table of contents2007 - 3 - residents of neurology: welcome to the department of neurology service....
TRANSCRIPT
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TABLE OF CONTENTS
Introduction ………………………..…………….………….... 3 Frequently called numbers …………………………………. ... 4 Department phone numbers ……….……………………….. ... 5 Dictation formats…………………………………………….... 6-7 PNS Anatomy………………………..…………………….. .... 8-20 Brain sections………………………………………........... ...... 21-25 NIH stroke scale. …………………………………………....... 26-37 SAH classification …………………………………… …….... 38 Level of consciousness……………………………………....... 38 Motor Assessment scale ……………………………................ 38 Glasgow Outcome scale………………………………. ……... 38 Glasgow Coma scale ………………………………………..... 39 rt-PA dose …………………………………………………. .... 40 Indications/Contraindications for rt-PA in stroke ……….. ….. 40-41 Acute Ischemic Stroke/TIA Clinical Guideline ……………. ... 42-43 Indications for Heparin therapy ……………………………. ... 44 Management of acute ischemic stroke …………………….. .... 45 Management of blood pressure in stroke ………………….. .... 46 Management of ischemic edema …………………………....... 46 Classification of aphasia ……………………………………. .. 47 Indications for CT Angiogram in ER ........................................ 48 Angiogram Orders …………………………………………..... 49 CSF Testing & Antibiotics used in Treatment of Bacterial Meningitis ……………………………………………………………….... 50-51 Antibiotic Therapy for Specific Bacterial Pathogens………. ... 52 Treatment of Herpes Encephalitis …………………………..... 52 Acute Multiple Sclerosis protocol …………………………..... 53 McDonald Criteria …………………………………............. ... 53 Dementia work-up …………………………………………. ...54 Mini-Mental exam ..................................................................... 55 Alcohol Withdrawal Medications…………………… ……. .... 56 Different MR signals ………………………………………..... 57 Hemorrhage on MRI ………………………………………. .... 57 Management of Status Migrainosus ………………………...... 58 Drugs Used in Migraine & DHE Protocol ………………… ... 58-60 Side Effects of Antidepressants ………………………… ........ 61
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Status Epilepticus Treatment for Adults ……………………. .. 62-66 Pentobarbital.............................................................................. 67 Standard Immunotherapy .......................................................... 68 IV immunoglobulin protocol .................................................... 69 Plasmapheresis protocol ............................................................ 69 Drugs that Increase Weakness in Myasthenia Gravis................ 70 Osserman’s Classification & Tensilon Test Protocol ................ 71 Orders for AIDP ........................................................................ 72 Diagram of Vital Capacities in Fatigue ..................................... 73 Algorithm for appearance of Dilated Pupils .............................. 74 Staging of Parkinson’s Disease ................................................. 75 Brain Death Protocol ................................................................. 76-77 Clinical References for Cerebrospinal Fluid Values.................. 78 Predicting Outcome from Hypoxic Ischemic Encephalopathy.. 79 Management of Concussion in Sports ....................................... 80-81 Prediction of Outcome in Comatose Survivors after Cardiopulmonary Resuscitation................................................. 82-85 .
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Residents of Neurology: Welcome to the Department of Neurology Service.
This book was designed to be a handy reference
that will fit in the pocket of your white coat. It
contains a variety of information, which we hope
will be useful to you in caring for patients. Given
that this is a continuous work in progress, if you
have any corrections or suggestions for other
topics that you think should be included, please let
us know. The Neurology Faculty
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Frequently Called Numbers Admitting .............................................................................3881 Campus Police ......................................................................3770 CT Scan ...............................................................................4542 ER ……………………………………….............................3888 Heart Station …………………………….............................3925 Inpatient Transfer Line .........................................................3888 Laboratory ……………………………… ............................3470 Library …………………………………..............................4225 MRI …………………………………….. ............................3933 Med. Design …………………………… .............................5389 Medical Records ………………………...............................3754 Medicine………………………………. ..............................3685 Neurodiagnostic (EEG,EO,IOM)………..............................3931 Neurology Outpatient Clinic …………................................3760-3787 Neurology Secretary……………………..............................3544 Neuropsychology …………………….... .............................5679 Neurosurgery …………………………................................3547 Pain Center …………………………….. .............................3666 Pharmacy ………………………………..............................3898 Psychiatry ……………………………….............................5695 PT, OT, Speech Pathology …………….. .............................5040 Stroke beeper …………………………................................444-1302 Activation ……………………........................................9999 Cancellation …………………… ....................................0000 Standby ……………………….. .....................................5555 Surgical Pathology …………………….. .............................3485 Transcranial Doppler …………………................................3544 Vascular laboratory ……………………. .............................3935 2-Surgical ICU ………………………… .............................4987 3A- ICCU ……………………………….............................4981 3B- ICCU ……………………………….. ...........................4975 3C- ICCU ……………………………… .............................4900 3D- MCCU ……………………………...............................4980 3D- Neuro ICU ………………………….............................4955 4AB- Medicine/Surgery ……………….. .............................4961 4CD – Ortho/Renal ...............................................................3731 5A- Surgery/Step down ………………………….. ..............4928 5B – Medicine/Surgery.........................................................4943 5CD- Neurology/Stroke Unit ………... ................................4950 6A – Geri Psych....................................................................6767 6B ICCU overflow................................................................4930 6CD- Rehab …………………………..................................6805
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Department of Neurology Academic Secretaries.............................................. 3544, 6187 Clinic ...................................................................... 3760, 6015 EEG Lab ................................................................ 3931 EMG Lab ............................................................... 4379 Epilepsy Center....................................................... 6783 FAX ........................................................................ 3093 Residents’ Library .................................................. 3972 Residents’ Room..................................................... 3843, 3848
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Dictation Formats What to dictate for Admission History& Physical
Chief complaint & reason for admission to the hospital. History of Present Illness including these elements: Location of problem Quality of problem Severity of problem (scale of 1-10) Duration of problem Timing of problem Context of problem
Modifying factors (exacerbating or relieving factors)
Associated signs and symptoms Past Medical History Social History Review of Systems- include each category: Constitutional Eyes Ears, Nose, Mouth, Throat Cardiovascular Respiratory Gastrointestinal Genitourinary Integumentary Musculoskeletal Neurological Hematologic/Lymphatic Allergic/Immunologic Psychiatric Endocrine
General physical Exam (body areas): Head, including face Neck
Chest, including breast and axillae
Abdomen Genitalia, groin, buttocks Back, including spine Each extremity Specific Organ Systems: Constitutional Eyes Ears, nose mouth, throat Cardiovascular Respiratory Gastrointestinal Musculoskeletal Skin Neurological Psychiatric Hematologic Lymphatic Immunologic Review the number of diagnoses or treatment options. Discuss the amount and/or the complexity of the data to be reviewed. State the orders, tests, and plans, for the patient while hospitalized.
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What to Dictate for Discharge Summary:
1. Identify yourself. 2. Patient name, please spell. 3. Patient unit number (6 digit # in the upper right corner of face sheet).
4. Discharge date- IMPORTANT.
5. Narrative summary (clinical resume of significant findings and events of
hospitalization) to include: a. Reason for admission b. Pertinent findings c. What was done d. Condition on discharge, to include (2-3 sentence synopsis):
i. Why patient was admitted ii. What was done
iii. Result of treatments
6. Hospital complications. 7. Consultations obtained.
8. Disposition (home, transfer to another facility, or expired).
9. Recommendations on discharge:
a. Discharge instructions b. Medication changes since admission c. Diet d. Activity e. Follow-up (who to follow-up with and when).
Make sure a copy of the Discharge Summary goes to any treating physician or referring doctor.
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Dermatomes
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Dermatomes
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Brachial Plexus
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Median Nerve
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Median Nerve
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Ulnar Nerve
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Musculocutaneous (A) and Ulnar (B) Nerve
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Ulnar Nerve
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Sciatic Nerve
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Peroneal Nerve
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Tibial Nerve
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Myotomes (arm) Anterior Primary Rami C5 C6 C7 C8 T1
ROXIMAL NERVES Rhomboid Major/Minor (Dorsal Scapular) Supra/Infra Spinatus (Suprascapular) Deltoid (Axillary) Biceps Brachii (Musculocutaneous)
RADIAL NERVES Triceps Anconeus Brachioradialis Extensor Carpi Radialis Extensor Digitorum Communis Extensor Carpi Ulnaris Extensor Pollicis Brevis Externsor Indicis Proprius
MEDIAN NERVES Pronator Teres Flexor Carpi Radialis Flexor Pollicis Longus Pronator Quadratus Abductor Pollicis Brevis
ULNAR NERVES Flexor Capri Ulnaris Flexor Digitorum Profundus Med) Abductor Digiti Minimi Adductor Pollicis First Dorsal Interosseus Posterior Primary Rami C5 C6 C7 C8 T1 Cervical Paraspinals High Thoracic Paraspinals
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Myotomes (leg)
PROXIMAL NERVES L2 L3 L4 L5 S1 S2Iliacus Adductor Longus (Obturator) Vastus Laterlais/Medials (Femoral) Rectus Femoris (Femoral) Tensor Fascia Lata (Gluteal) Gluteus Medius (Gluteal) Gluteus Maximus (Gluteal)
SCIATIC NERVES Semi Tendinosus/Membranosus (Tibial) Biceps Femors (SHT.HD) (Peroneal) Biceps Femoris (Long HD) (Tibial)
PERONEAL NERVES Tibialis Anterior Extensor Hallucis Peroneal Longus Extensor Digitorum Brevis
TIBIAL NERVES Tibialis Posterior Flexor Digitorum Longus Gastrocnemius Lateral Gastrocnemius Medial Soleus Abductor Hallucis Abductor Digiti Quinti Pedis
POSTERIOR PRIMARY RAMI L2 L3 L4 L5 S1 S2Lumbar Paraspinalis High Sacral Paraspinals
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Localization in Clinical Neurology
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Cross Section of the Brain
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Cross Section of the Brain
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The cerebellum
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Course of Cerebellar Arteries
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NIH Stroke Scale NIH Stroke Scale Items Function Score Exam1a. Level of Consciousness (Alert, drowsy, etc.)
