John Myburgh vs Anthony Holley - ICP Monitoring in TBI is So Last SeasonSMACC Conference
ICP monitoring in patients with traumatic brain injury remains an important practice, despite claims that it is outdated. While early studies on ICP monitoring had significant flaws, more recent high-quality randomized controlled trials have demonstrated benefits to monitoring intracranial pressure. The BEST TRIP trial found that ICP monitoring was associated with lower mortality and fewer intensive care treatments compared to usual care without monitoring. Experts continue to recommend ICP monitoring where resources allow, as it can guide more targeted therapy and improve outcomes for patients with severe traumatic brain injury.
This document summarizes the history and evidence around fluid management and the use of colloids like albumin and hydroxyethyl starch (HES). It discusses several large randomized controlled trials that compared albumin and HES to crystalloids in critically ill patients. The SAFE study found increased mortality with albumin compared to saline in ICU patients. Subsequent trials found increased mortality and renal failure with HES compared to crystalloids in sepsis patients. This led regulatory agencies around the world to restrict or withdraw approval for HES use in high-risk patients like those with sepsis or renal impairment. The evidence suggests colloids like HES may increase mortality and renal failure compared to crystalloid fluids in critically ill patients.
Mark Wilson and John Myburgh discuss intracranial pressure. Some fundamentals, some history to put it all in perspective and all the issues with focusing on just one number. Fascinating insights from two true experts.
For more head to: codachange.org/podcasts
Ponencia realizada por el Dr. Montalescot y presentada por el Dr. José Antonio Gómez Hospital en la Reunión EuroIMAT 2020, celebrada en Barcelona (20 y 21 de febrero de 2020).
An Updated presentation of the management of severe sepsis including best evidence for fluid resuscitation, vasopressors, blood pressure target, steroid replacement, blood transfusion and other moralities.
An 83-year-old woman with heart failure was admitted to the hospital for IV diuresis. Her mortality risk at one year would be around 37.9% according to data on age- and sex-stratified mortality rates after hospitalization for heart failure. If the patient was a man, the expected mortality would be lower at around 28.8% given the data for men aged 65-74 years old.
Interventional and Surgical Treatment of Valve Disease in Heart Failure PatientsDuke Heart
1) Transcatheter edge-to-edge repair (MitraClip) is recommended for treating severe secondary mitral regurgitation in heart failure patients with an ejection fraction of 20-50% and LVESD ≤70 mm who show reduced MR after the procedure.
2) TAVR improves left ventricular function and symptoms in patients with low-flow severe aortic stenosis but is still associated with high 1-year mortality of 20%.
3) The effect of isolated tricuspid valve intervention on outcomes in heart failure patients with reduced ejection fraction is currently undefined.
John Myburgh vs Anthony Holley - ICP Monitoring in TBI is So Last SeasonSMACC Conference
ICP monitoring in patients with traumatic brain injury remains an important practice, despite claims that it is outdated. While early studies on ICP monitoring had significant flaws, more recent high-quality randomized controlled trials have demonstrated benefits to monitoring intracranial pressure. The BEST TRIP trial found that ICP monitoring was associated with lower mortality and fewer intensive care treatments compared to usual care without monitoring. Experts continue to recommend ICP monitoring where resources allow, as it can guide more targeted therapy and improve outcomes for patients with severe traumatic brain injury.
This document summarizes the history and evidence around fluid management and the use of colloids like albumin and hydroxyethyl starch (HES). It discusses several large randomized controlled trials that compared albumin and HES to crystalloids in critically ill patients. The SAFE study found increased mortality with albumin compared to saline in ICU patients. Subsequent trials found increased mortality and renal failure with HES compared to crystalloids in sepsis patients. This led regulatory agencies around the world to restrict or withdraw approval for HES use in high-risk patients like those with sepsis or renal impairment. The evidence suggests colloids like HES may increase mortality and renal failure compared to crystalloid fluids in critically ill patients.
Mark Wilson and John Myburgh discuss intracranial pressure. Some fundamentals, some history to put it all in perspective and all the issues with focusing on just one number. Fascinating insights from two true experts.
