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approach to neurologic illness in medical ICU
approach to neurologic illness in medical ICU
approach to neurologic illness in medical ICU
approach to neurologic illness in medical ICU
approach to neurologic illness in medical ICU
approach to neurologic illness in medical ICU
approach to neurologic illness in medical ICU
approach to neurologic illness in medical ICU
approach to neurologic illness in medical ICU
approach to neurologic illness in medical ICU
approach to neurologic illness in medical ICU
approach to neurologic illness in medical ICU
approach to neurologic illness in medical ICU
approach to neurologic illness in medical ICU
approach to neurologic illness in medical ICU
approach to neurologic illness in medical ICU
approach to neurologic illness in medical ICU
approach to neurologic illness in medical ICU
approach to neurologic illness in medical ICU
approach to neurologic illness in medical ICU
approach to neurologic illness in medical ICU
approach to neurologic illness in medical ICU
approach to neurologic illness in medical ICU
approach to neurologic illness in medical ICU
approach to neurologic illness in medical ICU
approach to neurologic illness in medical ICU
approach to neurologic illness in medical ICU
approach to neurologic illness in medical ICU
approach to neurologic illness in medical ICU
approach to neurologic illness in medical ICU
approach to neurologic illness in medical ICU
approach to neurologic illness in medical ICU
approach to neurologic illness in medical ICU
approach to neurologic illness in medical ICU
approach to neurologic illness in medical ICU
approach to neurologic illness in medical ICU
approach to neurologic illness in medical ICU
approach to neurologic illness in medical ICU
approach to neurologic illness in medical ICU
approach to neurologic illness in medical ICU
approach to neurologic illness in medical ICU
approach to neurologic illness in medical ICU
approach to neurologic illness in medical ICU
approach to neurologic illness in medical ICU
approach to neurologic illness in medical ICU
approach to neurologic illness in medical ICU
approach to neurologic illness in medical ICU
approach to neurologic illness in medical ICU
approach to neurologic illness in medical ICU
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approach to neurologic illness in medical ICU

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a patient in medical ICU presents with neurologucal symptoms-how to approach him?

a patient in medical ICU presents with neurologucal symptoms-how to approach him?

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  • 1. Journal club
    • Dr Ranjith kumar
    • Postgraduate in neurology
    • Gandhi medical college
  • 2. Coma in non neurological intensive care units
    • Santiago ortega et al
    • University college of Wisconsin.
    • The Neurologist,Nov,2009.
  • 3. Back ground
    • Increased survival among medical and surgical ICU.
    • Increasing spectrum of illness secondary to critical illness
    • 1/3 of icu patients,55% mortality rate
    • Increase length of stay and disability
    • Systematic approach to identify potentially reversible etiologies and prognostic factors
  • 4.
    • Clinical history
    • Physical examination
    • Degree of sedation
    • Neurologic examination
    • Herniation syndromes
    • Coma scales
  • 5. Essential clinical history in patients with loss of consciousness
    • History
    • Time course-abrupt
    • gradual
    • fluctuating
    • Preceding focal signs
    • Previous episodes
    • h/o recent illness
    • h/o recent fall
    • Altered behaviour
    • Drugs
    • Medical psychological history
    • Alcohol drug abuse
    • Possible causes
    • SAH, seizure, bleeding
    • Tumour, venous thrombosis
    • Metabolic,subdural hematoma.
    • Focal lesion
    • TIA, seizure
    • Infection, metabolic
    • Subdural, epidural bleed
    • Toxic, metabolic, infection
    • Toxic-metabolic.
    • Metabolic, psychiatric
    • Toxic-metabolic
  • 6. Vital signs interpretation in comatose patients
    • Vital signs
    • Fever
    • Hypothermia
    • Hypertension
    • Potential illnesses
    • Infection, heatstroke, thyrotoxicosis,
    • Drugingestion(cocaine,amphetamines,Tca,anticholinergic)
    • Cold exposure, hypothyroidism,
    • hypoglycemia, shock,
    • Drugs(alcohol,barbiturates,opioids,sedatives)
    • Pheochromocytoma, drugs (cocaine,amphetamine,phencyclidine)
  • 7. Vital signs interpretation in comatose patients
    • Hypotension
    • Tachycardia
    • Bradycardia
    • HTN-Bradycardia
    • Addisons, sepsis, MI,
    • Blood loss, hypothyroidism
    • Alcohol, amphetamines,
    • ethylene glycol
    • Uremic coma, myxedema coma.