Alert Drowsy Stuportous (requires repeatedstimuli) Comatose
0 1 2 3
1b. LOC Questions (Month, age)
Both correct One Correct Incorrect
0 1 2
2. Best Gaze (Eyes open-patient follows examiner’s finger or face)
Normal Partial glaze palsy Forces Deviation
0 1 2
3. Visual (introduce visual stimulus/ threato patient’s visual field questions)
Normal Motor asymmetry Partial Complete
0 1 2 3
4. Facial Palsy (Show teeth, raise eyebrows & squeeze eyes shut)
Normal Motor asymmetry Partial Complete
0 1 2 3
5a. Motor Arm Left (elevate extremity 90° score drift/movement)
No drift Drift Some effort against gravity No effort against gravity No movement Amputation
0 1 2 3 4 9
5b. Motor Arm Right (elevate extremity 90° score drift/movement)
No drift Drift Some effort against gravity No effort against gravity No movement Amputation
0 1 2 3 4 9
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NIH Stroke Scale Items Function Score Exam6a. Motor Leg Left (elevate extremity 30° score drift/movement)
No drift Drift Some effort against gravity No effort against gravity No movement Amputation
0 1 2 3 4 9
6b. Motor Leg Right (elevate extremity 30° score drift/movement)
No drift Drift Some effort against gravity No effort against gravity No movement Amputation
0 1 2 3 4 9
7. Limb Ataxia (Finger-nose, heal down shin)
Absent Present in upper or lower Present in Both
0 1 2
8. Sensory (Pin prick to face, arm trunk, & leg- compare side to side)
Normal Partial loss Dense loss
0 1 2
9. Best Language (Name items, describe a picture & read sentences)
No aphasia Mild-moderate aphasia Severe Mute
0 1 2 3
10. Dysarthria (Evaluate speech clarity by patient repeating listed words)
Normal articulation Mild-moderate slurring Severe, nearly unintelligibleor worse
0 1 2
11. Extinction & Inattention ( Use of information from prior testing to identify neglect or double simultaneous testing)
No neglect Partial neglect Profound neglect
0 1 2
NIH Stroke Scale TOTAL:
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NIH Stroke Scale
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NIH Stroke Scale
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NIH Stroke Scale
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NIH Stroke Scale
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NIH Stroke Scale
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NIH Stroke Scale
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MAMA
TIP-TOP
FIFTY-FIFTY
THANKS
HUCKLEBERRY
BASEBALL PLAYER
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You know how.
Down to earth.
I got home from work.
Near the table in the dining room.
They heard him speak on the radio last night.
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HUNT-HESS CLASSIFICATION OF SAH
0 Unruptured aneurysm 1 Asymptomatic, or mild headache, & slight nuchal rigidity 1a No acute meningeal/brain reaction, but with fixed neuro-deficit 2 Moderate to severe headache3, nuchal rigidity; or cranial nerve palsy 3 Lethargy or confusion; mild focal deficit 4 Stupor, moderate to severe hemiparesis 5 Deep coma, decerebrate rigidity
LEVEL OF CONSIOUSNESS 1 Alert 2 Drowsy 3 Stuporous 4 Comatose
MOTOR ASSESSMENT- MRC SCALE
5 Normal strength 4+ Slightly less than full power against strong resistance 4 Able to overcome moderate resistance 4- Able to overcome mild resistance 3 Able to accomplish full range of motion against gravity only 2 Able to accomplish full range of motion when gravity eliminated 1 Only trace muscle contraction; may only be palpable 0 Flaccid
GLASGOW OUTCOME SCALE
1 Good recovery, fully independent 2 Moderately disabled, impaired but independent 3 Severely disabled, totally dependent 4 Vegetative survival 5 Dead
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GLASGOW COMA SCALE MOTOR
6 Obeys verbal commands 4 Localizes to noxious stimuli 3 Decorticate posturing 2 Decerebate posturing 1 No response
Verbal 5 Fully oriented 4 Disoriented, converses 3 Inappropriate words 2 Incomprehensive sounds 1 No vocalization Eye Opening 4 Opens eyes spontaneously 3 Opens eyes verbal commands 2 Opens eyes noxious stimuli 1 No eye opening
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rt-PA for Acute Ischemic Stroke Dose is .9 mg/kg, maximum 90 mg 10% of dose will be given IVP over 1 min., the rest is infused over 1 hour. Indications for rt-PA therapy
1 Age > 18 2 Clinical diagnosis of ischemic stroke with a measurable deficit as
impairment of language, motor function, cognition and/or gaze, vision, neglect
3 Time of onset well established to be less than 3 hours 4 CT performed and read
Contraindications for rt-PA
1 Evidence of ICH on pre-treatment evaluation 2 Clinical suspicion of SAH 3 Minor stroke or symptoms rapidly improving by the time of onset of
treatment 4 Recent intracranial surgery or serious head trauma 5 Intracranial neoplasm, AVM, or aneurysm 6 History of stroke in the previous 3 months 7 Major surgery or serious trauma in the previous 14 days 8 Arterial puncture at the non-compressible site or a lumbar puncture in the
previous 7 days 9 Known bleeding diathesis, e.g.: platelet count < 100,00/mm3 10 Current us of oral anticoagulant with a PT > 15 sec. 11 Administration of heparin within 48 hours preceding the onset of stroke,
with an elevated PTT on presentation 12 Serious medical illness that outweighs treatment benefit 13 Seizure at onset of stroke 14 Active internal bleeding or history of GI or urinary tract hemorrhage in the
previous 21 days 15 Uncontrolled hypertension at the time of treatment (systolic BP > 185 or
diastolic BP> 110 mmHg) 16 Clinical presentation consistent with acute MI or post myocardial infarction
pericarditis. 17 Blood glucose of <50 or > 400 mg /dl 18 Pregnant/lactating patients
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Management of Suspected Intracranial Hemorrhage Suspicion of intracranial hemorrhage prompted by:
Neurologic deterioration, new headache, acute hypertension, nausea, vomiting
IF intracranial hemorrhage is the presumed diagnosis: Discontinue rt-PA infusion Obtain an immediate CT scan Draw blood; PT, aPTT, platelet count, fibrinogen Prepare to give fibrinogen 6-8 U and cryoprecipitate containing Factor
VIII Prepare to give platelets 6-8 U
IF intracranial hemorrhage is not present on CT scan: end algorithm IF intracranial hemorrhage is present on CT scan:
Evaluate laboratory results; fibrinogen, PT, aPTT Consider alerting and consulting neurosurgeon Consider altering and consulting hematologist Consider second CT scan to assess size change
Consensus decision: Plan surgical and medical therapy
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ACUTE ISCHEMIC STROKE
Clinical Protocol Expected LOS: 3-5 days (check box to initiate order)
ORDERS (*) ARE 24 HOUR ORDERS AND MUST BE ASSESSED DAILY
Addressograph
Admission Day: Day 1 Date: Time:
ADMIT TO ICU Unit_____________________ Tag/Order Clinical Practice Guideline “Acute Ischemic Stroke” in
Care Manager
Patient not appropriate for Clinical Practice Protocol because:____________________
ATTENDING PHYSICIAN Dr:________________________________ Admitting Resident:_______________ _____ Pager#________________
DIAGNOSIS Ischemic Stroke
CONDITION OF PATIENT Good Fair Critical Other___________________
CATEGORY OF CARE Full Support Category of Care Order Form (Total support except Advanced Life support, DNRCC-Arrest, DNRCC)
ALLERGIES NKA _______________________________________
* NUTRITION (24 hour order) NPO completely Nurse to complete “Nursing Swallowing Screen” prior to oral medications or diet Other ____
* ACTIVITY(24 hour order) Complete bed rest (elevate head of bed 30˚), reposition q 2 hours if needed Other __________
CONSULTS Speech Therapy for bedside dysphagia screening exam Speech Therapy for Speech& Language
Evaluation & Treatment
Physical Therapy Evaluation and Treatment (ROM) Occupational Therapy Evaluation and Treatment Other______
NURSING *Cardiac monitor *Continuous pulse ox, call if Sp O2 < 94
Seizure precautions *No lifting or pulling of limbs on affected side
I & O ROM q 4 hours
*No invasive procedures except venous blood draws for 24 hours
until__________________________(date/time) if given tPA.
EPC cuffs 5000 units Heparin subcutaneous every 12 hours
Vital signs and neurological assessments q 30 min x 6 hours, then
Call MD immediately for: SBP > 185 or < 120 DBP > 105 or < 60 Pulse < 50 or > 120 RR > 30 T > 101˚F / 38.5˚C
neurological status change in mental status headache, vomiting evidence of bleeding
language or motor deficit
q 1 hour x 16 hours, then q 4 hours ( Recommended for patients post tPA)
OR
Vital signs and neurological assessments q 2 hours x 8 hours, then q 4 hours * Foley to dependent drainage
Evaluate stool, urine, emesis or other secretions for signs of blood. Hemoccult testing if there is evidence of
bleeding (Recommended for patients post tPA) Weight on admission O2 @ 2L per minute per NC
SIGNATURE MD/DO
(PRINT NAME)
Protocols do not replace clinical judgment and should be modified according to individual patient needs.
