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Managing Neurological Injuries: A Comprehensive Guide

Learn about the effects of neurological injuries, including traumatic brain injury and stroke, and discover strategies for airway and ventilator management in critical care settings. This comprehensive guide covers various conditions and their management approaches.

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Managing Neurological Injuries: A Comprehensive Guide

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  1. Breathing for the Head John Peterson, DO KU School of Medicine - Wichita

  2. Disclosures • I’ve known Alan and Jeff for a while……

  3. Objectives • Neurological injuries • Physiological effects • Airway management • Ventilator management

  4. Neurological injuries • Disturbances in consciousness • Encephalopathy • Traumatic brain injury • Acute Myelopathy • Ischemic stroke • Intracerebral hemorrhage • Subarachnoid hemorrhage • Brain tumors • Status epilepticus • Venous thrombosis • Cerebral Sinus • DVT/PE Bhardway, Anish, et. al., ed, Handbook of Neurocritical Care, 2nd ed. Springer, 2011. pp xi - xiii

  5. Disturbances in Consciousness • Drowsy • Stupor • Minimally conscious state • Vegetative state • Restored sleep/wake cycle • Locked – in syndrome • Coma • Brain death

  6. Encephalopathy • Vascular • Trauma • Neoplasm • Seizure • Organ Failure • Metabolic • Endocrine • Pharmacologic • CNS infection • Systemic infection • Inflammatory and immune – mediated encephalitis Bhardway, Anish, et. al., ed, Handbook of Neurocritical Care, 2nd ed. Springer, 2011, p 289

  7. Traumatic Brain Injury • Primary injury • Secondary injury • May be more injurious • Hypoxia and hypoperfusion most likely are the most critical factors in secondary injury Bhardway, Anish, et. al., ed, Handbook of Neurocritical Care, 2nd ed. Springer, 2011, p 308

  8. Acute Myelopathy • Traumatic • Degenerative spine • Neoplastic • Inflammatory • Systemic disease • Bacterial and viral infections • Vascular • Toxic/Metabolic

  9. Stroke • Defined • Focal neurological deficit that has an arterial distribution that correlates with specific region of the brain

  10. Normal Brain

  11. Ischemic stroke • Focal neurological deficit corresponding to arterial territory • Transient ischemic attack (TIA) • Symptoms resolve in less than 24 hrs • Typically less than 1 hr • Reversible Ischemic Neurologic Deficit (RIND) • Symptoms lasting 24 – 72 hrs Bhardway, Anish, et. al., ed, Handbook of Neurocritical Care, 2nd ed. Springer, 2011, p 341

  12. Ischemic Stroke

  13. Ischemic stroke • Embolic • Cardiac • Artery to artery embolus • Paradoxical embolus • Thrombotic • Intracranial atherosclerosis • Lipohyalinosis • Arterial dissection • Arteritis • Fibromuscular dysplasia • Vasospasm • Hypercoaguable states Bhardway, Anish, et. al., ed, Handbook of Neurocritical Care, 2nd ed. Springer, 2011, p 342

  14. Ischemic Stroke • Modifiable • Diabetes mellitus • Hypertension • Smoking • Hypercholesterolemia • Coronary artery disease • Non-modifiable • Age • Male • Family history Bhardway, Anish, et. al., ed, Handbook of Neurocritical Care, 2nd ed. Springer, 2011, p 342

  15. Intracerebral Hemorrhage

  16. Intracerebral Hemorrhage • 10 – 15% of all strokes • 30 day mortality: 35 – 52% • Only 20% are independent functional at 6 months • Etiology • Primary • Secondary to hypertension • Secondary • Aneurysmal, AVM, Tumor, Amyloidangiopathy, Coagulopathies, Trauma

  17. Intraventricular Hemorrhage

  18. Subarachnoid Hemorrhage • Trauma • Most common cause • Spontaneous • 80% Aneurysmal • 10 – 15% Perimesencephalicnonaneurysmal hemorrhage • 5% Nonaneurysmal • 2 – 5% of all strokes

