Neurological Failure

1
Neurological Failure
2

• 73 year old man is transferred to the ICU postop
  after emergency AAA surgery. He is
  hemodynamically stable. Two days later, he is
  weaning from the ventilator and the nurse calls
  you.
• The patient is fighting with the ventilator,
  thrashing about and hypertensive.
• When you arrive, he is trying to sit up and will
  not obey commands. He looks at you like you are
  the devil himself.

3

• This man clearly has an altered level of
  consciousness. What is the definition for
  delirium?
• Disturbance of consciousness with reduced ability
  to focus, sustain, or shift attention.
• A change in cognition or the development of a
  perceptual disturbance that is not better
  accounted for by a pre-existing, established, or
  evolving dementia.
• The disturbance develops over a short period of
  time (usually hours to days) and tends to
  fluctuate during the course of the day.
• There is evidence from the history, physical
  examination, or laboratory findings that the
  disturbance is caused by a medical condition,
  substance intoxication, or medication side
  effect.
• How is it different from coma?
• Coma is a clinical states in which patients have
  impaired responsiveness (or are unresponsive) to
  external stimulation and are either difficult to
  arouse or are unarouseable
• Coma is defined as "unarousable unresponsiveness"

4

• What is the differential diagnosis for delirium?
• Toxins
• Drugs
• Prescription medications, polypharmacy
• Drugs of abuse including alcohol intoxication or
  withdrawal, narcotics, cocaine, LSD, and
  phencyclidine
• Infection sepsis, systemic infections
• Poisons ethylene glycol, methanol, insecticides,
  carbon monoxide, etc.
• Metabolic derangements
• Electrolyte disturbance (elevated or depressed)
  sodium, calcium, magnesium, phosphate
• Endocrine disturbance (depressed or increased)
  thyroid, parathyroid, pancreas, pituitary,
  adrenal
• Hypercarbia
• Hyperglycemia and hypoglycemia
• Hyperosmolar and hypoosmolar states
• Hypoxemia
• Inborn errors of metabolism porphyria, Wilson's
  disease, etc.
• Nutritional Wernicke's encephalopathy, vitamin
  B12 deficiency, possibly folate and niacin
  deficiencies

5

• Brain disorders
• CNS infections encephalitis, meningitis, brain
  or epidural abscess
• Epileptic seizures, especially nonconvulsive
  status epilepticus
• Head injury
• Hypertensive encephalopathy
• Psychiatric disorders
• Systemic organ failure
• Cardiac failure
• Hematologic thrombocytosis, hypereosinophilia,
  leukemic blast cell crisis, polycythemia
• Liver failure acute, chronic
• Pulmonary disease, including hypercarbia and
  hypoxemia
• Renal failure acute, chronic
• Physical disorders
• Burns
• Electrocution
• Hyperthermia
• Hypothermia
• Trauma with systemic inflammatory response
  syndrome, head injury, fat embolism

6

• What are some of the risk factors for the
  development of delirium?
• Consider underlying brain diseases,
  polypharmacy, advanced age and sensory impairment
• How would you investigate this patient?
• What pharmacological and non-pharmacological
  treatments can be used to manage this patient?

7
Later that day

• A 50 year old man presents to the emergency
  department with the worse headache of his life.
• Over 30 minutes he becomes progressively obtunded
  to the point of coma.
• After intubation for airway control, he has a CT
  scan.

8
(No Transcript)
9

• What is the problem?
• What is the cause?
• How does it usually present?
• How is the diagnosis made?
• What treatments (supportive and definitive) are
  available?
• What complications can occur?

10
Still later that day

• A 50 year old man presents to the emergency
  department with the worse headache of his life.
• Over 30 minutes he becomes progressively obtunded
  to the point of coma.
• After intubation for airway control, he has a CT
  scan.

11
(No Transcript)
12

• What is the problem?
• What is the cause?
• How does it usually present?
• How is the diagnosis made?
• What treatments (supportive and definitive) are
  available?
• What complications can occur?

13
At 230 in the morning

• A 19 university student presents to the health
  centre with increasing confusion and headache
  over the last 24 hours.
• On examination, he has a blood pressure of 91/43,
  heart rate of 140, respiratory rate of 23,
  temperature of 40.1 and oxygen saturations of
  89.
• He is delirious and has a diffuse rash.

14

• What is the most concerning diagnosis on the
  differential?
• What treatments should be initiated immediately?
• What is the role for steroids in meningitis?
• What are the most common causative organisms?
• What other adjuvant treatment should be
  considered for this patient?

15
Then your pager goes off (again)

• You are call to the neurology ward for a 29 year
  old woman with a long history of temporal lobe
  epilepsy.
• She was admitted for EEG monitoring and planned
  surgery. Her medications have been stopped for
  four days.
• Upon your arrival, she has been having
  generalized tonic clonic seizures for 10 minutes.

16

• What are your immediate concerns?
• What is the definition of status epilepticus?
• Why is this an emergency?
• After 8 mg of ativan, she is still seizing.
• What do you do now?
• Describe the approach to the treatment of status
  epilepticus.

17
Next is a STAT trauma call

• 19 year old man is involved in a two car MVC.
• His GCS at the scene is 3 and he is intubated and
  resuscitated.
• Upon arrival in the trauma room, he is
  hemodynamically stable with no major injuries.
  He remains a GCS 3.
• He is taken urgently for CT head.

18
(No Transcript)
19
Sidebar

• Identify the findings on the following CT scans

20
(No Transcript)
21
(No Transcript)
22
(No Transcript)
23
(No Transcript)
24
(No Transcript)
25
(No Transcript)
26
Back to the case

• The patient is seen by the Neurosurgery service
  and they insert an intraventricular drain. He is
  then transferred to the ICU.
• What is the purpose of an intraventricular drain?
• What is the cerebral perfusion pressure?
• Describe the Monroe-Kelly doctrine,

27

• Later in the evening, the nurse calls you because
  the ICP is 45 for the last 20 minutes.
• What are some of the causes of intracranial
  hypertension?
• How would you emergently manage this problem?
• What is secondary injury and why is it important?

28
Questions??