May 10, 16

•Subarachnoid hemorrhage

• Best practices

• Intracerebral hemorrhage

• Blood pressure

•Traumatic brain injury

• Are we chillin’ yet?

• Stroke

• Interventional madness?

What’s new?

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SAHTuesday, May 10, 16

Exam, exam, examHunt/Hess

Intubate if needed Reverse coagulopathy

Manage blood pressureTreat pain

Think about hydrocephalusAntifibrinolytic agentsSeizure prophylaxis

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Hunt and Hess Classification

Grade 1Asymptomatic, minimal headache slight nuchal

rigidity

Grade 2Moderate to severe headache, nuchal rigidity; no

neurological deficit (except 3rd n. Palsy)

Grade 3 Drowsiness, confusion, or mild focal deficit

Grade 4 Stupor, moderate to severe hemiparesis; possible early decerebrate posturing

Grade 5 Deep coma, decerebrate posturing, moribund

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rebleedTuesday, May 10, 16

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Malhotra:CT/LP most effective in most settings .

Acad Emerg Med. 2016 Jan 4 (epub ahead of print)

Wu:CT/CTA not effective

Emerg Med J 2016;33:30-36

Martin:LP is a useful “rule-out”

Br J Neurosurg 2015;16:1-5

Sayer:LP has low diagnostic yield

Acad Emerg Med 2015;22:1267-‐1273

Dubosh:CT is extremely sensitive in certain cases

Stroke 2016;47:00-‐00

Meurer:CT/CTA is reasonable approachhemorrhage J Emerg Med 2016 (epub ahead of print)

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Take this home





CT/LP is still the standard...but not for long


ICHTuesday, May 10, 16

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Airway Imaging

Blood pressure managementAnticoagulation reversal

Osmotic therapyTransfer to appropriate level of care

Surgical interventionsGoals of care

Airway

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NICU Intubation - Nursing checklist

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Airway Imaging




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Airway Imaging





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J Hypertens 2008;26:1446-52

HemorrhagicIschemic

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NOACSTuesday, May 10, 16

Glund S Lancet 2015;386:680-90

Idarucizumab reverses dabigatran

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Siegal DM N Engl J Med 2015 Nov 11 [Epub ahead of print]

Andexanet reverses apixaban and rivaroxaban

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Airway Imaging




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Airway Imaging




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Neurosurgical considerations

VentriculostomyClot evacuation

Craniectomy

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Airway Imaging



Surgical interventions

Goals of care

Take this home


TBITuesday, May 10, 16

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Avoid hypotension and hypoxia

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Avoid hypotension and hypoxiaC-spine precautions

Head of bed up 30 degreesAirway

Hyperventilation?Osmotics

Anticoagulation reversalSeizure prophylaxis

Consider ventriculostomy

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Adult-Salvageable TBI -GCS 3-8 after resuscitation-Abnormal CT

-TBI with normal CT with:-Age > 40-Posturing-SBP < 90

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HyperventilationMannitol

Hypertonic salineVentriculostomy/drainage

Maintain CPP>50Vasoactives as needed

CraniectomyParalytics

Phenobarbitol burst suppressionTherapeutic hypothermia

Increasing ICP treatment

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N Engl J Med 2015;373(25):2402-12

Standard therapy favored over therapeutic hypothermia

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Fever is BAD

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Avoid hypotension and hypoxiaCPP = MAP - ICP

Dont hyperventilateOsmotics

Anticoagulation reversalSeizure prophylaxis

Consider ventriculostomy

Take home

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Acute Ischemic Stroke

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Rapid assessment and treatmentBlood pressure = perfusion

Endovascular therapy is an optionConsider Goals of Care

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Advance hospital notification by EMSRapid triage protocol and stroke notification

Single call activation systemStroke tools

Rapid acquisition/interpretation of imagingRapid lab testing

Mix tPA ahead of timeRapid access to IV tPATeam-based approachPrompt data feedback

JAMA 2014;311(16):1632-40

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JAMA 2014;311(16):1632-40Tuesday, May 10, 16

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J Hypertens 2008;26:1446-52

HemorrhagicIschemic

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N Engl J Med 2013;368:952-5

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N Engl J Med 2015;372:11-20

MR-CLEAN Investigators

Absolute difference 13.5%mRS 0-2

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N Engl J Med 2015;372

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Who is appropriate for endovascular thrombectomy?

-55 yo, stage IV metastatic disease, spontaneously resolving and then undergoing thrombectomy with TICI 3 reperfusion, a month more

before hospice?

-58 yo with no history, NIHSS 15 to 1, TICI 3 reperfusion and discharged to home with slight facial droop?

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Rapid assessment and treatmentBlood pressure = perfusion

Endovascular therapy is an optionConsider Goals of Care

Take this home

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Airway - fine tune itHyperventilation - don’t

Exam - repeat itBlood pressure - manage itCoagulopathy - reverse it

Osmotics - use themTransfer -slow down to speed upSeizure prophylaxis - consider it

Surgical/endovascular options - consider them


Goals of CareTuesday, May 10, 16

Thank [email protected]

Tuesday, May 10, 16



Documents

What’s New In Neurology? - macep.orgs New In Neurology_ MACEP 2016.pdf · Stupor, moderate to severe hemiparesis; possible early decerebrate posturing Grade 5 Deep coma, decerebrate