HEAD CASES:UPDATES IN CNSEMERGENCIESRobert Vissers MDPortland OR

High Risk Emergency Medicine Hawaii 2012

Objectives• Review critical interventions in high risk neuroemergencies

• Develop rapid, aggressive management of status epilepticus

• Optimize management decisions and reversal of anti-coagulation in ICH

• Discuss stroke management beyond 3 hours• The role of therapeutic hypothermia in brain injury• Does “worst headache” always equal LP?

Still sleeping…• Sent from urgent care for coma care• “She went to bed angry, she won’t wake up”• Unresponsive, normal vitals• Occasional disconjugate gaze, gaze to left, and neck spasm

• Language barrier but hx of being in an ICU for months when this happened before – she wouldn’t wake up

Status Epilepticus• Definition: > 5 minutes seizure or recurrent seizures without return to consciousness

• Injury begins within minutes• Kindling – more difficult to stop the longer it continues

• 20-30% mortality• Up to 1/3 may be non-convulsive

Status Epilepticus: Causes

Age < 16 Age > 16Fever/infection 36% 8%

Cerebrovasc Dz 3% 25%

Med Change 20% 19%

Metabolic 8% 29%

EtOH/Drugs 2% 13%

Only 25% of pts with SE have epilepsy

10% of patients present with SE as 1st manifestationof epilepsy

Therapy in Status Epilepticus• #1: Lorazepam IV

• Peds 0.1 mg/kg bolus X 2• Adults 2-4 mg bolus X 2

• Be aggressive• 90% seizures terminate within 5 minutes with Lorazepam

• No benefit beyond 8-12 mg

Therapy in Status Epilepticus• #2: Phosphenytoin IV

• 20 PE/kg bolus• 150 PE/min

• Be aggressive• 10 minute bolus• 20 minutes to clinical effect

Therapy in Status Epilepticus• #3: Valproate IV

• 20 mg/kg bolus• 5 mg/kg/min

• More aggressive load supported by studies• Over 10 minutes in SE• Lower dose in liver disease

Therapy in Status Epilepticus• OR #3: Levetiacetam (Keppra) IV

• 20 mg/kg bolus• 5 mg/kg/min

• IV formulation now approved• Over 10 minutes in SE• OK in liver disease (renal excretion)• 66% to 100% effective in SE studies

Therapy in Status Epilepticus• OR #4: Phenobarbital IV

• 20 mg/kg bolus• 1-2 mg/kg/min

• Respiratory depression• Likely need intubation• Potential hypotension

Still sleeping…• Loaded with benzos• Phosphenytoin• Intubated for CO2 retention and acidosis• Propofol drip• EEG placed in the ED (took an hour) and patient in non-convulsive status

• Began to wake up in the ED, seizures stopped

Other issues• Consider EEG if paralyzed• Consider non-convulsive/minimally convulsive status in unexplained coma and hx of seizures

• May represent a 1/3 of status epilepticus

• Post intubation sedation:• Propofol 1-2 mg/kg load then 1 mg/kg/hour• Midazolam 5-10 mg load then 0.2mg/kg/hour

SE Summary• SE if > 5 minutes• Be aggressive!• 8-12 mg Lorazepam IV 10 min• Phosphenytoin 10 min• Valproate/Keppra 10 min• Phenobarbital 15-20 min• Consider intubation 15-30 min• EEG

Each 20mg/kg

Case: ICH Management• 62 y.o. male collapsed at his office• Good pulse, increased RR• Non-responsive, non-verbal, not following commands

Case: ICH Management• ED Assessment• Vitals: HR 90, BP 220/120, RR 24, SaO2 94% • General:Unresponsive, non-verbal, gurgling• CVS: Irreg Irreg pulse• Chest: Clear• Abd: Non-distended• Ext: No rash, ecchymosis, or edema• Neuro: Localizes to deep pain, Pupils 5 mm and sluggish bilaterally

Case: ICH Management

ICH: Neurosurgical emergency?• Early surgery beneficial in:

• Cerebellar hemorrhage > 3 cm• Cerebellar hemorrhage with hydrocephalus

• No benefit to early intervention (<30 hours) in supratentorial ICH

Mendelow AD, et al. Early surgery vs initial conservative treatment …(STICH). Lancet, 2005.AHA/ASA guidelines for the management of spontaneous ICH. Stroke, 2010.

