Today on the podcast, we discuss Neuro-Emergencies and NeuroCritical Care with Neha Dangayach. This is a wide-ranging conversation that you will truly enjoy.
Neha Dangayach
Neha is joining the EMCrit team!!!!!!
Neha S. Dangayach MD, MSCR is an Assistant Professor of Neurology and Neurosurgery. Dr. Dangayach serves as the Director of Neuroemergencies Management and Transfers (NEMAT) for the Mount Sinai Health System, Neurocritical Care Fellowship Director and Research Co-Director for the Institute for Critical Care Medicine (ICCM). She is also a Co-Director of the Mount Sinai Hospital’s busy NSICU and collaborates with a compassionate team to provide world-class patient-centered Neurocritical Care. She leads the Mount Sinai Critical Care Resilience Program (MSCCRP), a multidisciplinary program including intensivists, nursing, social workers, physical, occupation and speech therapists, chaplains, nutritionists among others. Several projects under this program seek to help patients and families cope with ICU recovery. Her research focuses on resilience, spirituality and recovery in critical care; inter-hospital transfers for neuroemergencies and social media in medicine.
Topics of Discussion with Time Stamps
Neha's Slides
Neuro-Emergency Management and Transfer (NEMAT) Service
Tele-Stroke
Video the CT with phone
2 person job
scroll through every image of axial head ct q 2 seconds
Scroll through CTA MIPs, axial and coronal (sag is a bonus)
ICH
Blood Pressure
Specify how often to cycle BP cuff
Ischemic Stroke
Who to Intubate and Neuroprotective Intubation
Which Osmotic Agent for ICP
Platelet Reversal
Recent paper shows no benefit from PLTs or dDAVP in non-neurosurg bleeds [10.1097/CCM.0000000000004348]
Status Epilepticus
Choice of 2nd Line Agent
Keppra 60mg/kg (1/2 the dose in ESRD)
General Anesthetic of Choice is Midazolam
0.2 mg/kg bolus
start infusion 0.2 mg/kg/hr
titrate up every 5 minutes
max 2.9 mg/kg/hr
when getting close to 1mg/kg/hr, give ketamine 1mg/kg followed by 1 mg/kg/hr
Cirrhotics, get propofol
Additional New Information
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Should we be using different BP goals for those with lobar vs. deep spontaneous IPH, or by severity? Most of the patients in Interact-2 and Atach-2 were deep and GCS 14-15. Can we extrapolate the safety and outcomes data from those studies to those with lobar bleeds and poor exams?
Great question Matt. This meta-analysis of 6 RCTs shows that it is safe to lower SBP to less than 140 in patients with ICH volumes of <|= 15 cc; https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5662650/#!po=35.1852 This RCT, https://pubmed.ncbi.nlm.nih.gov/23391776/ showed that rapid lowering of SBP to <150 in patients with moderate sized ICH (approx volumes of 25 cc) does not reduce affect perihematomal perfusion adversely. The AHA guidelines recommend rapidly lowering SBP to less than 140 “ For ICH patients presenting with SBP between 150 and 220 mm Hg and without contraindication to acute BP treatment, acute lowering of SBP to 140 mm Hg is safe… Read more »
would have loved to hear her thoughts on transcranial dopplers – maybe for round 2?
Transcranial dopplers (TCDs) are a good bedside diagnostic modality. We have been using them routinely for monitoring vasospasm in SAH, ICH with IVH; cerebral edema in patients with fulminant hepatic failure, malignant MCA syndrome; ancillary test for declaration of brain death etc. They definitely need a lot of practice. Knowing their limitations, sensitivity/specificity in different vascular territories, learning how to interpret both the waveforms, sounds etc. can be very useful.
Great podcast thank you, so much information
Thank you so much. Glad you enjoyed it!
Scott
that was incredible. listened to it once. need to re-listen. comprehensive, and excellent.
I envy her shop.
thank you, and Dr. Dangayach.
Thank you so much for your kind words. We are lucky to have a great team!
Thank you Scott and Dr. Dangayach for such an informative and thought provoking podcast. Dr Dangayach, could you expound on the recommendation of keeping sbp <140 in traumatic ICH? In my shop the SICU intensivists and traumatologists often allow sbp up to 200 when no icp monitor is in place for sdh, edh. This is in order to maintain cpp with an unknown icp. However the neurocritical care attendings often ask for sbp <140 as you have stated. I've read guidelines to support the sicu intensivist stance but I have not seen the evidence for <140. Any clarification of this… Read more »
Hello Jonathan! CPP=MAP-ICP but if you don’t have an ICP monitor in place, it’s hard to target CPP. It’s important to balance the goals of maintaining perfusion while preventing hematoma expansion. https://braintrauma.org/guidelines/guidelines-for-the-management-of-severe-tbi-4th-ed#/:guideline/15-blood-pressure-thresholds Brain Trauma Foundation guidelines recommend “Maintaining SBP at ≥100 mm Hg for patients 50 to 69 years old or at ≥110 mm Hg or above for patients 15 to 49 or over 70 years old may be considered to decrease mortality and improve outcomes.” And here’s nice paper summarizing literature on early hypertension and worsened outcomes in TBI https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5357208/ Hope this is helpful.
Hello there,
This is such an beautiful article,
I really liked reading this.
Thank you!!
Source: https://www.treeganesha.com/
I would like to ask Dr Dangayach about the approach to VTE thromboprophylaxis in the traumatic neurosurgical patient. What is their approach in terms of the timing of VTE prophylaxis and the nuances of drugs in the various IC trauma types (EDH, SDH, ICH, etc)?
Hello Dean! VTE prophylaxis within 24-48 hours should be safe in TBI patients after confirming stability of intracranial hemorrhage (EDH, SDH, contusion etc.). Choice of agent may depend upon how comfortable your surgical team is with lovenox versus heparin. Our Neurotrauma surgeons have been starting VTE prophylaxis within 24 hours of presentation. Margolick J, Dandurand C, Duncan K, Chen W, Evans DC, Sekhon MS, Garraway N, Griesdale DEG, Gooderham P, Hameed SM. A Systematic Review of the Risks and Benefits of Venous Thromboembolism Prophylaxis in Traumatic Brain Injury. Can J Neurol Sci. 2018 Jul;45(4):432-444. doi: 10.1017/cjn.2017.275. Epub 2018 Jun 13.… Read more »
Unrelated to the podcast, but pertaining to NeuroCC… Does Neuro CC Fellowship training and board certification certify physicians to practice in a MICU or SICU at a community hospital, or academic medical center that does not have a dedicated neuro-ICU yet?
Hello Matt, it would depend upon that hospital’s policies. If they accept neurocritical care BE/BC status then you may be able to practice in a MICU/SICU. With the new ACGME recognition of Neurocritical care as a subspecialty, a lot of programs will be applying for ACGME accreditation. The board certification for neurocritical care will then be administered by one of the following primary boards, Anesthesiology, EM, Neurology and Neurosurgery. https://www.abpn.com/wp-content/uploads/2019/05/ACGME-Approves-Subspecialty-Training-in-Neurocritical-Care-release.pdf