PGY2 - NSICU Rotation

Preceptor

Dr Newey

Before you start

Contact Amy Renner to schedule your call schedule. You have 4 calls: 1 Monday, 2 Fridays, and 1 Weekend.

Requirements

Learn neurocritical care of patients after ischemic and hemorrhagic strokes, status epilepticus and other neurological diseases.

Contacts

• Mara Bowman, PA 330-242-9722

• Niki Carlton, PA 330-839-5618

• Kyle Maxey, PA 330-420-5855

• Amy Renner, NP 216-645-7039

Tips

• One of the neurology APPs should meet you on first day to exchange numbers, discuss call and give you a quick orientation.

• PA/NP will typically see floor consults, you will generally be in NSICU will do all H&Ps for new patients and admission orders, use neuro icu order sets based on patient diagnosis. Round around 9 am (Dani) and 10 am (Wachsman) to noon. Afternoons notes and admissions etc. PA/NP will do transfers and discharges. Patients will be transferred in from the NIL (neuro interventional lab), these patients need H&P and orders. Check who is primary, sometimes will get trauma primary patients in NSICU and we do not get involved unless consulted.

• Attend all stroke team alerts- if they are going to be admitted to NICU you will be responsible for the H&P and admitting orders. If they will be admitted to floor (or stay on the floor for inpatient) the APP will handle the consult note.

• On Thursday AM you will have APP coverage in NICU to help cover while you are in didactic. Please communicate with them about patient issues and who still needs to be rounded on.

• During the week the NICU, CVICU, SICU and MICU patients are rounded on by you and the attending.

• If there are 2 APPs during the weekday, they will help transfer patients and DC patients. Please communicate with them who these people are. This is to allow you the opportunity to focus on learning. Please take advantage of this service

• Brittany our PharmD has didactic on 2nd and 4th Tuesday of the month. If you are here, it is expected you will be present.

• NIH Stroke Scales should be documented everyday, however it needs to be documented on Day #1,2,3 and discharge.

• There is an APP and on-call schedule posted by the unit clerk

• For the majority of daily progress notes use "Prb Orient Doc." use the care coordination note for the HPI only. Use Hospital course for a overview of daily events. Update the problem list as well as provided plans for each problem item. Mark section as reviewed on the click generate note degenerative daily note. The SmartText for progress notes is "Neuro ICU progress note IP progress note."

• For Neuro H&P notes use "Prb Orient Doc." click the "History and Physical" tab at the top. Copy prior HPI from prior ED or hospitalist note. Then click "Subjective and Objective Note." Press F2 and select "Neuro ICU H&P" then select the "Stroke Care Path" for hemorrhagic or ischemic stroke or "H&P regular". Press F2 to work your way through the note template.

• For all admissions to the neuro ICU make sure to order daily magnesium levels, phosphorus levels, CBC with platelets, BMP. Also order one time hemoglobin A1c, lipid panel, echocardiogram with bubble study.

• For Neuro ICU consult notes use the "Neuro consult notes CCHS" and for consult progress notes use "neuro consult progress note SOAP CCHS" SmartText.

• For transfer notes use "Neuro ICU transfer note" SmartText.

• Blood pressure goals rules of thumb

  • ICH/ post operative→ SBP <160

  • Subarachnoid hemorrhage; pre-fixation → SBP <140

  • Ischemic stroke → post tPA <180/105 (24 hours)(if no tPA permissive HTN keep less than 220)

  • Following ICA stenting→ permissive hypotension (patients brain used to higher pressure, if BP too high can cause hyperperfusion injuries)

• Seizure prophylaxis (typically keppra)

  • Severe TBI (GCS <8 or abnormal CT head) → HOB 30 degrees, SBP <160, keppra 7 days

  • Subarachnoid hemorrhage (3-5 days)

  • No indication for seizure ppx if ICH or ischemic stroke

• Subdural indication for OR: 5 mm shift or >1 cm thick

• ICH indication for OR

  • Volume of hemorrhage >30 ml (volume of sphere 4/3 pi r3)

  • Take axial 2 dimensions and then scroll to bottom of hemorrhage and count number of clicks to top of hemorrhage, take this number and multiply by 0.5 (5 mm slices)

• Imaging

  • New onset ischemic strokes get MRI/MRA Hemorrhagic strokes get repeat CT of the head (rCTH) in 6 hours and usually also next day too + CTA and MRI New neuro changes overnight on call, call attending and generally get imaging as rule of thumb, always go and see the patient, trust your nurses they pick up very subtle changes.