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ACUTE ISCHEMIC STROKE
Clinical Protocol
Expected LOS: 3-5 days (check box to initiate order)
ORDERS (*) ARE 24 HOUR ORDERS AND MUST BE ASSESSED DAILY
Addressograph Admission Day: Day 1 Date: Time:
LABS CBC in a.m. X 1 * Glucose finger stick q 6 hours Fasting Lipid Profile in a.m. X 1 Other __________________________ ______________________________
__________________________ _______________________________
IV IV 0.45% NaCl @ _________ ml/hr IV Other _______________________________
MEDICATIONS Stroke Prevention Medications (if no tPA) & other medications should be ordered below.
CARE COORDINATION
Contact Care Coordinator for discharge planning
PATIENT FAMILY
EDUCATION
Stroke Education Folder, Specific material as needed Education Record – Patient/Caregiver – Stroke/TIA Form#49812 (Please include in
medical record) The Brain at Risk, Stroke (Story of Treatment and Recovery)
ADDITIONS/CHANGES – PLEASE NOTE: ASA, antiplatelet agents, Coumadin or heparin not recommended for 24 hours if tPA was given. Date & Time such medications can be started:_____________
TIME ORDER
SIGNATURE MD/DO
(PRINT NAME)
Protocols do not replace clinical judgment and should be modified according to individual patient needs. Rev: 08/2005 Page 2 of 2 PS0146
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Indications for Heparin Therapy I. Cluster or crescendo TIAs defined as 3 TIAs in the
last 24-48 hrs. IV heparin 15-18 units/kg/hr or 700-1000 units/hr.
II. Stroke-in-evolution, defined as appearance of new deficits within 2 hours, or fluctuation of neurological symptoms, unless there is evidence of
i. Ischemic edema ii. Fluctuation in blood pressure
iii. Acute metabolic or hypoxic metabolic abnormalities
III. Ischemic stroke attributed to cardiogenic embolism IV. Dissection of carotid arteries V. Cortical vein thrombosis
No Loading IV. Suspicion of basilar artery thrombosis
• Draw platelet count, PT & PTT prior to initiation of heparin therapy.
• PT & PTT stat q 6 h till achieving therapeutic aPTT (aPTT 1.4-2.0 x control), 6 hrs. after dosage change, and then daily
• Platelet count, Hbb, Hst q 4 days • Check for signs of bleeding daily • When switching to Coumadin or ASA, begin these
agents then taper heparin before D/C to rebound hypercoagulability.
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Management of acute ischemic stroke
1. Avoid intubation and hyperventilation 2. Cardiac monitoring for 24-48 hours 3. Monitor blood pressure and neurochecking q1h for 6 hrs,
then q2 hrs for 8 hrs, then q4hrs 4. Start IV 50 cc/h of .45 NSS 5. Draw blood for CBC, diff, platelets, CHEM 20, VDRL 6. Consider blood for ANA, ESR, RF, ACL, protein C,
protein S, antithrombin III, APC resistance, & toxicology mainly in patients <55 years
7. EKG 8. CXR 9. CT of brain without contrast 10. Urinalysis, and urine toxin screen when suspicious 11. Nursing swallowing screen, if patient fails, keep NPO
until reassessed 12. Complete bed rest with fall precautions 13. EPC cuffs for DVT prevention 14. Insulin sliding scale 15. ASA 325 mg po qd unless contraindicated or
unless the patient is treated with rt-PA 16. Heparin 5000 units SC q 12hrs unless contraindicated or
unless the patient is treated with rt-PA PA
17. Speech, rehabilitation, physical therapy, & social work consults on case-by-case basis
18. Carotid duplex, TCD, TTE, TEE, MRI, DWI & MRA will be requested depending on the suspected mechanism of stroke
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Management of blood pressure in acute ischemic stroke If eligible for tPA / thrombolytic therapy Check BP every 10 -15 min If Systolic >185 OR Diastolic > 110 Labetalol 10-20 mg IV over 1-2 min, may repeat once OR Nicardipine 5 mg/h IV infusion as initial dose and titrate to desired effect by increasing by 2.5 mg/h every 5 min to a max of 15 mg/h If blood pressure remain >185 /110 do not administer tPA If “NOT” eligible for tPA / thrombolytic therapy Check BP every 10 -15 min If Systolic > 220 OR Diastolic > 120 Labetalol 10-20 mg IV over 1 – 2 min May repeat or double dose every 10 – 20 min (max dose 150 mg) OR Nicardipine 5 mg/h IV as initial dose; titrate to desired effect by increasing by 2.5 mg/h every 5 min, max 15mg/h Aim for a 10-15%reduction in blood pressure If Diastolic > 140 Nitroprusside 0.5 – 1.0 mcg/kg/min Monitor BP q15 min, and avoid rapid fall of BP or hypotension
Management of ischemic edema (in cases of impending herniation or progressive cerebral edema)
1. Mannitol* 1g/kg IV over 12 minutes, then .25 g/kg IVP a 4 h for 3-4 days, then taper over 2-3 days
2. Monitor serum osmolality ½ hr following each dose of Mannitol for first 24 hrs, then daily in am
3. Monitor electrolytes, intake/output 4. Maintain serum osmolality ~ 310-315 mosm/l
* Dose should be reduced in patients with renal insufficiency
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Classification of aphasia
Atypical
Basal ganglia
Thalmic
Anom
ic
Transcortical Motor Sensory
Global
Conduction
Wernicke’s
Broca’s
Type of A
phasia
Good
Good
Good
↓ Good
↓
Good
Good ↓
Fluency
↓ ↓
Good
Intact ↓ ↓
Intact
↓
Intact
Com
prehension Intact or ↓ Intact
Good
Intact Intact
↓ ↓ ↓ ↓
Repetition
Intact Logorrheir
↓
Intact Intact ↓ ↓ ↓ ↓
Nam
ing
Right
hemiparesis,
dysrthria A
ttention &
Mem
ory deficit
R
ight hem
iplegia
-----
Right Hemiparesis
Other Signs
Head of caudate,
anterior limb of
capsule A
nerolateral thalam
us
Depends
on type
Anterior or
superior frontal tem
poroparietal,thalam
us
Massive
perisylvian
Posterior perisylvian
Posterior or inferior temporal
Frontoperietal operculum
Lesion location
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INDICATIONS FOR CT – ANGIOGRAM IN THE EMERGENCY ROOM First 0 to 6 hours of stroke symptom onset
• Young (<60) patients with neurological deficits consistent with TIA or stroke
• When suspecting acute occlusion of a major cerebral vessel • When intra arterial TPA or surgical removal of clot is a
therapeutic option
Between 6 and 9 hours of stroke symptom onset • When suspecting acute occlusion of the Basilar artery
The following clinical signs are supportive of acute cerebral embolism.
• Acute onset of deficits • Hemiparesis • Gaze deviation / neglect • Aphasia / Dysarthria
Other supporting signs are
• Declining mental status • Hypertension • Tachypnea • Cardiac arrhythmias • Carotid bruit or weak or absent carotid upstroke • Seizure
The following CT / MRI imaging findings are supportive of an acute cerebral embolic / thrombotic occlusion.
• Dense MCA sign • Dense PCA sign • Area of hypo density involving one half to one vascular territory
Pre-requisites for CTA
• No known renal disease • Creatinine less than 1.5 • BUN less than 21 • No history of allergic reaction to the contrast agent
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Cerebral Angiogram Orders
1. NPO after midnight except for medications. 2. PT, PTT, CBC & diff, platelets, BUN, Cr prior to study. 3. If patient is on heparin, hold heparin 4 hours before call to
angio suite, and check stat PTT before call to angio suite. 4. Keep patient in complete bed rest for 6 hrs. post angiogram. 5. Resume heparin- if needed- 6 hours post angiogram.
Special situations: History of migraine A. ASA 325 mg 6- 12 prior to study B. Perciactin 8 mg 6 hrs prior to study C. Solumedrol 100 mg IVP on call to angio., or prednisone 60 mg po
12 hrs before and on call to angio. Contrast allergy A. Prednisone 60 mg po 12 hrs and 6 hrs prior to, and on call to
angio. B. Cimetidine 300 mg IVP on call to angio C. Benadryl 50 mg IM on call to angio.
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CSF Testing Routine
Tube 1: CBC with diff & save Tube 2: (Chemistry) Glucose, Protein & save Tube 3: (Microbiology) gram stain & bacterial culture, latex agglutination
(bacterial antigen panel), HSV PCR & save (In clinically appropriate situations) Cryptococcal antigen, viral culture, west Nile panel, AFB smear & PCR, MTb culture VDRL/FTA, VZV PCR, Lyme titers, fungal culture.