  19. Subarachnoid Hemorrhage

  20. Vasospasm • Occurs between days 4 -12 • Lasts up to 21 days • Monitoring with transcranial doppler (TCD) • Treatment for symptomatic vasospasm • Triple H • Hypertension • Hypervolemia • Hemodilution • Angiography with balloon dilation or intra-arterial calcium – channel blocker infusion

  21. Epidural Hematoma Subdural Hematoma

  22. Post-Cardiac Arrest Brain Injury • Therapeutic hypothermia • Indicated for out-of-hospital ventricular fibrillation arrest • Possible benefit with asystole and PEA • 55% of the hypothermia group had a favorable outcome vs 39% in the normothermia group • At 6 months 41% of the hypothermia group died vs 55% of the normothermia group Bhardway, Anish, et. al., ed, Handbook of Neurocritical Care, 2nd ed. Springer, 2011, p 393

  23. Venous Thrombosis • Cerebral Sinus • Rare cause of stroke • Thrombophilia is most common cause • Systemic anticoagulation required • DVT/PE • 79% of pulmonary embolism originates from a lower extremity deep vein thrombosis • Neurological conditions predisposing to VTE • Spinal cord injury • Traumatic brain injury • Ischemic stroke • Intracerebral hemorrhage • Malignant glioma Bhardway, Anish, et. al., ed, Handbook of Neurocritical Care, 2nd ed. Springer, 2011, p 433-434, 506-507

  24. Venous Thrombosis • Deep Vein Thrombosis • Risk Factors • Venous valvular insufficiency • Right-sided heart failure • Postoperative period • Prolonged bedrest • Extremity trauma • Malignancy and cancer therapy • Pregnancy and postpartum period • Hormone therapy • Spinal cord injury • History of venous thromboembolism • Hypercoagulable state Bhardway, Anish, et. al., ed, Handbook of Neurocritical Care, 2nd ed. Springer, 2011, p 506-507

  25. Malignant Hyperthermia • Autosomal dominant condition • Triggers • Halogenated inhalational anesthetics • Succinylcholine • Extreme stress, vigorous exercise and heat exposure • Risk Factors • Myopathies Bhardway, Anish, et. al., ed, Handbook of Neurocritical Care, 2nd ed. Springer, 2011, p 437

  26. Malignant Hyperthermia • Signs and symptoms • Unexpected rise in end-tidal CO2 > 55 or PaCO2 >60 • Increased minute ventilation • Unexplained tachycardia, ventricular tachycardia or fibrillation, labile blood pressure, congestive heart failure • Metabolic acidosis with elevated serum lactate • Altered mental status (when anesthetic is stopped) • Generalized muscle rigidity, masseter rigidity (despite neuromuscular blockade), rhabdomyolysis • Acute renal failure • Hyperkalemia • Hyperthermia (Temperature can rise 1 – 2 C˚ q 5 min up to 44˚C) • This is a late finding • DIC • Especially with temp > 41˚C Bhardway, Anish, et. al., ed, Handbook of Neurocritical Care, 2nd ed. Springer, 2011, p 438

  27. Malignant Hyperthermia • Management • Stop offending agent • Admit to ICU • Increase minute ventilation to normalize PaCO2 • Body cooling • NG icy lavage, ice packs, fans, surface or invasive cooling systems • Target temp of 38.5 • Dantrolene • Continue for 3 days IV or PO dosing • Monitor for excessive muscle weakness or hepatotoxicity • Monitor for recrudescence Bhardway, Anish, et. al., ed, Handbook of Neurocritical Care, 2nd ed. Springer, 2011, p 438

  28. Neuroleptic Malignant Syndrome • Risks • Prior physical exhaustion and dehydration • Previous episode of NMS • Exposure to antipsychotic drugs • Signs and symptoms • Develop within 24hrs – 1 month after exposure to antipsychotic drugs • Regression within 1 wk – 1 month after discontinuation of drug • 10% Mortality Bhardway, Anish, et. al., ed, Handbook of Neurocritical Care, 2nd ed. Springer, 2011, p 435-436