    • Kocher-cushing reflex.
  • 8. Respiratory patterns in coma
    • Cheyne stroke
    • Kussmaul breathing
    • Agonal gasps
    • Central neurogenic hyprventilation
    • Apneusis
    • Cluster
    • ataxic
    • -Bihemispheric damage, metabolic
    • -Metabolic acidosis, post mesencephalic lesions
    • -Bilateral lower brainstem lesions
    • -Bihemispheric,midbrain,pons
    • -Lateral tegmentum of lower pons
    • -Bihemispheric or pons
    • -Dorsomedial medulla RAS
  • 9. Cutaneous and mucosal exam in comatose
    • Petechiae &ecchymosis
    • Hypermelanosis
    • Cherry red skin
    • Gray blue cyanosis
    • Telangiectasia
    • Ecthyma gangrenosum
    • Splinter hemorrages
    • pigmentedmacules
    • TTP,ITP,DIC,RMSF,meningococcemia,vasculitis,endocarditis
    • Addisons,chemotherapy,porphyria,melanoma
    • .CO poisoning
    • .Methemoglobinemia
    • Chronic alcoholism,vascular malformations
    • Pseudomonas sepsis
    • Anemia,sepsis,leucemia,endocarditis
    • Tuberous sclerosis,neurofibromatosis
  • 10. Neuro muscular blockers in ICU renal 137+ 80-100 pipecuronium renal 100+ 90-120 doxacurium renal 240 80-120 tubocurarine hepatic renal 110-140 120-180 pancuronium renal 80-100 30-67 rocuronium hepatic renal 60-130 20-60 vecuronium renal 20 30-40 atracuronium renal 2 12-18 mivacurium hepatic - 60-120 12-17 rapacurium renal -t1/2 5-10min succinylcholine
  • 11. Sedatives in ICU Cbf,icp 2-14 ketamine Cbf,icp,cpp 40-50 propofol Cbf, cpp, icp 10-19 haloperidol 48-144 phenobarbitone Cbf,icp,cpp 2-4 thiopental 10 fentanyl Cbf,icp 4-11 morphine 7-10 midazolam 3-7 lorazepam Icp, cbf, 50-120 diazepam
  • 12. Evaluation of comatose
    • Spontaneous activity, motor response, eye position and movements, pupillary reflexes, brainstem reflexes and asymmetry between right and left responses.
    • Decorticate (flexor) posturing-lesion above level of red nucleus.
    • Decerebrate posturing (extensor)-damage to lower midbrain or upperpons, severe damage and less chance of recovery.
    • Ciliospinal reflex
  • 13. Main opthalmologic findings in comatose
    • Vitreous sub hyaloid haemorrages
    • Papilledema,retinal exudates&haemorrages
    • Papilledema
    • Cholesterol embolus
    • Subconjunctival hemorrage
    • Periorbital eccymoses,
    • Battle sign
    • -SAH
    • -hypertensive encepalopathy
    • -ICT increase
    • -carotid atheroma
    • -endocarditis
    • -head trauma
  • 14. Eye movements in coma
    • Conjugate horizontal roving
    • Conjugate horizontal ocular deviation
    • Wrong way eyes
    • Downward ,inward eyes
    • Ocular bobbing
    • Ocular dipping
    • Dysconjugate eye movemnts
    • -Excludes midbrain, pons lesion
    • -Contralateral pon/ipsilateral frontal
    • -Paradoxically to,contralateral deep hemispheric leson.