Tube 4: CBC with diff & save • Multiple sclerosis panel can be added to any tube • Do not forget to order Serum MS panel for comparison • ACE, CSF antineuronal antibodies, cytology, Protien 14-3-3
Dosage of antibiotics commonly used in Therapy of Bacterial Meningitis
Dose & Dosing Interval
Antibiotic Children (>1 mo) Adults Penicillin G 50,000 U/kg q 4h 304 M U q4h
Ampicillin 75-100 mg/kg q6h 2g q4h
Cefotaxime 50 mg/kg q6h 2-3 g q6h
Ceftriaxone 50 mg/kg q12h 2-3 g qd
Ceftizoxime 50 mg/kg q6h 4g q8h
Naficillin 50 mg/kg q6h 1.5 g q4h
Chloramphenicol 25 mg/kg q6h 1.5 g q6h
Vancomycin 10 mg/kg q6h 0.5 g q6h
Trimethoprim- 5/25 mg/kg q6h 5/25 mg/kg q6h
Sulfamethoxazole Important reference – Wood AJJ. Treatment of bacterial meningitis.N. Engl J Med 1997; 336-708-716
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Antibiotics Recommended for Empirical therapy in Patients with Suspected Bacterial Meningitis Who Have a Non-Diagnostic Gram’s Stain of Cerebrospinal Fluid Group of Patients Likely Pathogen Choice of Antibiotic Immunocompetent Age < 3 mo* S. agalciae, E coli, or Ampicillin† plus broad- L. momocytogenes spectrum cephalosporin‡ Age 3 mo to <18 yr N. meningitidis, S. pneumoniae, Broad- spectrum Or H. influezae cephalosporin‡ Age 18- 50 yrs S. pneumoniae or Broad- spectrum N. meningitidis Cephalosporin§ Age >50 yr S. pneumoniae, Ampicillin¶, plus- broad L. monocytogenes or spectrum cephalosporin§
Gram-negative bacilli With impaired Cellular immunity L. Monocytogenes, or Ampicillin plus ceftazidime Gram-negative bacilli With head trauma, Neurosurgery, or Staphylococci, gram- Vancomycin plus Cerebrospinal fluid negative bacilli, or ceftazidime Shunt S. pneumoniae * Specific recommendations depend on the age as well as the condition of the infant. In pre-term, low birth-weight infants less than one month old, Vancomycin (15 mg/kg of body weight intravenously every 6 hours), plus ceftazidime (50-100 mg/kg intravenously every 8 hours) is recommended because of the higher risk of nosocomial infection with staphylococci or gram-negative bacilli. † The preferred dose is 100 mg/kg intravenously every 8 hours ‡ The preferred dose of Cefotaxine is 50 mg/kg intravenously every 6 hours; that of Ceftriaxone is 50-100 mg/kg intravenously every 12 hours. § The preferred dose of Cefotaxime is 2 g intravenously every 6 hours that of cefriaxone is 2 g intravenously every 12 hours. ¶ The preferred doe is 2 g intravenously every 4 hours; if penicillin G is given, the preferred dose is 4 million units intravenously every 4 hours.
2007
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Antibiotic Therapy for Specific Bacterial Pathogens Organism Antibiotics* H. influenzae Third-generation cephalosporin, Ampicillin (if sensitive); (if not sensitive), chloramphenicol† S. pneumoniae Penicillin G, third-generation cephalosporin Chloramphenicol Reduced penicillin-sensitive Third-generation cephalosporin
Penicillin resistant Third-generation cephalosporin N. meningitidis Penicillin G, chloramphenicol l† S. agalactiae Penicillin G or Ampicillin L. monocytogenes Ampicillin (plus Aminoglycoside) or Sulfamethoxazole Enterobacteriaceae Third- generation cephalosporin with or without Aminoglycoside P. aeruginosa Ceftazidime plus Aminoglycoside or Fluoroquinolone (e.g., ciprofloxacin) S. aureus Nafcillin * Third-generation cephalosporins: Cefotaxime, Ceftriaxone, Ceftizoxime. † For penicliin-allergic patients.
Management of Herpes encephalitis
1. EEG, MRI of brain with out and with Gladolenium 2. Lumbar puncture: routine testing and PCR for Herpes viral antigen. 3. Acyclovir 10.0-12.5 mg/kg IV q8h. Lower does should be considered in
older patients and in renal insufficiency. 4. IV NSS or 0.45 NSS at a rate of 75 cc/hr. 5. If there is a suspicion of a seizure, start phenytoin 12-18 mg/kg IV drip
in NSS, maximum rate of 50 mg/min.
2007
- 53 -
Treatment of Acute Multiple Sclerosis Exacerbation 1. IV NSS or .45 NSS at a rate of 50-75 cc/hr.
2. Methylprednisolone 1 gm qd for 3-4 days.
3. Patient will be discharged on prednisone 60 mg po daily, to be tapered by 10 mg q 2 days over 2 weeks.
4. As an alternative, patient can be discharged without above Prednisone taper.
5. Carafate 1 gm po q 8 hrs.
McDonald Criteria • 2 or more attacks; objective clinical evidence of 2 or more lesions
o No additional data needed • 2 or more attacks; objective clinical evidence of 1 lesion; plus
o Dissemination in space, demonstrated by: MRI, or 2 or more MRI-detected lesions consistent with MS plus
positive CSF, or Further clinical attack implicating a different site.
• 1 attack; objective clinical evidence of 2 or more lesions; plus o Dissemination in time (demonstrated by MRI).
• 1 attack; objective clinical evidence of 1 lesion (monosymptomatic presentation, clinically isolated syndrome); plus
o Dissemination in space, demonstrated by: MRI, or 2 or more MRI-detected lesions consistent with MS plus
positive CSF, and o Dissemination in time, demonstrated by:
MRI or Second clinical attack.
• Insidious neurological progression suggestive of MS; plus o Positive CSF, and o Dissemination in space, demonstrated by:
9 or more T2 lesions in brain, or 2 or more lesions in spinal cord, or 4-8 brain lesions plus 1 spinal cord lesion, or abnormal VEP associated with 4-8 brain lesions, or abnormal VEP with fewer than 4 brain lesions plus 1 spinal
cord lesion; and • Dissemination in time, demonstrated by:
o MRI, or o Continued progression for 1 year.
2007
- 54 -
Dementia Work-up:
1. History of hypertension, renal or hepatic disease, drug abuse, history of GI surgeries, family history
2. Blood work including B12, folate, niacin levels, heavy
metal screening, thyroid function tests (TSH, T3, T4)
3. CSF analysis, including VDRL
4. EEG: for prion diseases such as Cruetzfeldt-Jacob
5. MRI: look for NPH, Binswanger’s, multi-infarcts, tumors, PML, demyelination, atrophy
6. Neuropsychological testing
2007
- 55 -
2007
- 56 -
ALCOHOL WITHDRAWAL MEDICATIONS
Thiamine 100 mg IM or IV Before IV glucose, then 100 mg po qd x 5 days. Prophylaxis for Wernicke-Korskoff Syndrome
Cholordiazepoxide Until behavior and vital signs normalize (Librium) 25-50 mg po q2h prn Hold if sleepy or lethargic 10 mg IV q 5 min prn
Diazepam Until behavior & vital signs normalize (Valium) 10-30 mg po q2h prn Hold if sleepy or lethargic
Lorazepam Until behavior and vital signs normalize (Ativan) 2-5 mg po q 2 hr prn Hold if sleepy or lethargic
Phenobarbital Until behavior and vital signs normalize 60-120 mg po/im q2h prn Hold if sleepy or lethargic 20 mg IV q5 min
Propranolol Use to control tachycardia, hypertension, (Inderal) 10-20 mg po 6 h prn tremor. Will not prevent withdrawal seizures.
Clonidine Use to control hypertension (Catapress) 0.05-0.1 mg po q 1 h prn Will not prevent withdrawal seizures.
Nifedipine Use to control hypertension (Procardia) 10mg sl q 20 min prn
2007
- 57 -
DIFFERENT MR SIGNALS MRI-T1 MRI-T2 XRAY-CT2 Dense bone Dark Dark Bright Air Dark Dark Dark Fat Bright Bright Bright Water Dark Bright Dark Brain 3”anatomic” Intermediate Intermediate1 Bright means high signal intensity, dark means low, and intermediate means intermediate 2 Bright means high density/high attenuation of x-rays, dark means low 3 Gray matter appears grey, white matter white
EVOLUTION OF INTRACRANIAL HEMORRHAGE ON MRI Clinical phase
Time Component Hgb state T1WI T2WI
Hyperacute Immediate Intracellular Oxy-hemolobin Iso-to-hypointense
↑
Acute 5 hrs 1-5 days
Intracellular Extracellular
Deoxy-Hgb Deoxy-Hbg
Iso-to slight ↓ Very ↑
Very ↓ Very ↓
Subacute Early Late
>5 days
Intracellular Extracellular
Met-HemoglobinMet-Hemoglobin
Very ↑ Very ↑
Very ↓ Very ↑
Chronic Center Rim
> 15 days Extracellular Intercellular
Hemichrome Hemosiderin
→ Very ↓
Slight ↑ Very ↓
↑ Hyperintense ↓ Hypointense → Isotense
2007
- 58 -
MANAGEMENT OF STATUS MIGRAINOSUS
IV DHE Protocol 1 Admit to quiet room 2 IV fluid; NSS rate of75-100 cc.hr. 3 Reglan 10 mg IM 10 min. Prior to each DHE dose 4 Lomotil 5 cc po bid prn for diarrhea 5 DHE 0.5 mg IV drip in 100 cc NS over 15 min. Q 8 hrs for 6 doses If headache persists, and no nausea, increase does of 0.75 mg q 8 hrs Dose can be increased to 1 mg q 8 hrs If patient develops severe nausea, decrease dose of DHE of 0.3 mg q 8 hrs
Or DHE 1 mg in 250 cc NS slow IV drip over 8 hrs; q8 hrs x 3 days *Maximum dose of DHE should not exceed 3 mg/day 7. Vital signs (BP, P, RR) prior to and at the end of each DHE dose
*Warning: Parethesia in extremities, tachycardia, elevation, in blood pressure, chest pain, limb cyanosis.