For more head to: codachange.org/podcasts
Ponencia realizada por el Dr. Montalescot y presentada por el Dr. José Antonio Gómez Hospital en la Reunión EuroIMAT 2020, celebrada en Barcelona (20 y 21 de febrero de 2020).
An Updated presentation of the management of severe sepsis including best evidence for fluid resuscitation, vasopressors, blood pressure target, steroid replacement, blood transfusion and other moralities.
An 83-year-old woman with heart failure was admitted to the hospital for IV diuresis. Her mortality risk at one year would be around 37.9% according to data on age- and sex-stratified mortality rates after hospitalization for heart failure. If the patient was a man, the expected mortality would be lower at around 28.8% given the data for men aged 65-74 years old.
Interventional and Surgical Treatment of Valve Disease in Heart Failure PatientsDuke Heart
1) Transcatheter edge-to-edge repair (MitraClip) is recommended for treating severe secondary mitral regurgitation in heart failure patients with an ejection fraction of 20-50% and LVESD ≤70 mm who show reduced MR after the procedure.
2) TAVR improves left ventricular function and symptoms in patients with low-flow severe aortic stenosis but is still associated with high 1-year mortality of 20%.
3) The effect of isolated tricuspid valve intervention on outcomes in heart failure patients with reduced ejection fraction is currently undefined.
The COGENT trial was a randomized controlled trial that investigated whether a fixed-dose combination of clopidogrel and omeprazole reduced gastrointestinal events compared to clopidogrel alone in patients receiving dual antiplatelet therapy. The trial found no significant difference in gastrointestinal bleeding events between the combination group and clopidogrel alone group. Additionally, the trial found no evidence that omeprazole increased the risk of cardiovascular events when combined with clopidogrel. In fact, preliminary results found the combination group had a lower risk of the composite cardiovascular endpoint compared to clopidogrel alone. The results provide reassurance that coadministration of clopidogrel and a proton pump inhibitor does not increase cardiovascular
1) The IMPROVE-IT trial investigated whether adding ezetimibe to simvastatin therapy provides additional cardiovascular benefit compared to simvastatin monotherapy in 18,144 high-risk patients who had an acute coronary syndrome.
2) At a median follow-up of 6 years, combination ezetimibe/simvastatin therapy resulted in a statistically significant 9% relative risk reduction in major cardiovascular events compared to simvastatin alone.
3) Combination therapy also significantly reduced the risk of cardiovascular death, nonfatal myocardial infarction, or nonfatal stroke by 10% compared to simvastatin monotherapy.
This document discusses hypoperfusion in acute heart failure. It begins with case examples from Duke Hospital and considerations for diagnosis. It then covers inotropic options and mechanical support devices. Various studies on inotropes, percutaneous support devices, and extracorporeal membrane oxygenation are summarized. The conclusion is that hypoperfusion in acute heart failure presents major challenges for diagnosis and treatment.
1) The document compares the factor Xa inhibitor fondaparinux to enoxaparin for treating acute coronary syndrome, based on the OASIS-5 trial results.
2) The trial found that fondaparinux was as effective as enoxaparin for outcomes like death, MI, and ischemia, but had significantly lower rates of major bleeding at 9 days and 6 months.
3) Based on these results, fondaparinux provides an improved benefit-risk profile compared to enoxaparin for treating acute coronary syndrome.
Death by Neurological Criteria and Organ Donation: Bill KnightSMACC Conference
Bill Knight explains the concept of death by neurological criteria and the complexities surrounding organ donation in such situations.
Bill discusses the process of dying, the definition of death, how to approach the neurologically dead patient and how to consider organ donation.
Death is a complex topic.
Due to advancements in medical technology and processes, the definition of death is a challenging one.
Bill talks at length about the definition of death by the neurological criteria. Dying is an active process, whereas death is an event.
The acceptance of death by the neurological criteria is often challenging as Bill will highlight. Bill talks about the care of the dying or dead patient.
There is a point at which care will transition from supporting the patient to supporting the organs. This is still good care.
There is an alignment of parallel intentions – first and foremost resuscitation of patients and then failing that, proceeding to considering and actioning organ donation. This is important due to the shortage of viable donor organ worldwide.
The donation process itself is complex. Bill provides his thoughts. He insists that an intensivist be involved as this has been shown to increase the number of viable and healthy organs made available.
