Back in May, we had the opportunity to present about Neurologic Emergencies at the Hospitalist and Rescuscitationist Conference (H&R22). For those not familiar, H&R is a conference led by Philippe Rola that brings together passionate educators and clinicians to explore strategies to take caring for sick patients to the next level. It is an awesome conference and we are grateful that Phil is allowing us to share our talk on this platform! We also highly suggest you learn more about the conference here and check out all the talks from May 2022 here.
Part 1: Casey & Neha's H&R talk
For those that don't have time to listen to the whole talk, or even for those that do, we wanted to share some major take aways from the lecture.
We used 3 cases in Part 1 to:
Case 1: Altered Mental Status After Surgery
(The case reveals acute unilateral weakness and gaze deviation, further workup uncovers a large-vessel-occlusion stroke)
- Pearl: Evaluating patients with AMS can be difficult. It is crucial to have a standardized and rigorous approach that assesses their consciousness, language, neglect, gaze, pupil reactive, and motor asymmetry. The NIHSS can be a helpful tool, but for altered patient, it is critical to do a more detailed assessment of the cranial nerves.
- Cutting Edge: Many patients will not qualify for thrombolysis. However, mechanical thrombectomy has changed the game for acute stroke. Thus, for any alter patient with focal or laterializing findings, it is critical to also get a CTA head and neck. CT perfusion can also be helpful in these cases, however, note that it is only validated in the extended window (> 6 hours from LSW). In the hyperacute phase, it may actually overcall the core tissue. Still, if this is available at your center, train yourself to consider it when you are making workup decisions for altered patients that have LVO-compatible exams.
- Cutting Edge: Tenecteplase (TNK).
- Since May, additional data has been published that supports TNK as non-inferior to tPA for AIS.
- The AcT trial found similar rates of excellent outcomes (mRS 0-1) at 90-120 days with TNK and tPA, and TNK hit the prespecified non-inferior cut off. There were also similar rates of symptomatic ICH between the two groups.
- This trial used the 0.25mg/kg up to 25mg dose, which has been the real world adoption for the drug.
- An observational cohort study recently published also demonstrates how TNK can reduce door to needle time, unfavorable outcomes, and hospital costs.
- Pearl: Unlike tPA which is an infusion, TNK is a single push-dose. Thus, you MUST ensure that you have a good, working IV (as there is no pump to beep at you if there is resistance during the infusion).
Case 2: Found Down At Home
(Case presents another AMS patient with right sided weakness and a dilated and sluggishly reactive left pupil. Workup reveals an large L ICH)
- Pearl: there are 5 key principles to managing patients with ICH.
- Pearl: Blood pressure management has been emphasized in the recent AHA/ASA guidelines. It is critical to lower blood pressure smoothly and rapidly to a target of 130-150mmHg (ideal is 140mmHg), which is best achieved with continual blood pressure monitoring and IV infusions whenever possible.
- Pearl: Because ICH has a mass effect, many of these patients develop ICP issues. We love this illustration for thinking through ICP management strategies:
- Pearl: Anticoagulation reversal — have a plan. We talk about this on the ICH podcast and there are some tips in #neuropostitpearls (#24 and #20).
- Cutting Edge: We have yet to find the time interval and technique that will revolutionize ICH evacuation in the same way that clot evacuation revolutionized acute stroke care.
- Ongoing questions are should we remove the blood? How should we remove the blood? and When should we remove the blood
- Exciting techniques that are under investigation include:
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- We plan to have a post soon that explores a little bit more about the conundrum of ICH evacuation and the strategies that are being piloted, like this:
Case 3: Just Alcohol Withdrawal?
(A man with ESRD and alcohol dependence is brought in for AMS. He is hypertensive and combative. He is transferred to the ICU and on arrival has a seizure. Further workup reveals posterior hyerdensities on CT concerning for PRES).
- Pearl: What to think about in a patient with new seizures
- Pearl: Please give enough benzos (Lorazepam 4-8mg or Midazolam/Diazepam 5-10mg) and use an evidenced based dosing for second line agents, thanks for the nice chart, @pulmcrit!
- Cutting Edge: The brain may become more refractory to GABA-oriented treatment as status epilepticus progresses due to GABA receptor composition changes and internalization (the evidence for this is still insufficiently understood and to what degree this matters is debated). That said, there is evidence that Ketamine may be an effective anesthetic agent when GABA-ergic drugs like propofol and midazolam are not effective
- Pearl: Dosing for Ketamine is much higher for status epilepticus than for sedation. Different protocols exist. A recent analysis of ketamine for refractory status epilepticus in children was just published in Neurology, their protocol started at 1mg/kg/hour. At Emory and Mt Sinai, we give a larger starting dose (2mg/kg as a bolus) and then start the gtt at 2mg/kg/hour. If further suppression is needed, doses up to 7 to 8 mg/kg/hour can be used, although there is risk of cardiac toxicity at these high doses.
- There is no robust evidence to support when to start Ketamine (and there is a significant amount of practice variation). It is reasonable to consider starting this when the patient is on ~1-1.6 mg/kg/hour of midazolam without cessation of seizures.
- A nice feature of this study (in the slide above) is that they measured ICP during the ketamine infusion and found no increase in ICP.
(Pearls for PRES as a cause of Status Epilepticus)
- Pearl: PRES may result in focal or generalized seizures. It is a common complication — occurring in up to 2/3 of patients. Management is largely supportive –> withdraw the offending agent, address any underlying causes, and lower blood pressure.
- Pearl: PRES is a misnomer:
- PRES is also not always reversible. It may leave irreversible damage due to ischemia and hemorrhage. Fortunately our patient's seizures were controlled with a combination of propofol and ketamine. He was successfully extubated and a CT head several months later was normal.
Stay tuned for Part 2 of the H&R lecture, to be posted soon, where we'll discuss cortical SAH, RCVS, hypoxic ischemic encephalopathy and neuroprognostication and a framework for coma!
Want an Audio-Only Version?
- EMCrit 336 – Team NeuroEMCrit's Critical Neuro Cases – Part 2 - November 3, 2022
- NeuroEMCrit – Team NeuroEMCrit's H&R Conference Talk, Part 1 - October 3, 2022
- NeuroEMCrit – The Perils of the ICH Score - August 1, 2022
It would be nice if all the podcasts had Cme to go with them
For CTA, what are your thoughts on using an IO if peripheral access for CTA (ex: high suspicion of LVO) is proving to be overly time consuming/difficult?
Great talk. We have given hypertonic saline (100 mL 7.6% NaCl) via peripheral lines in our institution (Töölö Hospital, Finland) for years without any problems. So no need for a central access if in a hurry and the ICP needs to come down!
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