Toradol- Ketorolac 1. 30 – 60 mg IM 2. Pretreat with 10 mg Reglan IM
Intravenous phenothiazines Chlorpromazine 5 mg IVP q 10 min. prn up to 25 mg of Prochlorperazine 2 mg IVP q min prn up to 10 mg (mix 1 cc of the drug in 4 cc of NSS and inject 1 cc at a time over 1 min). Warning: orthostatic hypotension; extrapyrmidal manifestations; drowsiness
Morphine sulfate pump in individual cases
Droperidol- Inapsine
DRUGS USED FOR MIGRAINE HEADACHE Abortive Tylenol (acetaminophen); 650 mg at onset, then 650 mg q 4h prn
NSAIDs: Anaprox, Naprelan, Aleve (naproxen sodium): 550-1100 mg at onset, then 275-550 mg q4-6h prn
2007
- 59 -
Drugs used for Migraine Headaches (Continued) Imtrex (sumatriptan):
Tablets: 25-50 mg at onset, then 25-50 mg q2 hrs prn, total 300 mg/d & 600 mg/week Injections: 6 mg sc at onset, then in 1 hr prn, total of 2 doses a day or 4 doses/week Nasal spray: 20 mg intranasal, 1 q hr, max 2 doses a day or 4/week
Zomig (Zolmitripitan): 2.5 or 5 mg tab, q 2 hrs, max 10 mg/day or 20 /week Amerge (Nortriptan): 5 mg tab q2 hrs, max 2/day or 4/week Maxalt: 10 mg tablet, dissolved in mouth q 4, max 2/day, 4/week Warning: avoid in heart disease, hypertension, bailar migraine, allergy to sumatriptan, or within 24 hrs of use of DHE or ergotamine; watch for serotonin syndrome DHE: Sc: 0.5 mg at onset, may increase or repeat in 1-2 hrs, total 2 mg/day, and 6 mg/week IV: 0.5-1.0 mg IV in 100 cc NSS over 10-15 min + 10 mg of Reglan (see DHE protocol) Nasal spry (Migranal): 1 spray in each nostril, to be repeated in 15 min, max 2 mg/day, 4 mg/week Warning: heart disease, HTN paresthesia in extremities or cyanosis
Lidocaine: 4 % intranasally, 0.5cc in one or both nostrils to be repeated in 2 min for 2 does. Give with head hyperextended and flexed to side of headache.
Compazine: (prochlorperazine) or Thorazine (chlorpromazine): 25-50 mg supp or tabe at onset, then q8h prn, total 3 days/week. 25 mg IM can be used
Reglan (metaclopramide): 10-20mg tabs/supp at onset qoh prn, up to 60 mg/week Midrin (isometheptene/acetaminophen [65-325]): 1-2 cps at onset, then 1 q1h up to 5/day and 10/week Cafergot (ergotamine/caffeine): 1-2 (1-2 mg) onset, then 1 q ½ h prn, total 5/day & 10/week 1/2-1 supp at onset, then ½ - 1 supp q1h prn, up to 2/day, or 5/week
2007
- 60 -
Drugs used for Migraine Headaches (Continued) Prophylactic B-blockers: Inderal (propranolo): 80 mg LA p to 240 mg/day warning: asthma, CHF, hypotension, bradycardia
AEDs: Depokote (Valproic acid): 250-500 mg po bid- qid warning: liver failure, pancreatitis, pregnancy, tremor, alopecia
Neurontin (gabapentin): 300 mg big- 1200 mg Warning: drowsiness, leg edema Topamax (topiramate) 25 mg bid- 100 mg –bid Warning: drowsiness, weight loss, mood changes
TCA’s Elavil (amitriptyline) 25 mg- woo mg qhs Pamelor (nortriptyline): 25-75 mg qhs Warning: orthostatic hypotension, glaucoma, prostatic hypertrophy, tremor, arrhythmias
Calcium channel blockers Calan (verapamil): 80 mf tid-qid, or long acting 240 mg/day Warning: sick sinus syndrome, CHF, hypotension SSRIs: Prozac (fluoxetine): 20-80 mg qhs Zoloft (sertaline): 50-150 mg qhs Warning: serotonin syndrome Sasert (methysergide): 4-8 mg/day Warning: retroperitoneal & organ fibrosis; patients need to be taken off the medication for at least one month after a 6-month use, with yearly CXR, echocardiogram, & Ct of abdomen. Periactin (cyproheptadine): 8-16 mg/day Warning: drowsiness Steroids: 60 mg for 5 days, then taper gradually over 2 wks Lithium carbonate: 300 mg tid-qid Warning: thyroid dysfunction, renal failure, tremor
2007
- 61 -
Receptor Blockade of Antidepressants & Related Side Effects D
oam
iner
gic
• ex
trapy
rmid
al
mov
emen
t di
sord
ers
• en
docr
ine
ch
ange
s
(pro
-lact
in
elev
atio
n)
+1
+1
+1
+1
+1
+1
+1 +1
+1
0 H
alop
erid
ol
(H
adol
) +4
α 2 a
dren
ergi
c •
bloc
k
antth
yper
tens
ive
ef
fect
s of
clo
nidi
ne,
gaua
nabe
nz, a
nd
met
hyld
opa
• pr
iapi
sm +1
+/0
+2
+1
+2
+/0
+/0 +2
+/0 0
Phen
tola
min
e (R
eliti
ne)
+3
α 1 a
dren
ergi
c •
post
ural
hy
pote
nsio
n •
dizz
ines
s •
frefle
x •
tach
ycar
dia
• ad
ditiv
e w
/
ant
ihyp
erte
nsiv
e pr
azos
in
+3
+2
+4
+3
+4
+3
+3 +4
+/0
+/0
Phen
tola
min
e (R
eglit
ine)
+4
His
tmin
ergi
c •
seda
tion,
dr
owsi
ness
•
wei
ght g
ain
• hy
pote
nsio
n •
pote
ntia
ion
o
f C
NS
de
pres
sant
s
+2
+1
+3
+1
+4
+2
+3 +1
+/0
+/0
Dip
henh
yfra
min
e
(B
enad
ryl)
+2
Cho
liner
gic
(m
usca
rinic
) •
blur
ed v
isio
n •
dry
mou
th
• si
nu ta
chyc
ardi
a •
cons
tipat
ion
• ur
inar
y re
tent
ion
• m
emor
y
dys
func
tion +2
+1
+3
+1
+2
+/0
+/0 0 +/0 0
Atr
opin
e (b
ella
donn
a a
lkal
oid)
+4
Rec
epto
r:
Pot
entia
l sid
e ef
fect
s
caus
ed b
y bl
ocka
de
Tetra
- & tr
icyc
lics
Imip
ram
ine
(Tof
rani
l )
Des
ipra
min
e (N
orpr
ami n
Am
itrip
tylin
e (E
levi
l)
Nor
tript
ylin
e (p
amel
or)
Dox
epin
(Sin
equa
n)
Am
oxip
ine
(Ase
ndin
)
Map
rotil
ine
(Lud
iom
il)
Non
-tric
yclic
s
Traz
odon
e (D
esyr
el)
Fluo
xelin
e (P
roza
c)
Bup
ropo
lon
(Wel
lbut
rin)
Ref
eren
ce A
gent
2007
- 62 -
2007
- 63 -
AED Initial dose Maintenance
daily dose Common Adverse Effects
Serious Adverse Effects
Phenytoin 15-20 mg/kg
4-7 mg/kg/day (adults) 5-10 mg/kg/day (pediatric) once a day dosing
Confusion, fatigue, gingival,hyperplasia, osteopenia, ataxia, rash
Rash leading to Steven-Johnson Syndrome, Cardiac conduction defect, hepatotoxicity
Phenobarbital
Load only in status epilepticus with 20 mg/kg, requires respiratory & cardiovascular support
60-240 mg (adults) 3-7 mg/kg/day (pediatrics <12 yrs 3-4 mg/kg/day in neonates) once a day
Adults-sedationChildren- hyperactivity, osteopenia
Respiratory depression, hypotension with IV load
Carbamazepine
100-200 mg (adults) 10 mg/kg (pediatric)
400-200 mg (adults) 10-35 mg/kg/day (pediatrics) tid dosing, long acting forms available
Sedation, fatigue, rash, neutropenia
Rash leading to Steven-Johnson Syndrome (SJS) hepatotoxicity, aplastic anemia, cardiac conduction defect
Valproate
250-500 mg (adults) 15 mg/kg/day (pediatrics)
1500-3000 mg (adults) 15-60 mg/kg/day (pediatrics) Three times a day dosing
Weight gain, Polycystic Ovarian Syndrome, osteopenia, tremors, fatigue
Hepatotoxicity, thrombocytopenia, pancreatitis
Ethosuximide
250 mg (adults)10-15 mg/kg/day (pediatrics)
250-1500 mg (adults) 15-40 mg/kg/day (pediatrics) Once a day dosing
Fatigue None
Gabapentin
300 mg tid (adults) 10-15 mg/kg (pediatrics)
900-3600 mg (adults) 25-60 mg/kg (pediatrics) 3 times a day dosing
Dizziness, weight gain, fatigue
None reported
2007
- 64 -
AED Initial dose Maintenance daily
dose Common adverse effects
Serious adverse effects
Levetirecetam 500 mg bid 1000-4000 mg twice a day dosing
Dizziness, fatigue, confusion
None reported
Topiramate
25 mg bid (adults) 1-3 mg/kg/day(pediatrics)
100-400 mg (adults) 5-9 mg/kg/day (pediatrics) Twice a day dosing
Lethargy, dysphasia, confusion, distal paresthesiaeweight loss
Renal stones, glaucoma
Lamotrigine
25 mg bid with EI AED, 25 mg qod with VPA (adults) 06 mg/kg/day with EI AED, 0.1 mg/kg/day with VPA (pediatrics)
200-600 mg with EI AED, 100- 300 mg with VPA (adults) 5-15 mg/kg/day with EI AED, 1-5 mg/kg/day with VPA (pediatrics)
Insomnia, restlessnessheadaches
Rash leading to SJS
Zonisamide
100 mg qd (adults) 2-4 mg/kg (pediatric)
200-600 mg (adults) 4-8 mg/kg (pediatrics)
Somnolencedizziness, anorexia, weight loss
Rash, renal stones, blood dyscrasias, hepatotoxicity
Oxcarbazepine
300 mg bid (adult) 8-10 mg/kg (pediatric)
1200-2400 mg (adult) 20-50 mg/kg (pediatric)
Sedation, dizziness, nausea, diplopia
Hyponatremia, rash, hepatotoxicity
Tiagabine
4 mg/day (adult) pediatric dosing not established
32-64 mg bid-qid
Sedation, impaired cognition
Rare cases of status epilepticus
2007
- 65 -
Bo
und
Frac
tion
(%)
90-9
5
75
45
80-9
0
<5
25
<5
55
9-17
95
40
<10
40
Titra
tion
Tim
e to
Min
imum
Ef
fect
ive D
ose
(day
s)
1-7
7-14
45
7-14
7-14
7-14
1-7
28-4
2
28-4
2
28-4
2
7-14
1-7
1-7
Usua
l Effe
ctive
Pl
asm
a Co
ncen
tratio
n (m
g/da
y)
10-2
0
8-12
1-14
50-1
20
40-1
00
20-1
40
4-16
2-16
4-10
NE
10-3
5
5-45
10-4
0
Usua
l Ad
ult
Dos
e (m
g/da
y)
300-
100
800-
1.600
15-4
0
1,000
-3,00
0
750-
1,500
2,400
-3,60
0
1,800
-3,60
0
100-
500
200-
400
32-5
6
600-
1,800
1000
-300
0
100-
400
Meta
bolis
m
> 90
% he
patic
W/ in
ducti
on
> 90
% he
patic
W/ in
ducti
on
> 90
% he
patic
W/ in
ducti
on
> 95
% he
patic
W/ in
ducti
on
65%
hepa
tic n
o ind
uctio
n
60%
hepa
tic
>95%
rena
l
>90%
hepa
tic, n
o ind
uctio
n
30%
hepa
tic, n
o ind
uctio
n
>90%
hepa
tic, n
o ind
uctio
n
>90%
hepa
tic, m
ild in
ducti
on
>65%
rena
l exc
retio
n
>70%
hepa
tic, n
o ind
uctio
n
Hal
f- Li
fe
(hrs
)
22
8-22
100
15-2
0
60
14-2
3
5-7
12-6
0*
19-2
5
5-13
8-10
†
6-8
63
PHA
RM
AC
OK
INET
ICS
OF
AN
TIC
ON
VULS
AN
T D
RU
GS
Dru
g
Phen
ytoin
Carb
amas
epine
Phen
obar
bital
Valpr
oate
Etho
suxim
ide
Felba
mate
Gaba
penti
nt
Lamo
trigine
Topir
amte
Tiaga
bine
Oxca
rbaz
epine
Leve
tirace
lam
Zonis
amide
NE= Not established * Varies widely depending on coadministered drugs. † 10-monohydroxyl metabolite, active metabolite.