    • -Thalamic,upper midbrain lesion
    • -Bilateral pontine damage
    • -Diffuse cortical anoxia
    • -Brainstem damage
  • 15. Abnormal pupillary responses in coma Metabolic encephalopathy, B/l thalamic, pontine lesions, hydrocephalus,narcotics,OP,barbiturates Midbrain damage or compression Seizure Thalamus, sympathetic efferents from posterior hypothalamus, tegmentum, descending to the cervical cord Bilateral small ,reactive b/l dilated and unreactive b/l dilation&reactive Unilateral miosis
  • 16. Pupillary responses and coma Compression of ipsilateral III nerve -Fascicular lesion -Nuclear lesion -Extracranial defect T1-T2 to carotid bifurcation -Between hypothalamus and spinal cord -ICA vs cavernous sinus vs SOF vs orbit Unilateral, unreactive & enlarged -unilateral ptosis -bilateral ptosis Unilateral,small,reactive, ipsilateral ptosis -with face anhydrosis -anhydrosis entire side of body -without anhydrosis
  • 17. Glasgow coma scale
  • 18. FOUR score scale
    • Eye response
    • 4-eyelid open or opened, tracking or blinking to command
    • 3-eyelids open, not tracking
    • 2-eyelids closed, open to loud voice, not tracking
    • 1-eyelids closed, open to pain, not tracking.
    • 0-eyelids remain closed with pain
    • Motor response
    • 4-thumbs up, fist, or peace sign to command
    • 3-localizing to pain
    • 2-flexion response to pain
    • 1-extensor posturing
    • 0-no response to pain or generalized myoclonus/status
    • Brainstem reflexes
    • 4-pupil & corneal reflex present
    • 3-open pupil wide & fixed
    • 2-pupil/corneal reflexes absent
    • 1-pupil & corneal reflex absent
    • 0-absent pupil, corneal & cough reflexes
    • Respiration
    • 4-not intubated, regular breathing pattern
    • 3-not intubated, cheyne-stokes breathing pattern
    • 2-not intubated, irregular breathing pattern
    • 1-breathes above ventilator rate
    • 0-breathes at ventilator rate
  • 19. Cerebral herniation :clinical syndromes Decrease consciousness, small & reactive pupils, normal eye movements. Fixed pupils, cheyne stroke respiration, opthalmoplegia, decorticate posturing Initial obstruction hydrocephalus, thalamus, hypothalamus displacement Supra tentorial diffuse brain edema, haemorrage, midline tumors Central herniation Dilated ipsilateral pupil with preserved or sluggish reaction to light. CnIII,ophthalmoplegia,ipsilateral hemipareis Ipsilateral III compression Hemispheric/lateral middle fossa Uncal herniation
  • 20. Cerebral herniation clincal syndromes All brainstem reflexes are lost, flaccid paralysis, ataxic respiration, then ceasing Medulla-lower pons, cerebellar tonsils Infra tentorial lesions Foramen magnum herniation Decerebrate posturing, midposition pupils, sometimes irregular and loss of pupillary, oculocephalic and oculo vestibular reflexes Midbrain and upper pons Advanced stage of central herniation, upward infra tentorial lesions Midbrain compression
  • 21. Differential diagnosis in non neurological ICU
    • Metabolic coma
    • Structural coma
  • 22. major causes of organic coma-supra tentorial
    • Unilateral
    • Hemorrhagic contusion
    • Subdural hematoma
    • Epidural hematoma
    • MCA occlusion & edema
    • IC bleed
    • Abscess
    • tumor
    • Bilateral
    • Traumatic injury
    • Multiple infarcts (vasculitis
    • coagulopaty, cardiac emboli)
    • Bilateral thalamic infarct
    • Primary lymphoma
    • ADEM
    • Anoxia
    • Metastases
    • Leucoencephalopathy(chemotherapy,radiotherapy)
  • 23. Major causes of organic coma-infratentorial
    • Brainstem
    • pontine bleed
    • basilar artery occlusion
    • central pontine myelinolysis
    • brainstem contusion
    • Cerebellum
    • cerebellar infarct
    • cerebellar bleed
    • cerebellar abscess
    • cerebellar tumour
  • 24. Medical ICU
    • Metabolic encephalopathy-28.6%
    • Seizures-28.1%
    • Hypoxic ischemic encephalopathy-23.5%
    • Stroke-22.1%
    • Sepsis is major cause of neurological complication-38.8%
    • Bleck et al-2 yr period
  • 25. Primary CNS processes
    • Acute stroke-1-4% in non neuro icu.
    • Angiographic studies
    • De clotting of Av shunts
    • Vascular line insertions
    • Air embolism
    • Cardioversion
    • Anticoagulation
    • Thrombolytic therapy
  • 26. Primary CNS processes
    • Meningitis & encephalitis-change in mental state with fever, csf analysis and antibiotics.