  29. Brain Tumors • Second most common cause of death from intracranial disease • 33% overall 5 year survival • 33% of all tumors are gliomas • 67% are high grade • Metastatic tumors are the most common brain neoplasm • Lung (18 – 64%) • Breast (2 – 21%) • Melanoma (4 – 16%) • Colorectal tumors (2 – 12%) • Renal cell carcinoma (1 – 8%) • Lymphoma (< 10%) • Unknown origin (1 – 18%) Bhardway, Anish, et. al., ed, Handbook of Neurocritical Care, 2nd ed. Springer, 2011, p 445-446

  30. Brain Tumors

  31. Brain Tumor

  32. Brain Tumors • Headache • Seizure • Progressive focal neurological deficits • Visual defects • Altered mental status • Intracerebral hemorrhage • Intracranial pressure elevation

  33. Hydrocephalus • Caused by impaired cerebrospinal fluid flow, reabsorption or excessive production • Cerebrospinal fluid • Forms at 0.3mL/min • 20mL/hr • 500mL/day • Total volume ~150mL • 75mL in cranial vault • Normal pressure ~10mmHg Bhardway, Anish, et. al., ed, Handbook of Neurocritical Care, 2nd ed. Springer, 2011, p 469. 471

  34. Hydrocephalus

  35. Hydrocephalus

  36. Neuromuscular Disorders • Acute generalized weakness • CNS • Bilateral hemispheric • Brainstem • Spinal cord • Motor neuron • West Nile infection • Poliomyelitis • Enterovirus infection • Neuromuscular junction • Myasthenia gravis • Lambert-Eaton myasthenic syndrome • Organophosphate poisoning • Botulism • Tick Paralysis • Hypermagnesemia • Snake/insect/marine toxins Bhardway, Anish, et. al., ed, Handbook of Neurocritical Care, 2nd ed. Springer, 2011, p 478

  37. Neuromuscular Disorders • Acute generalized weakness causes cont. • Neuropathies • Guillain – Barré syndromes • Critical illness polyneuropathy • Chronic idiopathic demyelinatingpolyneuropathy • Toxic neuropathies • Vasculitic neuropathy • Porphyric neuropathy • Diptheria • Lymphoma • Carcinomatous meningitis • Acute uremic polyneuropathy • Eosinophilia-myalgia syndrome Bhardway, Anish, et. al., ed, Handbook of Neurocritical Care, 2nd ed. Springer, 2011, p 478

  38. Neuromuscular Disorders • Acute generalized weakness causes cont. • Myopathies • Critical illness myopathy • Dermatomyositis • Polymyositis • Periodic paralysis/hypokalemicmyopathy • Myotonic dystrophy • Acid maltase deficiency • Muscular dystrophies • Mitochondrial myopathies • Corticosteroid-induced myopathy Bhardway, Anish, et. al., ed, Handbook of Neurocritical Care, 2nd ed. Springer, 2011, p 478

  39. Neuromuscular Disorders • Causes of acute respiratory muscle weakness • CNS • Diseases of high cervical cord or medulla • Motor neuron disease • Neuromuscular junction • Myasthenia gravis • Lambert-Eaton myasthenic syndrome • Neuropathies • Idiopathic bilateral phrenic nerve paresis • Guillain-Barré syndrome (rare) • Neuralgic amyotrophy • Large artery vasculitis • Multifocal motor neuropathy • Myopathies • Acid maltase deficiency Bhardway, Anish, et. al., ed, Handbook of Neurocritical Care, 2nd ed. Springer, 2011, p 478

  40. Neuromuscular Disorders • Causes of acute predominantly bulbar weakness • CNS • Brainstem diseases • Bilateral white matter diseases • Syrinx • Motor neuron • Amyotrophic lateral sclerosis • Kennedy disease • Neuromuscular junction • Myasthenic gravis • Lambert-Eaton myasthenic syndrome • Botulism • Neuropathies • Guillan-Barré syndrome (rare) • Carcinomatous meningitis • Skull base tumor or metastases • Miller-Fisher disease • Sarcoidosis • Basilar meningitis • Myopathies • Dermatomyositis • Polymyositis • Oculopharyngeal muscular dystrophy • Myotonic dystrophy • Distal myopathy with vocal cord paralysis Bhardway, Anish, et. al., ed, Handbook of Neurocritical Care, 2nd ed. Springer, 2011, p 479

