The ability to quickly diagnose and manage acute neurological complications is a critical skill for all ICUs, even in centers that do not have specialized care units for these patients, and three presenters during CHEST 2020 highlighted the important factors in recognizing and managing stroke, nonconvulsive status epilepticus (NCSE), and increased intracranial pressure (ICP).
The live session, Fundamentals of Neurocritical Care for the Medical ICU, will be available for viewing for registered CHEST 2020 attendees through February 1, 2021.
Neha S. Dangayach, MD, said that for acute ischemic stroke, parallel processing was extremely important. Understand how a stroke code is called at your hospital or health system, and always engage with the stroke team when determining whether a patient needs TPA or CT perfusion imaging. Engagement with the endovascular team is also a must, said Dr. Dangayack, assistant professor of neurosurgery and neurology, codirector of the Neurosciences Intensive Care Unit, and director and founder of the Critical Care Recovery Program at the Icahn School of Medicine at Mount Sinai and Mount Sinai Health System.
Thrombectomies are the gold standard, saving lives and improving functional outcomes, Dr. Dangayach said. A CT angiography is similar to an EKG for a myocardial infarction, so make sure to get vessel imaging.
Dr. Dangayach said that studies such as the DAWN Trial, which studied thrombectomy between 6 to 24 hours after a stroke, and the WAKE-UP Stroke Trial, which assessed the benefits of thrombosis in patients whose stroke occurrence could not be pinpointed, show great promise that the window of opportunity for treatment is getting bigger.
“We truly are dealing with the dawn of a new era as we’re pushing that window, pushing those boundaries with patients even well beyond the original TPA window of 3 hours,” Dr. Dangayach said. “So we’re now all the way up to 24 hours, and there are ongoing studies to extend that window by using the tissue window, the tissue clock, using CT perfusion imaging.”
Sumedh S. Hoskote, MBBS, consultant, pulmonary, and critical care medicine, and assistant professor of medicine at the Mayo Clinic, shared the fundamentals required in the care of nonconvulsive status epilepticus (NCSE). Up to 20% of all comatose patients in the ICU and almost 15% of convulsive status epilepticus patients develop NCSE.
Dr. Hoskote said that NCSE requires high clinical suspicion to diagnose. NCSE in the ICU is possible when the patient has an unexplained mental status change with one of these etiologies: History of epilepsy or convulsive status epilepticus, anoxic brain injury, cerebrovascular incident such as stroke or subarachnoid hemorrhage, toxic/metabolic process, sepsis, encephalitis or meningoencephalitis, trauma, or tumor.
Basic initial diagnostics and management require routine blood work and, if applicable, testing for levels of anti-epileptic medication, Dr. Hoskote said. Additional measures include head CT, electroencephalogram (EEG), and respiratory and circulatory support, if needed.
“Early diagnosis is the key, and continuous EEG may be required,” Dr. Hoskote said. “The management needs to be individualized, and expert input is highly valued.”
Joshua Botdorf, DO, assistant professor in the department of critical care and respiratory care at the MD Anderson Cancer Center, said that managing an ICP crisis in a medical ICU requires forethought and planning long before an event happens.
“It’s good that if you’re going to be seeing any sort of patients who are going to be at risk for raised intercranial pressure—or especially events in which they may herniate—have an already prepackaged plan of how you’re going to approach this patient, much like you would have for cardiopulmonary arrest, and already have ready assigned roles for your staff members that will help in managing these patients as urgently as possible,” Dr. Botdorf said.
The plan outlined by Dr. Botdorf started with basics such as elevating the head of the patient’s bed and maintaining neutral head position, followed by hyperventilation and sedation. The next step involves osmolar therapy, followed by external ventricular drain, imaging, and talking early with a neurosurgeon about a decompression measure such as a hemicraniectomy.