2007
- 66 -
Impa
ct the
offen
ding
agen
t has
of
P45
0 sys
tem
Induc
es 3A
4, 2C
19, 1
A2, 2
D6, &
2B6
Induc
es 3A
4, 2C
9, 2C
19, &
2D6
Induc
es 3A
4, 2C
19, 1
A2,
2D6,
& 2B
6
Inhibi
ts 2 C
9
Inhibi
ts2C1
9 & In
duce
s 3A4
Inhibi
ts2C1
9 & In
duce
s 3A4
Inhibi
ts2C1
9 & In
duce
s 3A4
ox°
↓ ↓ ↓ ↓ n n n n n n n --
Z ↓ ↓ ↓ n n n n n n x -- n
lev
x x x x x x x x x -- n n
tia
↓ ↓ ↓ pb
n n x n -- x n n
fel
↓ ↓ ↓ ↑ n n x -- n x n n
gab
x x x x x x -- x x x n n
top
↓ ↓ ↓ ↑sl
n -- x n n x n n
lam
↓ ↓ ↓ ↑ -- n x n n x n ↑
va
↓ ↓ ↓ -- ↓ ↓ x ↑ ↓ x n n
phb
var
↓ -- ↑ n n x ↑ n x n ↑
epo
↑ ↑ ↑
cbz
var
↑ ↓ var
n n x ↓ n x n n
dph
-----
var
var
↑/pb
n ↑ x ↑ n x n ↑
P450
Meta
bolis
m Pa
thway
2C
/2C9
3a4/1
A2/2C
8
2C9
2C9/2
C19/2
A6
2C19
3A4/2
E1
3A4
3A4
SUMM
ARY
OF A
ED D
RUG
INTE
RACT
IONS
AMO
ONG
EACH
OTH
ER
Impa
ct of
offen
ding a
gent
has o
n the
plas
ma co
ncen
tratio
ns of
the d
rugs
listed
in co
lumn h
eadin
g
Offen
ding
Age
nt dp
h
cbz*
phb
va
lam*
topR
gabR
fel
tia
levR
z ox
↑ (in
creas
ed co
ncen
tratio
n of t
he dr
ug lis
ted in
colum
n hea
ding)
; ↓ (d
ecre
ased
conc
entra
tion o
f the d
rug l
isted
in co
lumn h
eadin
g); v
ar (v
ariab
le eff
ect o
n the
co
ncen
tratio
n of th
e dru
g list
ed in
the c
olumn
head
ing);
n (n
o data
curre
ntly a
vaila
ble: R
(offe
nding
agen
t is ≥
60%
rena
lly el
imina
ted; x
(no i
ntera
ction
expe
cted s
ince t
drug
listed
in th
e colu
mn he
ading
or ro
w is
rena
lly el
imina
ted);
pb (
dece
ase i
n plas
ma pr
otein
bindin
g allo
wing
for a
tran
sient
incre
ase i
n acti
ve un
boun
d con
centr
ation
drug
listed
in th
e colu
mn he
ading
); * (
induc
es its
own m
etabo
lism)
; ° (oxc
arba
zepin
e is p
rodr
ug; th
e arro
ws re
pres
ent th
e imp
act th
e offe
nding
agen
t has
on ox
carb
epin
activ
e meta
bolite
MHD
) d
ph =
phen
ytoin
cbz=
carb
amaz
epine
epo=
carb
amze
pine e
poxid
e fel=
felba
mate
lam
= lam
otrigi
ne le
v= le
vetira
cetam
ox=
oxca
rbep
ine
gab=
gaba
penti
n phb
=Phe
noba
rbita
l tia=
taiga
bine
top=
topir
amate
va=
valpr
oic ac
id z=
zonis
amide
2007
- 67 -
Pentobarbital Pentobarbital is chemically different from pentothal, with an
intermediate half-life of 11 to 23 hours. Suggested advantages are
that this is an effective anticonvulsant with a relatively short half-
life, thus drug coma can be reversed fairly quickly. Loading dose
is 15 mg/kg (ranged 6 to 25 mg/kg.) Initial maintenance rate
should be 1.5 mg/kg/h which is increased every 5 to 10 minutes
until SE is controlled or a flat EEG is attained. Plasma levels
attained when SE was controlled ranged from 6.5 to 101 µg/mL.
Frequency and type of side effects are similar to those reported
with Phenobarbital.
2007
- 68 -
Standard Immunotherapy for Immune mediated Neuropathics (GBS, CIDP, VN, MMN)
Therapy Neuropathy Route Starting Maintenance Types Dose Dose Predinsone* CIDP, VN PO 60-100 mg/d 60-100 mg qod, For 4 wk reducing dose by 10 mg q 2-4wk. In diabetes, consider daily dosing to simplify glucose control. Methylprednisolone* CIDP, VN IV 1 gm daily or 1 gm q 2-4 wk Qod for a total Of 3-5 doses Azathioprine CIDp PO 50 mg/d Increase by 50 mg (Imuran)* increments q 2-4 wk 2-3 to mg/kg/d Cyclophosphamide CIDP, VN PO 50 mg/d Repeat dose monthly (Cytoxan)* MMN for 6 mo Cyclosporine CIDP PO 100 mg bid Increase by 100 mg (Neoral, Sandimmune)* increments to 3-6 mg/kg/d on bid schedule IVIG* GBS, CIDP, IV 0.4gm/kg/d 0.4-1 gm/kg as a MMN for 5 days single dose q 4-8 wk Prn Plasmapheresis GBS, CIDP IV Exchange total Total of exchanges of MMN of 250 mL/kg 50-250 mL/kg may be Plasma over repeated prn 7-14 days Abbreviations: CIDP= chronic inflammatory demyelinating polyneuropthy; GBS= Guillain-Barre syndrome IVIG= intravenous immune globulin; MMN = multifocal motor neuropathy VN= vasculitic neuropathy *Not FDA approved for this indication
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IV IMMUNOGLOBULIN PROTOCOL 1. Admit to Neurology (Short stay or Regular Admission) 2. Diagnosis: 3. Procedure: IVIG infusion 4. Condition: Stable 5. Vitals: As needed 6. Activity: Ad lib 7. Nursing: Supportive care; Please weigh patient. 8. Diet: Low Sodium diet 9. Allergies: 10. IV: D5W with 0.5 NS at 50 cc/hr 11. Labs: Serum IgA level- If low, do not give standard preparation. Call pharmacy for Gammagrad S.P. Optional Premedications- to be given prior to IVIG infusion □Tylenol 650 mg one tab po q 6-8 hrs □ Benadryl 25 mg po tid 1gm/kg IVIG slow IV over 12 hrs x 2 days In elderly patients/ heart disease: 400 mg/kg x 5 days
PLASMAPHERESIS PROTOCOL 1. Admit to Neurology (Short stay or Regular Admission) 2. Diagnosis: 3. Procedure: Plasmapheresis 4. Condition: Stable 5. Vitals: As needed 6. Activity: Ad lib 7. Nursing: Supportive care 8. Diet: Low Sodium diet 9. Allergies: NKDA 10. IV: (not necessary for short stay) 11. Labs: STAT H/H (Results to be given to Red Cross).