  41. Neuromuscular Disorders • Acute failure of the autonomic nervous system • CNS • Diseases affecting the hypothalamus, brainstem, medulla, high cervical cord • R insular stroke • Neuromuscular junction • Lambert-Eaton myasthenic syndrome • Botulism • Neuropathies • Diabetic autonomic neuropathy • Amyloid neuropathy • Guillain-Barré with predominant dysautonomia • Paraneoplasticdysautonomia • Connective tissue disorders • Sjogrens • Systemic lupus erythematosus • Infectious • Chagas • HIV • Leprosy • Diptheria Bhardway, Anish, et. al., ed, Handbook of Neurocritical Care, 2nd ed. Springer, 2011, p 479

  42. Neuromuscular Disorders • Indications for ICU admission • Respiratory weakness • FVC < 40ml/kg • NIF < - 40 cmH2O • > 30% decline in FVC or NIF in 24 hrs • Signs of fatigue or dyspnea • Significant neck flexor weakness or poor cough • CXR • Infiltrates, atelectasis or pleural effusion • Dysphagia/inability to protect airway • Increased aspiration risk • Bulbar dysfunction/bilateral facial weakness • Failed swallow evaluation • Autonomic instability • Dysrhythmia • Blood pressure lability • Profound sensitivity to sedatives • Planned interventions • Plasma exchange • Frequent vital checks or intensive nursing care • Rapid onset of symptoms (< 7 days) Bhardway, Anish, et. al., ed, Handbook of Neurocritical Care, 2nd ed. Springer, 2011, p 480

  43. Neuromuscular Disorders • Intubation indications • Consider early intubation • May reduce pulmonary complications • FVC < 20 mL/kg • NIF < - 30 cmH2O • PaO2 < 70 (decrease by > 50% in 24 hrs) on room air • Hypoventilation (PaCO2 > 45) • Dysphagia Bhardway, Anish, et. al., ed, Handbook of Neurocritical Care, 2nd ed. Springer, 2011, p 480

  44. Neuromuscular disorders • Extubation criteria • Pressure support of 5 with PEEP 5 for > 2hrs (prolonged SBT) • Some evidence for PS of 0 with PEEP of 5 or T-piece predicts more successful extubation • Successful secretion management Bhardway, Anish, et. al., ed, Handbook of Neurocritical Care, 2nd ed. Springer, 2011, p 481

  45. Status Epilepticus • A seizure that persists a sufficient length of time or is repeated frequently enough to produce a fixed and enduring epileptic condition • Historically, is defined by a seizure lasting 30 min and should be considered for seizures lasting 5 – 10 min • Nonconvulsant status epilepticus should be considered with coma patients with unclear etiology • May occur in as many as 8 -34% of critically ill patients Bhardway, Anish, et. al., ed, Handbook of Neurocritical Care, 2nd ed. Springer, 2011, p 489

  46. Status Epilepticus • Etiologies • Neurovascular • Tumor • CNS Infection • Inflammatory disease • Traumatic brain injury • Primary epilepsy • Hypoxia/ischemia • Drug/substance toxicity or withdrawl • Fever • Metabolic abnormalities Bhardway, Anish, et. al., ed, Handbook of Neurocritical Care, 2nd ed. Springer, 2011, p 491

  47. Status Epilepticus • Medical treatment • May require inducing a coma • Neuromuscular blockade • Will not stop the seizure, only the motor manifestation • Airway and ventilator management • May not be required for nonstatus seizure • Will be required for induced coma Bhardway, Anish, et. al., ed, Handbook of Neurocritical Care, 2nd ed. Springer, 2011, p 499

  48. Spinal Cord Injury • Trauma is the most common cause • ~ 50% are motor vehicle related • 24% related to falls • 9% sports injury • 11% assault • > 50% involve the cervical spine Bhardway, Anish, et. al., ed, Handbook of Neurocritical Care, 2nd ed. Springer, 2011, p 325

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