ICH: No emergency?

“Looks bad – no point in sending the patient”

• Really? Can nothing be done?• Early DNR leading to self-fulfilling bad outcomes• Recommend early aggressive care and postpone DNR orders until at least the second full day of admission

AHA/ASA guidelines for the management of spontaneous ICH. Stroke, 2010.

ICH: Blood pressure?• “physicians must manage blood pressure on the basis of incomplete efficacy evidence”

• Cerebral Perfusion Pressure 50-70 mm Hg• CPP = (MAP – ICP)

AHA/ASA Guidelines:• Treat systolic > 200 or MAP > 150• Treat systolic > 180 or MAP > 130 if raised ICP suspected

ICH: Blood pressure?AHA/ASA Guidelines:• Treat systolic > 200 or MAP > 150• Treat Systolic >180 or MAP > 130 if ICP suspected

Drug Initial dose InfusionLabetalol 5-20 mg q15 min 2mg/minEsmolol 250 mcg/kg 25-30 mcg/kg/hrNicardipine N/A 5-15 mg/hrEnalapril 1.25-5mg q6h N/ANitroprusside N/A 0.1-10 mcg/kg/min

Case: ICH Management

• Recently started on moxifloxacin for pneumonia

• INR 6.6

PMH Diabetes, atrial fibrillationMeds Coumadin, atenololAllergies PenicillinSocial Occasional alcohol use

ICH: Reversing coagulation?• I don’t have that fancy factor VII• Increased mortality and morbidity • Phase III trial stopped

Increased INR?• Vitamin K 10 mg IV over 10 minutes• FFP 4-6 units • Can start before INR back if known coumadintherapy Mayer SA, et al. Efficacy and safety of factor VII for acute ICH.

NEJM, 2008.

Setting the Vent• Maintain PaCO2 between 35-40 mm Hg• Maintain plateau pressure <30 cm H2O• Elevate head 30°

• Assist control• Tidal volume: 6-8mL kg IBW (500cc)• RR 18-20 (titrate to CO2)• FiO2 100%• PEEP 5 cm H2O

Bad game…• 68 y.o. watching the blazer game with son and complained of arm numbness and weakness

• Family noted slurred speech and facial droop• Shaking of left arm?• Became less responsive en route• In ED unresponsive, no movement• Straight to CT, neuro called prehospital

Non-Hemorrhagic CVA: Stroke update

• Extending the window from 3 to 4.5 hours?• CT or CTA?• Intra-arterial intervention?

Now what?• CT/CTA done in 12 minutes• Neuro – are we sure this is a stroke?• CT negative for bleed• CTA show basilar artery occlusion• TPA ordered, but BP now 196/105• What if it was 4 hours out?• Given TPA – hypotensive, not improving – now what?

The 3-4.5 hour window• Recommended in the 2009 AHA/ASA guidelines to increase tPA therapy for stroke to 4.5 hours

• Some exclusions:• Age > 80• Any patient taking anticoagulants• Baseline NIHSS > 25• Patients with hx of both prior stroke and DM

• CTA or MRI to identify sub groups post 3 hours, with salvageable tissue, underway

CTA

• Good at identifying vascular occlusion site• From above, can prognosticate on potential

area of infarct• Fast, readily available• Downsides:

• Radiation• Dye load• Interpretation

Posterior Circulation Strokes• Do very well – up to 80% have minor or no disability

• Or very badly - Basilar Artery Stroke (BAO) , 20% of posterior strokes, has over a 90% mortality

• Crossed findings – ipsilateral cranial nerves, contralateral motor and sensory

• 5 D’s – dizzy, diplopia, dysarthria, dysphagia, dystaxia

Posterior Circulation Strokes• Intra-arterial thrombolysis in BOA may be life saving

• Window extended to 24 hours in BOA• Up to 50% improvement in mortality

Intra-arterial intervention• Recent Cochrane Review, Stroke, 2011• Systematic review controlled randomized trials (4)• Lytics vs Intervention by 6 hours:

“Overall, intervention results in a significant increase in the proportion of patients with a

favorable outcome despite a significant increase in intracranial hemorrhage”

New ACLS

Play to WinGoal should be neurologically intact

discharge from hospital.