Consult surgical team (on call) for placement of a Quinton catheter for access. Quinton catheter setup tray to floor. Chest x-ray to check placement of central line prior to use. If the American Red Cross are delayed, please check their expected arrival time. Phone number: 248-3331. Check Central line site after plasmapheresis When pheresis is complete and patient’s vital signs are stable, the patient may be discharged with instructions of central line care.
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DRUGS THAT INCREASE WEAKNESS IN MYASTHENIA GRAVIS
Anesthetics Antihypertensives Hormones Ether Atenolol ACTH Halothane Nadolol Corticosteroids Mathoxyflurane Oxprenolol Oral contraceptive Chloroform Propranolol Thyroid hormones Xylocaine Tenormin Trimethaphan Insecticides Antiarrhythmetics Camsylate Parathion Lidocaine Verapamil Malathion Procainamide Organophosphates Quindine Antiheumatics Chloroquine Muscle Relaxants Antibiotics D-penicillamine Curare Amikacin Succinylcholine Gentamycin Cathartics Decamethonium Kanamycin Citrate of Magnesia Dimethyltubocurrarine Lincomycin Epson salts Gallamine Neomycin Hexafluorenium Streptomycin Diuretics Metocurine Tobramycin Carbonic anhydrase Orphenadrine Viomycin inhibitors Pancuronium Bacitracin Chlorthalidone Tubocurarine Clindamycin Ethacrynic acid Norfloxacin Furosemide Sedatives Polumyxin B Thiazides Barbiturates Tetracyclines Narcotics Flurocarbon (e.g. morphine) Antiepileptics Propellants Tranquilizers Diazepam Benzodiazepines Phenytoin Chlorpromazine Trimethadione Promazine
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Osserman’s classification clinical staging of therapy and prognosis I. Ocular myasthemia (15- 20 percent)
II.
A. Mild generalized myasthenia with slow progression; no crises; drug responsive (30%)
B. Moderately severe generalized myasthenia; severe skeletal & bulbar involvement but not crises; drug response less than satisfactory (25%)
III. Acute fulminating myasthenia; rapid progression of severe symptoms with
respiratory crises & poor drug response; high incidence of thymoma; high mortality (15%)
IV. Late severe myasthenia, same as III but progression over 2 years from class I
to class II (10%) TENSILON TEST PROTOCOL It is best if patient is free of all other cholinesterase inhibitor for at least 24 hours. However, in evaluating the patient who is possible cholinergic crisis versus myasthenic crisis this is not always possible. When not controlled for previous use, document the last time the anticholinesterase was used which type. The patient should be seared comfortably or laying down. A measurable parameter needs to be identified prior to instituting the test e.g. a weak eye muscle. Tensilon test is not a very useful test for generalized fatigue. For more generalized weakness, it is more appropriate to order an EMG study with repetitive stimulation. Tensilon is usually available in a 10 mg vial (1 ml vial)/ A 1 ml. tuberculin syringe is used to draw up the Tensilon. A second syringe of atropine 0.4 mg is also drawn up or available in case of difficulty with the enrophonium. The initial test dose of 2 mg (0.2ml) of Tensilon is given and the patient is observed for the next 60-90 seconds. In addition to observing for the measured parameter e.g. weak eye muscle, the patient may become tachycardic, experience some shortness of breath, and very anxious. Comfort the patient verbally as much as possible. Assure them the effect is temporary and it will pass. If the initial test dose fails to elicit a response, administer the next dose of 3 mg (0.3 ml) and observe for an appropriate time interval. If no response, the remainder of the dosage 5 mg (0.5ml) may be given and the patient observed for an appropriate time interval. If patient is critically ill, they should be monitored throughout this procedure.
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TESTS TO BE ORDED FOR SUSPECTED AIDP (GBS) Most important: Frequent (at least q shift) monitoring of respiratory function. This would include monitoring bedside vital capacity (VC) and negative inspiratory forde (NIF). In early in the course of the disease, more formal pulmonary function testing can be performed. NCV/EMG Lumbar puncture Blood tests to be ordered: ESR ANA SPEP Quantitative Immuglobulins HIV test Stool Cultures Urine for porphyrins Order as indicated: Titers for Campylobacter jejuni Titers for influenza Titers for myocoplasma pneumonia Titers for Lyme’s disease Titers for CMV virus Titers for EBV virus Titers for Herpes simplex 1 virus Titers for Varicella zoster virus Titers for hepatitis viruses
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Respiratory Failure
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A schematic approach for sorting out the nature of anisocoria
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Staging of Parkinson’s Disease Hoehn &Yahr Stage Stage 0= No signs of disease Stage 1= Unilateral disease Stage 1.5= Unilateral plus axial involvement. Stage 2 = Bilateral disease, without impairment of balance. Stage 2.5 = Mild bilateral disease, with recovery on pull test. Stage 3= Mild to moderate bilateral disease; some postural instability; physically independent Stage 4= Severe disability; still able to walk or stand unassisted. Stage 5= Wheelchair bound or bedridden unless aided.
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University of Toledo Medical Center DETERMINATION OF DEATH BY BRAIN CRITERIA FOR ADULTS AND CHILDREN 1 YEAR OF AGE AND OLDER To obtain Determination of Death by Brain Criteria, the attending service will complete this form and follow the instructions on the reverse side. I. REQUIRED CLINICAL AND LABORATORY FINDINGS CIRCLE RESPONSE
A. Cause of coma is sufficient to account for the loss of brain function YES NO B. There is no likelihood of recovery of brain function YES NO C. Core temp. > 32° C D. The following metabolites are normal or if abnormal cannot account for patient’s YES NO
Condition. Na, K, Cl, C02, BUN, creatinine, glucose, NH3, E. There is no indication of toxic levels of CNS depressants YES NO F. Toxicology screen performed YES NO G. No neuromuscular blocking agents YES NO
SIGNATURE:__________________________ Date and Time ____________
II. REQUIRED FINDINGS ON NEUROLOGICAL EXAMINATION CIRCLE RESPONSE FIRST EXAM SECOND EXAM
A. Comatose with no responsiveness to external stimuli or extensor posturing YES NO YES NO B. Absent pupillary light reflexes YES NO YES NO C. Pupils dilated to (mm) _____________ YES NO YES NO D. Absent corneal reflexes (oculocephalic reflex) YES NO YES NO E. Absent dolls eyes YES NO YES NO F. Absent cold water caloric responses YES NO YES NO G. Absent suck, gag, and rooting reflexes YES NO YES NO H. Absent spontaneous respirations YES NO YES NO I. Flaccid extremities with no spontaneous movements YES NO YES NO _____________ _________________ Date & Time Date & Time SIGNATURE: __________________ ___________________
III. APNEIC OXYGENATION TEST – Core temp must be > 36.5 ° C (higher than the 32 ° needed for clinical diagnosis of brain death) Results (performed before and after on 100% 02 p02 pC02 pH Before ___________ ________________ _________________ After _______________ ________________ __________________ SIGNATURE:_________________________ Date & Time ________________ LABORATORY PROCEDURES, e.g., angiography (optional for age >1 year), EEG (for brain death), or Technetium-99m Brain Scan A. Procedure:_________________ _________________________ ___________________________ Date & Time________________ _________________________ ____________________________ Results _________________ _________________________ ___________________________ IV. CLINICAL CONFIRMATION OF DEATH BY BRAIN CRITERIA A. Neurological/Neurosurgical Consultant B. ICU consultant (if applicable) C. Attending Physician 1. Signature _____________________ 1. Signature _________________________ 1.Signature ___________________ 2. Date & time _____________________2. Date & Time _________________________ 2. Date & Time _____________________
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DETERMINATION OF DEATH BY BRAIN CRITERIA INSTRUCTIONS FOR ADULTS AND CHILDREN 1 YEAR OF AGE OR OLDER
I. CLINICAL EXAMINATION
The attending service should complete section I, the first exam of section II, and the apnea oxygenation test. When these are completed, the attending service is encouraged to call the Neurology/Neurosurgery consultant. All items I and II require a “Yes” response.
Attending to attending communication is always important.
Repeat of the clinical examination will be done at different intervals depending on the use of a optional confirmatory laboratory procedures.
If confirmatory test is consistent with brain death, then no further observation period is needed before 2nd clinical exam.
If no confirming laboratory test is used, the period of observation should be 6 hours. IT IS CRITICAL TO PERFORM A THOROUGH CLINICAL EVALUATION AND APPROPRIATE DIAGNOSTIC TESTING TO EXCLUDE REVERSIBLE OR TREATABLE CONDITIONS.
II. ICE WATER CALORIC STIMULATION
1. Check auditory canals for obstruction. 2. Flex head to 30� above horizontal with patient supine. 3. Irrigate external auditory canal with 40 ml. of ice water. 4. Observe for tonic deviation of eyes.
III. APNEIC OXYGENATION TEST: Performance of the Apneic Oxygenation Test should be requested from Respiratory Therapy. The examining physician must be present during the Test to insure patient safety and to witness the Test.
The Apneic Oxygenation Test is carried out as follows:
1. Ventilation on 100% oxygen for 20 minutes 2. Draw blood for determination of arterial blood gases 3. Insertion of a catheter via the endotracheal tube into the trachea above the carina for insufflation
with 100% 02 at 6L/min long enough for a rise in pCO2 to 20 points above baseline or a total of 60, or a maximum of 10 minutes while the ventilator is turned off
4. Repeat blood draw for determination of blood gases 5 Removal of catheter and resumption of ventilation
IV. LABORATORY CONFIRMATION OF DEATH BY BRAIN CRITERIA MAY BE USED TO SHORTEN THE PERIOD OF OBSERVATION. A cerebral angiography to demonstrate absence of cerebral blood flow, EEG (to demonstrate electrical cerebral silence) or Technetium-99m Brain Scan may be considered.