The timing is also important. Available evidence does not support the need for immediate procurement after brain death. Taking time to optimise perfusion and allow recovery and cardiac function is appropriate and should be done.
Bill also discusses other treatment options at the time of death such as optimising endocrine function.
Finally, Bill will provide some practical considerations when communicating with the dead patient’s family. This involves being clear on your messaging. You are supporting organs, not life.
To reinforce this point, Bill suggests not examining or talking to the patient. He also recommends using all of the available hospital support services.
Similarly, it is best to not introduce the topic of organ donation to the family yourself as the treating clinician. Utilise the Organ Procurement Organisations (or similar services) and get them involved early to speak with the family.
Join Bill Knight in his talk on the North American perspective on Organ Donation, brain death and management of the brain dead donor prior to organ donation.
For more like this, head to our podcast page. #CodaPodcast
- The document discusses contrast-based fractional flow reserve (cFFR) which uses intracoronary contrast to induce hyperemia rather than intravenous adenosine.
- Studies have shown cFFR has higher diagnostic accuracy than resting physiology measures like iFR and Pd/Pa, correctly identifying around 85% of lesions compared to around 80% for resting measures.
- cFFR provides an alternative approach to assessing coronary physiology that is faster and avoids the side effects of intravenous medications like adenosine.
1) The IMPROVE-IT trial investigated whether adding ezetimibe to simvastatin therapy provides additional cardiovascular benefit compared to simvastatin monotherapy in 18,144 high-risk patients who recently had an acute coronary syndrome.
2) Patients receiving ezetimibe/simvastatin had a lower rate of major cardiovascular events (32.7% vs 34.7%) over a median follow-up of 6 years, demonstrating the additional clinical benefit of further lowering LDL-C with ezetimibe.
3) Ezetimibe/simvastatin also reduced the rate of the composite endpoint of cardiovascular death, non-fatal myocardial infarction, or non-fatal stroke compared to
Delaney shares insights into the mysterious world of statistics and trials. This 12 minute podcast is particularly useful for Registrars preparing for their exams and was recorded at BCC4. For similar podcasts and audio; head to www.intensivecarenetwork.com and to rego for BCC5 in Cairns, check out www.bedsidecriticalcare.com
Eplerenone in Patients with Systolic Heart Failure and Mild Symptoms.
Presented at AHA by: Faiez Zannad, M.D., Ph.D., John J.V. McMurray, M.D., Henry Krum, M.B., PhD., Dirk J. van Veldhuisen, M.D.,Ph.D., Karl Swedberg, M.D., Ph.D, Harry Shi, M.S., John Vincent, M.B., PhD., Stuart J Pocock, Ph.D. and Bertram Pitt, M.D. for the EMPHASIS-HF Study Group * Eplerenone in Mild Patients Hospitalization And SurvIval Study in Heart Failure
Courtesy of http://www.cardiovascularbusiness.com
ACTEP2014: Sepsis management has anything change taem
This document discusses sepsis management and what has changed. It begins with an introduction to the pathophysiology of sepsis, severe sepsis, and septic shock. It then discusses early goal directed therapy (EGDT) and landmark studies like Rivers 2001 that promoted protocolized resuscitation to targets like central venous pressure, mean arterial pressure, ScvO2, and transfusion thresholds. However, later large trials like ProCESS 2014 found no difference in mortality between EGDT, standard therapy, and usual care. Targets like CVP are not accurate predictors of fluid responsiveness. Studies also found no difference in outcomes between higher and lower blood pressure or hemoglobin transfusion thresholds. There remains uncertainty around optimal fluid type, vas
Troponin use it in all patients with acute heart failure contradrucsamal
Alan Maisel is the director of the coronary care unit and heart failure program at the San Diego Veterans Hospital. He discusses whether troponins are needed in the assessment and management of heart failure. While troponins can be elevated in heart failure and correlate with worse outcomes, their role in clinical decision making for heart failure is unclear as evidence is still lacking around using them to guide specific biomarker-directed therapy. Further research is needed to determine appropriate cut-off levels that should prompt further ischemic workup and how clinicians should modify treatment based on troponin levels in heart failure.
http://www.theheart.org/web_slides/1225049.do
A randomized double-blind, double-dummy trial on MAGELLAN (VTE Prophylaxis in Medically Ill Patients) to show noninferiority of rivaroxaban to enoxaparin at 10 days and superiority at 35 days
1. Mr. SG, a 42-year-old male, was diagnosed with chronic immune thrombocytopenia purpura (ITP) and hepatitis B after being found to have low platelet count during a routine blood test.