    • Posterior reversible leuco encephalopathy-acute hypertensive crisis involving brain, vaso genic edema, control with labetolol, nicardipine etc.
  • 27. Conditions associated with acute hypertensive crisis & hypertensive encephalopathy
    • Toxemia of pregnancy
    • Drugs-cyclosporine
    • tacrolimus
    • interferon
    • fludarabine
    • cisplatin
    • gemcitabine
    • erythropoetin
    • Uncontrolled essential hypertension
    • Secondary hypertension-
    • SLE,AGN,CRF
  • 28. Primary CNS processes
    • New onset seizure-0.8-4%,focal most common.
    • Myoclonic seizures-metabolic, drugs,hypoxia.
    • Non convulsive status-10%(50%of TBI),
    • 52% mortality in critically ill
    • Myoclonic status epilepticus-12hrs of cardiac resuscitation, persists up to 48 hrs, poor prognostic sign, unresponsive to medication.
  • 29. Common precipitants of seizures in ICU
    • Metabolic: renal,
    • hepatic,
    • electrolyte,
    • Endocrine
    • Hypoxia/ischemia
    • Sepsis
    • Stroke
    • Primary CNS inflammations
    • Withdrawal
    • delirium tremens
    • BZD
    • narcotics
    • Drugs:
    • Anti arrythmics- lidocaine, flecainide
    • Antibiotics-imipenam, ciprofloxacin, norfloxacin, penicillin derivatives
    • Antidepressants-amit, nortript,doxepin
    • Bronchodilators-theophylline
    • Immunosupressive drugs-cyclosporine,OTR3,FK506
  • 30. Secondary CNS processes
    • Encephalopathy is the most common neurological complication in medical ICU.
    • Prolonged sedation
    • Drug intoxication
  • 31. Sodium disturbances
    • Hypo natremia-incidence of1%,prevalence of 2.5%.
    • Postoperative patients
    • Lethargy, confusion, coma ,seizures.
    • Central pontine myelinolysis
    • Hypernatremia-increase use for ICT.
    • Lethargy, obtundation, coma
    • Progressive shrinkage of brain leading to cerebral vascular damage and sub dural hamatoma
  • 32. Calcium disturbance
    • Hyper calcemia- ionised calcium levels and rate of rise.
    • Delirium, depression, coma.
    • Hypo calcemia-commonly associated with sepsis.
    • Irritabilty, tremors and seizures
  • 33. Magnesium disturbances
    • Hypo magnesemia-commonly associated with hypo calcemia.
    • Tremor, tetany, myoclonus and seizures.
    • Hyper magnesemia- cns depression with lethargy, confusion and weakness.
    • Serum levels>6meq/l causes coma
  • 34. Acid base disturbances
    • Severe acidemia-<7.2,metabolic,respiratory,mixed
    • Increase of icp, decrease seizure thresold, stimulate chemoreceptor trigger zone.
    • Severe acute alkalemia-ph>7.60
    • Cerebral vasoconstriction, decreased oxygen extraction
    • Respiratory depression, tetany,coma,siezures
  • 35. renal
    • Uremic encephalopathy-BUN doubles, drowsiness, asterexis, myoclonus
    • Post dialysis disequilibrium-rapid dialysis, first dialysis, extreme baseline pre dialysis BUN
    • Younger patients, previous neurological deficits
    • Cerebral edema along osmotic gradient
    • Combative behavior, headache, myoclonic jerks, cramps, cortical blindness, coma, seizures
    • Avoided by continuous veno venous hemodialysis
  • 36. liver
    • Acute hepatic failure-hyper ammonemia, hepatic encephalopathy.
    • Gr IV -80% mortality
    • pH dependent partial pressure of gaseous ammonia from blood
    • Hypoglycemia/hyperglycemia-confusion, coma, seizures, focal neurological deficits.
  • 37. Hypoxic ischemic encephalopathy
    • Hypotension, hypoxemia, asphyxia,
    • laryngeal edema
    • Severity and duration of hypoxia
    • Transient confusion, antegrade amnesia, focal, multi focal or global cns damage or brain death.