V. CLINICAL CONFIRMATION BY A NEUROLOGICAL/NEUROSURGICAL CONSULTANT, THE ICU CONSULTANT IF APPLICABLE AND THE ATTENDING PHYSICIAN OR DESIGNATED ATTENDING ARE REQUIRED. If neurosurgery or neurology is attending service, opposite service must be consulted.
If there is agreement that the brain criteria of death are met, any of the above physicians will write a concluding note in the progress notes stating that Death by Brain Criteria exists in this patient. A physician will then declare the patient dead and any life support systems may be withdrawn. MCO Form #278-B(Adult)
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CLINICAL REFERENCES FOR CEREBROSPINAL FLUID VALUES
Normal and Abnormal Values of Cerebrospinal Fluid (CSF) Pressure Color White blood Red blood Glucose Protein (mm H2O) cell count cell count (per mm3) (per mm3) Normal 70-190 Clear & 0-3 0-5 60-80 15-45 Colorless mg/100ml mg/100ml Acute 250-800 usually cloudy 100’s to 0-5 greatly Greatly bacterial yellow or 10,000’s, reduced, increased, Meningitis or white nearly all sometimes as high as Because of to 0 400-500 Puss mg/100mL Aseptic slight clear 50-500, 0-5 Normal slight Meningitis increase mostly increase(up Lymphocytes to around 100 mg /100mL) Viral Slight clear & 30-400 0-5 Normal Slight Encephalitis increase colorless increase (rarely above 100mg/100ml Cerebro- up to 500 bloody Normal Normal Vascular Accident (hemorrhagic into ventricles or subarachnoid space) Remarks 1. If manometer reads pressure of 300 mg H2O or more, remove it at once and use fluid
init do a microscopic reading. 2. To differentiate between a traumatic tapp and blood in the CSF due to subarachnoid
hemorrhage, centrifuge the CSF. In a traumatic tap the supernatant is clear; in a subarachnoid hemorrhage the supernatant will be yellowish.
3. A fall in the chloride level of the CSF is characteristic of tuberculous meningitis. 4. In infants younger than 1 year, the most common organism to cause acute meningitis
is Gram-negative Escherichia coli; in children it is Hemophilus influenzae; in adults it is Gram-negative Neisseria meningitidis.
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PRACTICE PARAMETER: THE MANAGEMENT OF CONCUSSION IN SPORTS
The usefulness of a grading scale has been well established in sports medicine to determine the severity of a concussion. This practice parameter presents the following grading scale arrived at by a consensus of experts who reviewed all existing scales, including the recommendations in the Colorado Medical Society Guidelines. Grade 1:
1. Transient confusion 2. No loss of consciousness 3. Concussion symptoms or mental status abnormalities on examination resolve
in less than 15 minutes Grade 1 concussion is the most common yet the most difficult form to recognize. The athlete is not rendered unconscious and suffers only momentary confusion (e.g., inattention, poor concentration, inability to process information or sequence tasks) or mental status alternations. Players commonly refer to this state as having been “dinged” or having their “bell rung.” Grade 2:
1. Transient confusion 2. No loss of consciousness 3. Concussion symptoms or mental status abnormalities on examination last more
than 15 minutes With Grade 2 concussion, the athlete is not rendered unconscious but experiences symptoms or exhibits signs of concussion or mental status abnormalities on examination that last longer than 15 minutes (e.g., poor concentration or post-traumatic amnesia). Any persistent Grade 2 symptoms (greater than 1 hour) warrant medical observation.
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Grade 3:
1. Any loss of consciousness, either brief (seconds) or prolonged (minutes) Grade 3 concussion is usually easy to recognize – the athlete is unconscious for any period of time. Timing of initial management and return to play are outlined in tables 1 and 2. Table 4 Initial management following first event Grade
On-site evaluation
Neurological evacuation
Same day return to play
Grade 1 Yes Not required, but may be pursued depending on clinical evaluation
Yes, if normal sideline assessment while at rest and
with exertion, including detailed mental status
examination Grade 2 Yes Yes No Grade 3 Yes Yes No Table 5 When to return to play after removal from contest Grade of concussion Time until return to play * Multiple Grade 1 concussion Grade 2 concussion Multiple Grade 2 concussions Grade 3 – brief loss of consciousness (seconds) Grade 3 – prolonged loss of consciousness (minutes) Multiple Grade 3 concussions
1 week 1 week 2 weeks 1 week 2 weeks 1 month or longer, based on clinical decision of evaluating physician
* Only after being asymptomatic with normal neurological assessment at rest and with exercise.
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PREDICTION OF OUTCOME IN COMATOSE SURVIVORS AFTER
CARDIOPULMONARY RESUSCITATION RECOMMENDATIONS FOR THE PROGNOSTIC VALUE OF THE CLINICAL
EXAMINATION Strong (Level A) evidence
Features of the neurological examination; Glasgow Coma Scale (GCS) score; Motor part of the GCS; Brainstem reflexes (papillary light reflexes, corneal reflexes and eye movements)
The prognosis is invariably poor in comatose patients with absent papillary or corneal reflexes, or absent or extensor motor responses three days after cardiac arrest (Level A).
Good (Level B) evidence
Present of seizures or myoclonus status epilepticus (defined as spontaneous, repetitive, unrelenting, generalized Multifocal myoclonus involving the face, limbs, and axial musculature in comatose patients)
Patients with myoclonus status epilepticus within the first day after a primary circulatory arrest have a poor prognosis (Level B).
Good (Level B) evidence
Circumstances surrounding CPR: Anoxia time; Duration of CPR; Cause of the cardiac arrest (cardiac vs. non-cardiac); Type of cardiac arrhythmia
Prognosis cannot be based on the circumstances of CPR (Level B).
Weak (Level C) evidence
Elevated body temperature Prognosis cannot be based on elevated body temperature alone (Level C).
RECOMMENDATIONS FOR THE PROGNOSTIC VALUE OF
ELECTROPHYSIOLOGIC STUDIES Good (Level B) evidence
Somatosensory evoked potential (SSEPs)
The assessment of poor prognosis can be guided by the presence of bilaterally absent cortical SSEPs (N20 response) within one to three days (Level B).
Weak (Level C) evidence
EEG and evoked/event-related potential (EP) studies
Burst suppression or generalized epileptiform discharges on EEG predicted poor outcomes but with insufficient prognostic accuracy (Level C).
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RECOMMENDATIONS FOR THE PROGNOSTIC VALUE OF BIOCHEMICAL MARKERS
Good (Level B) evidence
Serum neuron-specific enolase (NSE)
Serum NSE levels >33 µg/L at days one to three post-CPR accurately predict poor outcome (Level B).
Insufficient (Level U) evidence
Serum S100; Creatine kinase brain isoenzyme (CKBB)
There are inadequate data to support or refute the prognostic value of other serum and CSF biochemical markers (Level U).
Insufficient (Level U) evidence
Intracranial pressure; Brain oxygenation
There are inadequate data to support or refute the prognostic value of ICP monitoring (Level U).
RECOMMENDATIONS FOR THE PROGNOSTIC VALUE OF RADIOLOGIC STUDIES
Insufficient (Level U) evidence
Neuroimaging studies: CT; MRI; PET
There are inadequate data to support or refute whether neuroimaging is indicative of poor outcome (Level U).
Confounding factors Some factors may confound the reliability of the clinical exam and ancillary tests. Major confounders could include the use or prior use of sedatives or neuromuscular blocking agents, induced hypothermia therapy, present of organ failure (e.g., acute renal or liver failure) or shock (e.g., cardiogenic shock requiring inotropes). However, studies in comatose patients have not systematically addressed the role of these confounders in neurological assessment.
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COMA DECISION ALGORITHM Exclude major confounders
No brain stem reflexes at any time
(pupil, cornea, oculocephalic, cough) ► Yes Brain death testing ► No
Indeterminate outcome
- or -
Day 1: Myoclonus status epilepticus
► Yes Poor
outcome
FPR* 0% (0-8.8) ► No
Indeterminate outcome
- or -
Day 1-3: Serum NSE*>33 ug/L**
► Yes Poor
outcome
FPR 0% (0-3) ► No
Indeterminate outcome
- or -
Day 3: Absent pupil or corneal reflexes;
extensor or absent motor response ► Yes
Poor outcome
FPR 0% (0-3) ► No
Indeterminate outcome
- or -
Day 1-3: SSEP* absent N20 responses** ► Yes
Poor outcome
FPR 0.7% (0-3.7) ► No
Indeterminate outcome
Decision algorithm for use in prognostication of comatose survivors after CPR. The numbers in parentheses are exact 95% confidence intervals. The confounding factors potentially could diminish prognostic accuracy of this algorithm. *NSE = neuro-specific enolase; SSEP = somatosensory evoked potential; FPR = false positive rate. ** These tests may not be available on a timely basis. Serum NSE testing may not be sufficiently standardized.
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Communication with family and further decision making The complexity of evaluation and various options of decision making require neurological professional expertise. More than one scheduled meeting with the family is generally required to facilitate a trusting relationship. The neurologist can explain that the prognosis is largely based on clinical examination with some help from laboratory tests. In a conversation with the family, the neurologist may further articulate that the chance of error is very small. When a poor outcome is anticipated, the need for life supportive care (mechanical ventilation, use of vasopressors or inotropics agents to hemodynamically stabilize the patient) must be discussed. Fully informed and more certain, the family or proxy is allowed to rethink resuscitation orders or even to adjust the level of care to comfort measures only. However, these decisions should be made after best interpretation of advance directives or the previously voiced wishes of the patient.