2. He received supportive treatments including platelet transfusions, antibiotics, and antacids. Rituximab treatment was started along with antiviral medication to prevent hepatitis B reactivation.
3. The plan is to continue rituximab weekly for 4 weeks along with long-term antiviral therapy and monitoring of platelet counts and liver function to manage the ITP and hepatitis B.
Wavy triple an ECG sign (Yasser’s sign) in hypocalcaemia -Cardiology and Eme...YasserMohammedHassan1
The Wavy triple an electrocardiographic sign (Yasser’s sign) is a new diagnostic sign seen in 97.3% (36 cases) of hypocalcemia. Dramatic improvement of both clinical manifestation and the new electrocardiographic sign simultaneously after calcium replacement had happened.
This document discusses various methods for assessing coronary artery disease, including iFR, FFR, and resting gradients like Pd/Pa. It summarizes recent clinical trials comparing these techniques. The key points are:
1) Resting indices like iFR and Pd/Pa provide equivalent information to each other but differences remain when compared to FFR, especially for proximal left anterior descending artery lesions.
2) Trials comparing iFR to FFR did not definitively show iFR was non-inferior in reducing hard clinical outcomes like death and myocardial infarction.
3) Contrast-enhanced FFR may be superior to resting indices as it has the highest correlation with FFR and best diagnostic accuracy.
BCC4: Michael Parr on ICU - Surviving Trauma GuidelinesSMACC Conference
Michael Parr, director of Liverpool ICU in Australia, speaks about "Surviving Trauma Guidelines". He does so through the use of an interesting case of a patient admitted to ICU following a MVA. This educational podcast was recorded at BCC4.
This document summarizes several clinical trials related to critical care medicine. It discusses trials on topics such as decompressive craniectomy for traumatic brain injury, hypothermia for traumatic brain injury, erythropoietin for brain injury, blood pressure management for intracerebral hemorrhage, vasopressin versus norepinephrine for septic shock, dexmedetomidine for delirium, timing of renal replacement therapy for acute kidney injury, acetazolamide for chronic obstructive pulmonary disease, paracetamol for fever, balanced fluids versus saline, and transfusion thresholds.
Mrs. J, a 56-year-old female, presented with complaints of pain in her right hip and both knees. She was diagnosed with osteoarthritis in both knees. She underwent a bone marrow aspirate concentrate (BMAC) injection in both knees, which provided a natural alternative to surgery. Her hypertension was managed with nefidipine and amiloride/hydrochlorothiazide. She was discharged in a stable condition with recommendations for pain medication, diet and lifestyle modifications, and continued management of her osteoarthritis and hypertension.
BCC4: Anthony Delaney on Traumatic Brain Injury in the Real WorldSMACC Conference
Delaney helps highlight recent research into pre-hospital intubation and intracranial pressure monitoring for patients with TBI. This talk was recorded at Bedside Critical Care Conference 4 and is available with the Intensive Care Network on Libsyn and on www.intensivecarenetwork.com
Secondary brain injury occurs after the initial primary brain injury and can develop hours or days later due to complications from the primary mechanism of injury. Neurocritical care aims to prevent secondary brain injuries by maintaining adequate oxygenation and circulation to the brain and managing factors like intracranial pressure and hypotension that can exacerbate the initial injury. However, the best time to save neurons is before they reach the neurocritical care unit since once there, the damage may already be done.
The COGENT trial was a randomized controlled trial that investigated whether a fixed-dose combination of clopidogrel and omeprazole reduced gastrointestinal events compared to clopidogrel alone in patients receiving dual antiplatelet therapy. The trial found no significant difference in gastrointestinal bleeding events between the combination group and clopidogrel alone group. Additionally, the trial found no evidence that omeprazole increased the risk of cardiovascular events when combined with clopidogrel. In fact, preliminary results found the combination group had a lower risk of the composite cardiovascular endpoint compared to clopidogrel alone. The results provide reassurance that coadministration of clopidogrel and a proton pump inhibitor does not increase cardiovascular
1) The IMPROVE-IT trial investigated whether adding ezetimibe to simvastatin therapy provides additional cardiovascular benefit compared to simvastatin monotherapy in 18,144 high-risk patients who had an acute coronary syndrome.