Cardiac arrest• 52 y.o. male witnessed collapse (on stage at a hemp festival)

• No pulses• CPR started• VF, shocked by EMS• Epi X 1• ROSC• King LT placed

Cardiac arrest: The rise of “C”“C” Circulation and Cerebral Outcome

precedes Airway and Breathing

Cardiac arrest: CompressionsKey to success:• High quality, uninterrupted chest compressions

• Airway can wait• Passive ventilation may be superior to positive pressure ventilation

• Consider supraglottic airway without interruption

Bobrow BJ, et al. Passive oxygen insufflation of oxygen superior to BVM for witnessed VF arrest. Ann Emerg Med, 2009.

Cardiac arrest: Cooling• Unconscious adults out-of-hospital cardiac arrest • Cool to 32-34° C for 24 hours

• Cooling catheters• Ice packs • Cooling blankets• Cooled NS 4° C

ROSC: Cool to be cool• Ice Packs applied to groin, axilla, neck• Cools about 0.2-1° C/Hour

ROSC: Cool to be cool• Cooling blankets, circulating cooled water with material to promote heat exchange may be best

• Cool 1-1.5°/hour

ROSC: Cool to be cool• Can achieve adequate cooling with combination• Remove ice packs when 33° C reached and maintain with blankets

• Number to treat for one survivor to leave hospital neurologically intact 4-13

Nolan JP, et al. therapeutic hypothermia after cardiac arrest: and advisory statement. Resuscitation, 2003.

Really? Worst ever?• 39 y.o., with headache.• Bad. Real Bad. 10/10.• “Worst ever.”• Normal vitals.• Normal CNS exam.• Morbidly obese.• PMHx IBS, fibromyalgia, interstitial cystitis

Your Worst Headache: SAH

• CT?• LP?• CTA?• MRI?

SAH• All have headache, sudden, “thunderclap”, “worst of life”

• Signs of meningeal irritation 80%• Sudden LOC up to 45%• Seizure 10-25%• Onset during exertion 60-70%

SAH• Global or focal neuro findings in 25-50%• Most commonly cranial nerve finding, particularly oculomotor nerve palsy with ipsilateral mydriasisfrom PCA aneurysm

Decision rule for SAH• > 40 years old• Witnessed LOC• Neck pain or stiffness• Onset with exertion• Ambulance arrival• Vomiting• Diastolic BP > 100, Systolic > 160

• Perry JJ, Stiell IG, Sivilotti ML, Bullard MJ, Lee JS, EisenhauerM. High risk clinical characteristics for subarachnoid haemorrhage in patients with acute headache: prospective cohort study. BMJ. 2010;341:c5204.

Decision rule for SAH• If one or more present • AND acute onset headache reaching maximal intensity in the first hour – SAH should be investigated

• Perry JJ, Stiell IG, Sivilotti ML, Bullard MJ, Lee JS, Eisenhauer M. High risk clinical characteristics for subarachnoid haemorrhage in patients with acute headache: prospective cohort study. BMJ. 2010;341:c5204.

Let’s try it….• > 40 years old • Witnessed LOC • Onset with exertion • Ambulance arrival • Vomiting • Diastolic BP > 100, Systolic > 160 • Neck pain or stiffness

But what about the duration?• Started 8 hours ago• Can negative plain CT rule it out?

CT Sensitivity• 100% within 6 hours• 93% within 24 hours• 80% at 3 days• 50 % at one week

LP Sensitivity• Negative in first few hours• By 12 hours 100% have xanthochromia• Present for 2 weeks, 70% present at 3 weeks• Spectrophotometry much more sensitive than naked eye

• Negative in 10-15% of SAH

CTA Sensitivity• CTA 98% sensitive for aneurysm• CT/CTA may have > 99% sensitivity for aneurysm• More informative study if positive• Less invasive, less negotiation• Superior to MRI/MRA

• McCormack RF, Hutson A. Can computed tomography angiography of the brain replace lumbar puncture in the evaluation of acute-onset headache after a negative noncontrast cranial computed tomography scan?. AcadEmerg Med. Apr 2010;17(4):444-51.