Neurological Neurological FailureFailure

73 year old man is transferred to the ICU 73 year old man is transferred to the ICU postop after emergency AAA surgery. He postop after emergency AAA surgery. He is hemodynamically stable. Two days is hemodynamically stable. Two days later, he is weaning from the ventilator later, he is weaning from the ventilator and the nurse calls you.and the nurse calls you.

The patient is fighting with the ventilator, The patient is fighting with the ventilator, thrashing about and hypertensive.thrashing about and hypertensive.

When you arrive, he is trying to sit up and When you arrive, he is trying to sit up and will not obey commands. He looks at you will not obey commands. He looks at you like you are the devil himself.like you are the devil himself.

This man clearly has an altered level of This man clearly has an altered level of consciousness. What is the definition for delirium?consciousness. What is the definition for delirium? Disturbance of consciousness with reduced ability to focus, Disturbance of consciousness with reduced ability to focus,

sustain, or shift attention. sustain, or shift attention. A change in cognition or the development of a perceptual A change in cognition or the development of a perceptual

disturbance that is not better accounted for by a pre-disturbance that is not better accounted for by a pre-existing, established, or evolving dementia. existing, established, or evolving dementia.

The disturbance develops over a short period of time The disturbance develops over a short period of time (usually hours to days) and tends to fluctuate during the (usually hours to days) and tends to fluctuate during the course of the day. course of the day.

There is evidence from the history, physical examination, There is evidence from the history, physical examination, or laboratory findings that the disturbance is caused by a or laboratory findings that the disturbance is caused by a medical condition, substance intoxication, or medication medical condition, substance intoxication, or medication side effect. side effect.

How is it different from coma?How is it different from coma? Coma is a clinical states in which patients have impaired Coma is a clinical states in which patients have impaired

responsiveness (or are unresponsive) to external responsiveness (or are unresponsive) to external stimulation and are either difficult to arouse or are stimulation and are either difficult to arouse or are unarouseableunarouseable

Coma is defined as "unarousable unresponsiveness"Coma is defined as "unarousable unresponsiveness"

What is the differential diagnosis for delirium?What is the differential diagnosis for delirium? Toxins Toxins

Drugs: Drugs: Prescription medications, polypharmacy Prescription medications, polypharmacy Drugs of abuse including alcohol intoxication or withdrawal, narcotics, Drugs of abuse including alcohol intoxication or withdrawal, narcotics,

cocaine, LSD, and phencyclidine cocaine, LSD, and phencyclidine Infection: sepsis, systemic infections Infection: sepsis, systemic infections Poisons: ethylene glycol, methanol, insecticides, carbon monoxide, etc. Poisons: ethylene glycol, methanol, insecticides, carbon monoxide, etc.

Metabolic derangements Metabolic derangements Electrolyte disturbance (elevated or depressed): sodium, calcium, Electrolyte disturbance (elevated or depressed): sodium, calcium,

magnesium, phosphate magnesium, phosphate Endocrine disturbance (depressed or increased): thyroid, parathyroid, Endocrine disturbance (depressed or increased): thyroid, parathyroid,

pancreas, pituitary, adrenal pancreas, pituitary, adrenal Hypercarbia Hypercarbia Hyperglycemia and hypoglycemia Hyperglycemia and hypoglycemia Hyperosmolar and hypoosmolar states Hyperosmolar and hypoosmolar states Hypoxemia Hypoxemia Inborn errors of metabolism: porphyria, Wilson's disease, etc. Inborn errors of metabolism: porphyria, Wilson's disease, etc. Nutritional: Wernicke's encephalopathy, vitamin B12 deficiency, possibly Nutritional: Wernicke's encephalopathy, vitamin B12 deficiency, possibly

folate and niacin deficiencies folate and niacin deficiencies

Brain disorders Brain disorders CNS infections: encephalitis, meningitis, brain or epidural abscess CNS infections: encephalitis, meningitis, brain or epidural abscess Epileptic seizures, especially nonconvulsive status epilepticus* Epileptic seizures, especially nonconvulsive status epilepticus* Head injury* Head injury* Hypertensive encephalopathy Hypertensive encephalopathy Psychiatric disorders* Psychiatric disorders*

Systemic organ failure Systemic organ failure Cardiac failure Cardiac failure Hematologic: thrombocytosis, hypereosinophilia, leukemic blast cell Hematologic: thrombocytosis, hypereosinophilia, leukemic blast cell

crisis, polycythemia crisis, polycythemia Liver failure: acute, chronic Liver failure: acute, chronic Pulmonary disease, including hypercarbia and hypoxemia Pulmonary disease, including hypercarbia and hypoxemia Renal failure: acute, chronic Renal failure: acute, chronic

Physical disorders Physical disorders Burns Burns Electrocution Electrocution Hyperthermia Hyperthermia HypothermiaHypothermia Trauma: with systemic inflammatory response syndrome, *head injury, Trauma: with systemic inflammatory response syndrome, *head injury,

fat embolism fat embolism

What are some of the risk factors for the What are some of the risk factors for the development of delirium?development of delirium? Consider: underlying brain diseases, Consider: underlying brain diseases,

polypharmacy, advanced age and sensory polypharmacy, advanced age and sensory impairmentimpairment

How would you investigate this patient?How would you investigate this patient? What pharmacological and non-What pharmacological and non-

pharmacological treatments can be used pharmacological treatments can be used to manage this patient?to manage this patient?