2) At a median follow-up of 6 years, combination ezetimibe/simvastatin therapy resulted in a statistically significant 9% relative risk reduction in major cardiovascular events compared to simvastatin alone.
3) Combination therapy also significantly reduced the risk of cardiovascular death, nonfatal myocardial infarction, or nonfatal stroke by 10% compared to simvastatin monotherapy.
This document discusses hypoperfusion in acute heart failure. It begins with case examples from Duke Hospital and considerations for diagnosis. It then covers inotropic options and mechanical support devices. Various studies on inotropes, percutaneous support devices, and extracorporeal membrane oxygenation are summarized. The conclusion is that hypoperfusion in acute heart failure presents major challenges for diagnosis and treatment.
1) The document compares the factor Xa inhibitor fondaparinux to enoxaparin for treating acute coronary syndrome, based on the OASIS-5 trial results.
2) The trial found that fondaparinux was as effective as enoxaparin for outcomes like death, MI, and ischemia, but had significantly lower rates of major bleeding at 9 days and 6 months.
3) Based on these results, fondaparinux provides an improved benefit-risk profile compared to enoxaparin for treating acute coronary syndrome.
Death by Neurological Criteria and Organ Donation: Bill KnightSMACC Conference
Bill Knight explains the concept of death by neurological criteria and the complexities surrounding organ donation in such situations.
Bill discusses the process of dying, the definition of death, how to approach the neurologically dead patient and how to consider organ donation.
Death is a complex topic.
Due to advancements in medical technology and processes, the definition of death is a challenging one.
Bill talks at length about the definition of death by the neurological criteria. Dying is an active process, whereas death is an event.
The acceptance of death by the neurological criteria is often challenging as Bill will highlight. Bill talks about the care of the dying or dead patient.
There is a point at which care will transition from supporting the patient to supporting the organs. This is still good care.
There is an alignment of parallel intentions – first and foremost resuscitation of patients and then failing that, proceeding to considering and actioning organ donation. This is important due to the shortage of viable donor organ worldwide.
The donation process itself is complex. Bill provides his thoughts. He insists that an intensivist be involved as this has been shown to increase the number of viable and healthy organs made available.
The timing is also important. Available evidence does not support the need for immediate procurement after brain death. Taking time to optimise perfusion and allow recovery and cardiac function is appropriate and should be done.
Bill also discusses other treatment options at the time of death such as optimising endocrine function.
Finally, Bill will provide some practical considerations when communicating with the dead patient’s family. This involves being clear on your messaging. You are supporting organs, not life.
To reinforce this point, Bill suggests not examining or talking to the patient. He also recommends using all of the available hospital support services.
Similarly, it is best to not introduce the topic of organ donation to the family yourself as the treating clinician. Utilise the Organ Procurement Organisations (or similar services) and get them involved early to speak with the family.
Join Bill Knight in his talk on the North American perspective on Organ Donation, brain death and management of the brain dead donor prior to organ donation.
For more like this, head to our podcast page. #CodaPodcast
- The document discusses contrast-based fractional flow reserve (cFFR) which uses intracoronary contrast to induce hyperemia rather than intravenous adenosine.
- Studies have shown cFFR has higher diagnostic accuracy than resting physiology measures like iFR and Pd/Pa, correctly identifying around 85% of lesions compared to around 80% for resting measures.
- cFFR provides an alternative approach to assessing coronary physiology that is faster and avoids the side effects of intravenous medications like adenosine.
1) The IMPROVE-IT trial investigated whether adding ezetimibe to simvastatin therapy provides additional cardiovascular benefit compared to simvastatin monotherapy in 18,144 high-risk patients who recently had an acute coronary syndrome.
2) Patients receiving ezetimibe/simvastatin had a lower rate of major cardiovascular events (32.7% vs 34.7%) over a median follow-up of 6 years, demonstrating the additional clinical benefit of further lowering LDL-C with ezetimibe.