    • Fixed pupils, myoclonic status, sustained upward gaze poor prognosis
    • Delayed post anoxic encephalopathy
    • Lucid interval of 1-4 weeks
    • Diffuse hemispheric demyelination, cognitive cerebellar, pyramidal and coma.
  • 38. Sepsis encephalopathy
    • Most common (70%) in medical icu.
    • Highest mortality
    • Multi organ failure
    • Decreased cerebral O2 extraction ratios, disordered amino acid transport, micro abscesses, inflammatory mediators, dys regulation of neurotransmitters, direct cytotoxicity, disruption of blood brain barrier
  • 39. Surgical ICU
    • Cholesterol embolisation-vascular catheterisation
    • diffuse encephalopathy, retinal hemorrhage, transient hemiparesis, livedo reticularis, purple toes, renal failure, muscle weakness
    • Muscle/renal biopsy-stacked needle shaped crystals
    • Fat embolism-trauma and long bone fracture/surgery
    • Multifocal ischemic stroke-Cardiothoracic surgery. watershed infarcts, LV thrombus, aortic atherosclerosis ,aortic cross clamping, infective endocarditis, arrythmias.
    • MRI limited by pacemakers
  • 40. Transplant ICU
    • Transplant organ/procedure related
    • Immunosuppressive therapy
  • 41. Renal/liver transplantation
    • Cutaneous neuropathies ad spinal cord infarction
    • Re vascularisation procedure
    • BP changes
    • Hyper coagulabilty-secondary to rapid correction of uremia
    • Increase in ICT during postoperative anicteric phase
  • 42. Cardiac/BMT
    • Single/multiple cerebral infarctions-emboli, global hypo perfusion, arrhythmias, bypass pump, supra therapeutic heparin
    • Infections, Hippocampal damage
    • Bmt-37% met encephalopathy,
    • CNS infection with minimal signs
  • 43. cyclosporine
    • Tremor and restlessness
    • Syndome1-confusion,cortical blindness, visual hallucinations
    • Syndrome2-ataxia,cerebellar tremor, and focal weakness
    • Within 2 weeks, IV,normal levels
    • Psychosis, mutism, central pontine myelinolyis,actionmyoclonus.
  • 44. Tacrolimus/muromonab
    • Fine tremor, paresthesias, apraxia, aphasia, akinetic mutism.
    • Cortical blindness, CIDP
    • Aseptic meningitis and toxic encephalopathy
    • Csf pleocytosis with neutrophil predominance, mild protein elevation, normal glucose and sterile cultures
    • Seizures, psychosis, visual loss
  • 45. Offering prognosis
    • Etiology, severity, secondary CNS damage, age.
    • 5-pont Glasgow outcome scale,6-point pediatric cerebral performance category scale, GCS, FOUR score-motor score, sphincter conrol, self care, communication, pupillary reactivity
    • Children and young adults, toxic or metabolic abnormalities-better
    • Absence of brainstem reflexes, low GCS, hypoxia ,hypotension-worst
    • MRI,MRS, DTI.
  • 46. Anoxic coma
    • Pupils, corneal reflex, motor response to pain ,myoclonic status, SSEP, serum neuron specific enolase.
    • No response or extension to pain, EEG with malignant characteristics, absent bilateral ssep-poor prognosis
    • Elevated NSE at 24 and 48 hrs >33ng/ml -poor prognosis
    • EEG with alternating high voltage slow waves with low voltage irregular fast activity-good prognosis
  • 47. Brain death and organ donation
    • Irreversible loss of brain function including brainstem
    • Traumatic brain injury and SAH
    • Prerequisites to diagnosis
    • Identify patients who are likely to progress to brain death
    • Consent, ethical
    • Optimize and treat any physiological disturbance associated with brain death to protect organs for transplantation
  • 48. hypothermia
    • To minimize secondary brain damage
    • Avoid hyperthermia-excito toxicity, free radical generation, inflammation, apoptosis.
    • Therapeutic hypothermia-core body temp <33 c
    • Massive ischemic stroke, TBI, anoxia
    • External cooling devices, iv cold saline infusions, iv cooling catheters.
    • Electrolyte abnormalities, cardiac arrhythmia,infection.
  • 49.
    • Thank you

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