Later that day…Later that day…

A 50 year old man presents to the A 50 year old man presents to the emergency department with the emergency department with the worse headache of his life.worse headache of his life.

Over 30 minutes he becomes Over 30 minutes he becomes progressively obtunded to the point progressively obtunded to the point of coma.of coma.

After intubation for airway control, After intubation for airway control, he has a CT scan.he has a CT scan.

What is the problem?What is the problem? What is the cause?What is the cause? How does it usually present?How does it usually present? How is the diagnosis made?How is the diagnosis made? What treatments (supportive and What treatments (supportive and

definitive) are available?definitive) are available? What complications can occur?What complications can occur?

Still later that day…Still later that day…

A 50 year old man presents to the A 50 year old man presents to the emergency department with the emergency department with the worse headache of his life.worse headache of his life.

Over 30 minutes he becomes Over 30 minutes he becomes progressively obtunded to the point progressively obtunded to the point of coma.of coma.

After intubation for airway control, After intubation for airway control, he has a CT scan.he has a CT scan.

What is the problem?What is the problem? What is the cause?What is the cause? How does it usually present?How does it usually present? How is the diagnosis made?How is the diagnosis made? What treatments (supportive and What treatments (supportive and

definitive) are available?definitive) are available? What complications can occur?What complications can occur?

At 2:30 in the morning…At 2:30 in the morning…

A 19 university student presents to A 19 university student presents to the health centre with increasing the health centre with increasing confusion and headache over the last confusion and headache over the last 24 hours.24 hours.

On examination, he has a blood On examination, he has a blood pressure of 91/43, heart rate of 140, pressure of 91/43, heart rate of 140, respiratory rate of 23, temperature of respiratory rate of 23, temperature of 40.1 and oxygen saturations of 89%.40.1 and oxygen saturations of 89%.

He is delirious and has a diffuse rash.He is delirious and has a diffuse rash.

What is the most concerning diagnosis What is the most concerning diagnosis on the differential?on the differential?

What treatments should be initiated What treatments should be initiated immediately?immediately?

What is the role for steroids in What is the role for steroids in meningitis?meningitis?

What are the most common causative What are the most common causative organisms?organisms?

What other adjuvant treatment should What other adjuvant treatment should be considered for this patient?be considered for this patient?

Then your pager goes off Then your pager goes off (again)…(again)…

You are call to the neurology ward for You are call to the neurology ward for a 29 year old woman with a long a 29 year old woman with a long history of temporal lobe epilepsy.history of temporal lobe epilepsy.

She was admitted for EEG monitoring She was admitted for EEG monitoring and planned surgery. Her medications and planned surgery. Her medications have been stopped for four days.have been stopped for four days.

Upon your arrival, she has been Upon your arrival, she has been having generalized tonic clonic having generalized tonic clonic seizures for 10 minutes.seizures for 10 minutes.

What are your immediate concerns?What are your immediate concerns? What is the definition of status What is the definition of status

epilepticus?epilepticus? Why is this an emergency?Why is this an emergency? After 8 mg of ativan, she is still seizing.After 8 mg of ativan, she is still seizing. What do you do now?What do you do now? Describe the approach to the treatment Describe the approach to the treatment

of status epilepticus.of status epilepticus.

Next is a STAT trauma Next is a STAT trauma call…call…

19 year old man is involved in a two 19 year old man is involved in a two car MVC. car MVC.

His GCS at the scene is 3 and he is His GCS at the scene is 3 and he is intubated and resuscitated.intubated and resuscitated.

Upon arrival in the trauma room, he Upon arrival in the trauma room, he is hemodynamically stable with no is hemodynamically stable with no major injuries. He remains a GCS 3.major injuries. He remains a GCS 3.

He is taken urgently for CT head.He is taken urgently for CT head.

SidebarSidebar

Identify the findings on the Identify the findings on the following CT scansfollowing CT scans

Back to the caseBack to the case

The patient is seen by the The patient is seen by the Neurosurgery service and they insert Neurosurgery service and they insert an intraventricular drain. He is then an intraventricular drain. He is then transferred to the ICU.transferred to the ICU.

What is the purpose of an What is the purpose of an intraventricular drain?intraventricular drain?

What is the cerebral perfusion What is the cerebral perfusion pressure?pressure?

Describe the Monroe-Kelly doctrine,Describe the Monroe-Kelly doctrine,

Later in the evening, the nurse calls Later in the evening, the nurse calls you because the ICP is 45 for the last you because the ICP is 45 for the last 20 minutes.20 minutes.

What are some of the causes of What are some of the causes of intracranial hypertension?intracranial hypertension?

How would you emergently manage How would you emergently manage this problem?this problem?

What is secondary injury and why is it What is secondary injury and why is it important?important?

Questions??Questions??