3) Ezetimibe/simvastatin also reduced the rate of the composite endpoint of cardiovascular death, non-fatal myocardial infarction, or non-fatal stroke compared to
Delaney shares insights into the mysterious world of statistics and trials. This 12 minute podcast is particularly useful for Registrars preparing for their exams and was recorded at BCC4. For similar podcasts and audio; head to www.intensivecarenetwork.com and to rego for BCC5 in Cairns, check out www.bedsidecriticalcare.com
Eplerenone in Patients with Systolic Heart Failure and Mild Symptoms.
Presented at AHA by: Faiez Zannad, M.D., Ph.D., John J.V. McMurray, M.D., Henry Krum, M.B., PhD., Dirk J. van Veldhuisen, M.D.,Ph.D., Karl Swedberg, M.D., Ph.D, Harry Shi, M.S., John Vincent, M.B., PhD., Stuart J Pocock, Ph.D. and Bertram Pitt, M.D. for the EMPHASIS-HF Study Group * Eplerenone in Mild Patients Hospitalization And SurvIval Study in Heart Failure
Courtesy of http://www.cardiovascularbusiness.com
ACTEP2014: Sepsis management has anything change taem
This document discusses sepsis management and what has changed. It begins with an introduction to the pathophysiology of sepsis, severe sepsis, and septic shock. It then discusses early goal directed therapy (EGDT) and landmark studies like Rivers 2001 that promoted protocolized resuscitation to targets like central venous pressure, mean arterial pressure, ScvO2, and transfusion thresholds. However, later large trials like ProCESS 2014 found no difference in mortality between EGDT, standard therapy, and usual care. Targets like CVP are not accurate predictors of fluid responsiveness. Studies also found no difference in outcomes between higher and lower blood pressure or hemoglobin transfusion thresholds. There remains uncertainty around optimal fluid type, vas
Troponin use it in all patients with acute heart failure contradrucsamal
Alan Maisel is the director of the coronary care unit and heart failure program at the San Diego Veterans Hospital. He discusses whether troponins are needed in the assessment and management of heart failure. While troponins can be elevated in heart failure and correlate with worse outcomes, their role in clinical decision making for heart failure is unclear as evidence is still lacking around using them to guide specific biomarker-directed therapy. Further research is needed to determine appropriate cut-off levels that should prompt further ischemic workup and how clinicians should modify treatment based on troponin levels in heart failure.
http://www.theheart.org/web_slides/1225049.do
A randomized double-blind, double-dummy trial on MAGELLAN (VTE Prophylaxis in Medically Ill Patients) to show noninferiority of rivaroxaban to enoxaparin at 10 days and superiority at 35 days
1. Mr. SG, a 42-year-old male, was diagnosed with chronic immune thrombocytopenia purpura (ITP) and hepatitis B after being found to have low platelet count during a routine blood test.
2. He received supportive treatments including platelet transfusions, antibiotics, and antacids. Rituximab treatment was started along with antiviral medication to prevent hepatitis B reactivation.
3. The plan is to continue rituximab weekly for 4 weeks along with long-term antiviral therapy and monitoring of platelet counts and liver function to manage the ITP and hepatitis B.
Wavy triple an ECG sign (Yasser’s sign) in hypocalcaemia -Cardiology and Eme...YasserMohammedHassan1
The Wavy triple an electrocardiographic sign (Yasser’s sign) is a new diagnostic sign seen in 97.3% (36 cases) of hypocalcemia. Dramatic improvement of both clinical manifestation and the new electrocardiographic sign simultaneously after calcium replacement had happened.
This document discusses various methods for assessing coronary artery disease, including iFR, FFR, and resting gradients like Pd/Pa. It summarizes recent clinical trials comparing these techniques. The key points are:
1) Resting indices like iFR and Pd/Pa provide equivalent information to each other but differences remain when compared to FFR, especially for proximal left anterior descending artery lesions.
2) Trials comparing iFR to FFR did not definitively show iFR was non-inferior in reducing hard clinical outcomes like death and myocardial infarction.
3) Contrast-enhanced FFR may be superior to resting indices as it has the highest correlation with FFR and best diagnostic accuracy.