• Mechanical thrombectomy

  • Ischemic stroke caused by a large artery occlusion in the proximal anterior circulation who are evaluated at stroke centers that do not use automated infarct volume determination 6-24 hours of time last known well AND there is a clinical-ASPECTS mismatch (i.e. NIHSS 10 or greater)

  • If the facility is a center using automated infarct determination and can start treatment within 6 to 24 hours of time last known well and there is a clinical-core mismatch defined by dawn trial or imaging target mismatch as defined by DEFUSE 3 trial and can start treatment within 6 to 16 hours

  • You can do this procedure even if they already had tPA

• Post cardiac arrest consults

  • (General plan) Hypothermia Protocol 33-36 (35); shiver protocol (diprivan, roc, high dose buspar for shivering) x24 hours then once warmed maintain normothermia x72 hours. (limit sedation and paralytics) CT Head to assess for structural abnormality. Avoid nitroprusside/nitroglycerin as this will cause cerebral vasodilation and increased risk for elevated ICP. Maintain normocarbia/normoxia. MRI 3-7 days post arrest. Get ECHO, TnI, EKG, lactate.

• Valproic acid toxicity treatment

  • Levocarnitine - 100 mg/kg initial bolus followed by a 50 mg/kg maximum of 3g intermittent infusion over 15 to 30 minutes every 8 hours.

  • Continue until the levels of ammonia are decreasing and clinical improvement is evident

• Status epilepticus management

  • Start with bzd (max dose per administration ativan 8 mg)

  • If no improvement redose

  • Still no improvement start fosphenytoin 20 mg/kg PE (note fosphenytoin is 1.5 mg of 1mg phenytoin and therefore 1 PE) run at a rate of 100 mg/min older patients or 50 mg/min if younger

  • If still no improvement can intubate, propofol, ketamine and BZD help suppress subclinical seizures but it is important to note that BZD when tapered can lead to rebound seizures (makes sense- withdrawal)

  • If you have patients on propofol for longer period of time i.e. >2 days get TG levels if they are around 400 or higher they are at high risk for PRIS (propofol related infusion syndrome) and will develop reduced cardiac function (risk is also higher for younger folks); also important to note that pentobarbital can also cause cardiac dysfunction.

  • Depakote off label 20 mg/kg and 10 mg/kg/min; keppra for maintenance later but not initially

  • Maintenance with propofol (usually start around 55/hr) or ketamine (1-2 mg/kg bolus and up to 4 mg/hr (ordered in mcg/kg/hr) maintenance)

• Management of acute ICP elevations with intraventricular hemorrhage etc.

  • GCS <8 intubate and RSI with fentanyl/lidocaine to reduce ICP

  • HOB 30 degrees, Hyperventilate

  • 1 g phenytoin or keppra

  • 1-1.5 g/kg/dose mannitol or hypertonic saline (bolus 100-->250 (or 300) ml 3% 100 cc over 10 minutes) (saline better if don't know renal function), then start infusion of hypertonic saline at 1 ml/kg/hour (if no central line can start 2% at the same rate with bolus or continuous infusion) need q 6 hour sodiums. Target sodium is 145 → 155 in setting of elevated ICP

  • If bleeding in 3rd ventricle concern for possible obstructive hydrocephalus which would be neurosurgical indication Posterior fossa syndrome

    • Collection of symptoms following surgical excision of a mass in the brain stem region and usually occur as soon as 24 hours after surgery

      • Aphasia, Mutism, Dysphagia, Ataxia, Eye movement issues, Nausea and Emesis

    • Treatment - Valium and zofran. Nimodipine is indicated for aneurysmal SAH (not for traumatic!) dose is 60 mg every 4 hours for 21 consecutive days; goal is to reduce vasospasm and subsequent ischemic injury in setting of blood (irritant)

• The neurology list can be found under "System Lists – AK", "AK Provider Groups", "AK Neurology".

Readings and Resources

• The Golden Hour of the Neurological Emergencies - Dr. Dani suggests reading this to understand neurological emergencies