Keppra Critical care Use
Using Keppra in special situations All off label ref: Uptodate Craniotomy, seizure prophylaxis 500 mg bid iv, up to 3 gram per day Status epilepticus Loading dose 1 to 3 gram at 5 mg/kg/minute or 50 mg/kg over 15 minutes, up to 4.5 gram followed by maintenance dose Subarachnoid...
ICH Post tpa bleed
ICH Bleed after given TPA Get CBC, PT, aPTT, fibrogen level Type and match Cryoprecipitate 10 units over 30 minutes Tranexamic acide 1 gram over 10 minutes or Aminocaproic acid 4 gram over 1 hour...
ICH Subdural Hematoma
Bleeding into the space outside the brain under the dura. Acute SDH – caused by tear of bridging veins, rarely from small cortical arterial bleed Chronic SDH: form a hydroma Acute on chronic SDH: from rebleed Risk factors Older age alcohol abuse previous traumatic brain injury more often in...
Neuro Calculators
Stroke and Critical care risks NIH Stroke scale CHA2DS2VASc Stroke Risk Modified Rankin Scale ASPECTS – Alberta Stroke Program Early CT score Glasgow Coma Scale Seizure – anticonvulsant calculator Phenytoin Correction Cognitive evaluation RASS – Richmond agitation sedation scale MMSE – Mini Mental status exam MOCA – Montreal Cognitive...
ICU-Pain, agitation, delirium
PAD = Pain, agitation, delirium Pain Multimodal analgesia likely to reduce opiod use Acetaminophen: oral and rectal Low dose Ketamine: 0.5 mg/kg iv then 1-2 mcg mcg/kg/min infusion may cause hallucination & delirium Neuropathic pain: Gabapentin 15/mg/kg/d in divided dose Pregabalin 150 mg/d NSAID, iv lidocaine not recommended Agitation/Sedation...
Hypoxic-ischemic Encephalopathy
Prognosis assessment Prognosis based on history: Out of hospital cardiac arrest 44% survive initially 30% alive at 24 hours 13% at 1 month 6% after 6 months CPR over 15 minutes No patient survive > 6 weeks Other variables for poor prognosis age >70 renal failure prior to event...
Delirium
Definition Alteration of consciousness unable to focus agitation, overactivity tremulousness and hallucinations Prevention Avoid multiple medications, dehydration, immobilization, sensory impairment, sleep disruption treat underlying illness if severe disruptive behavior: low dose short acting agent, see below Modify risk factor: Orientation: clock, calendar, window with outside view, visits by friends...
Dysequilibrium Syn
Dialysis dysequilibrium syndrome A clinical diagnosis, no specific diagnostic test. Need to rule out other causes Main symptoms: headache, nausea, blurred vision, restlessness If severe; decreased Level of consciousness. seizure, coma Seen in patients first started on dialysis or missed multiple dialysis Risk factors BUN over 175 extremes of...
Cerebellar hemorrhage
Consider surgical treatment if hemorrhage is over 3 cm in diameter, or volume over 15 cm square deteriorating neurologically or Brainstem compression or hydrocephalus...
NOAC associated bleeding
Time Anticoagulation effect resolved 5 half live since last dose Dabigatran (Pradaxa): 2.5 to 3.5 days Rivaroxaban (Xarelto): 1-2 days Apixaban (Eliquis): 1.5 to 3 days Management Discontinue medication Specific reversal agent Dabigatran: idarucizumab (Praxbind) initial dose 2.5 g iv, repeat in 20 min, total of 5 g Apixaban,...