BCC4: Michael Parr on ICU - Surviving Trauma GuidelinesSMACC Conference
Michael Parr, director of Liverpool ICU in Australia, speaks about "Surviving Trauma Guidelines". He does so through the use of an interesting case of a patient admitted to ICU following a MVA. This educational podcast was recorded at BCC4.
This document summarizes several clinical trials related to critical care medicine. It discusses trials on topics such as decompressive craniectomy for traumatic brain injury, hypothermia for traumatic brain injury, erythropoietin for brain injury, blood pressure management for intracerebral hemorrhage, vasopressin versus norepinephrine for septic shock, dexmedetomidine for delirium, timing of renal replacement therapy for acute kidney injury, acetazolamide for chronic obstructive pulmonary disease, paracetamol for fever, balanced fluids versus saline, and transfusion thresholds.
Mrs. J, a 56-year-old female, presented with complaints of pain in her right hip and both knees. She was diagnosed with osteoarthritis in both knees. She underwent a bone marrow aspirate concentrate (BMAC) injection in both knees, which provided a natural alternative to surgery. Her hypertension was managed with nefidipine and amiloride/hydrochlorothiazide. She was discharged in a stable condition with recommendations for pain medication, diet and lifestyle modifications, and continued management of her osteoarthritis and hypertension.
BCC4: Anthony Delaney on Traumatic Brain Injury in the Real WorldSMACC Conference
Delaney helps highlight recent research into pre-hospital intubation and intracranial pressure monitoring for patients with TBI. This talk was recorded at Bedside Critical Care Conference 4 and is available with the Intensive Care Network on Libsyn and on www.intensivecarenetwork.com
Secondary brain injury occurs after the initial primary brain injury and can develop hours or days later due to complications from the primary mechanism of injury. Neurocritical care aims to prevent secondary brain injuries by maintaining adequate oxygenation and circulation to the brain and managing factors like intracranial pressure and hypotension that can exacerbate the initial injury. However, the best time to save neurons is before they reach the neurocritical care unit since once there, the damage may already be done.
Anyone Can Intubate, or Not: Teaching airway skills the antifragile waySMACC Conference
Becoming competent in airway management requires good decision making and and technical skills. Ultimately what matters is how your clinical performance impacts patient outcomes. For this we need to have a clear understanding of what defines success ensuring that its more than just 'getting the tube'. Come to this talk and you'll experience a Canadian take on Guinness, adventure sports, flying a plane and how other factors including failure influence airway management outcomes.
Presentation from the SWEETs 16 conference, Sweden. This presentation works on the applications of simulation for a major change management project in becoming ready for the closure of a paediatric hospital and the impact on an adult emergency department.
The document outlines steps for intubation including preparing, anticipating challenges, ensuring oxygenation and ventilation through various means including initially placing an endotracheal tube, addressing a failed intubation by continuing oxygenation and ventilation, planning for a surgical airway if intubation and ventilation cannot be achieved, and successfully performing a surgical airway with the bottom line being oxygenation and ventilation were maintained.
GEMC: Meningitis and Other CNS Infections: Resident TrainingOpen.Michigan
This is a lecture by Dr. Frank Madore from the Ghana Emergency Medicine Collaborative. To download the editable version (in PPT), to access additional learning modules, or to learn more about the project, see http://openmi.ch/em-gemc. Unless otherwise noted, this material is made available under the terms of the Creative Commons Attribution Share Alike-3.0 License: http://creativecommons.org/licenses/by-sa/3.0/.
This document discusses 7 hacks for medical education and lifelong learning. It recommends learning from masters like Osler, discovering the hidden curriculum, and applying cognitive science techniques like retrieval practice and spaced repetition. It also suggests joining the FOAM (Free Open Access Meducation) movement, being a critical thinker by evaluating sources, and working smarter through time management. The overall message is that learning is difficult but must be embraced in order to continually improve, master knowledge, and have a positive impact.
Workshop on the benefits of social media, professional learning networks and digital creation and curation. Given at the Laerdal Aus Simulation Users Network Sydney 2016
FOAMed in 2012 focused on airway management, checklists, and optimizing resuscitation room performance. Key topics included new airway devices, using checklists to guide procedures like intubation, and approaches like the "Vortex" to manage difficult airways. FOAMed resources highlighted evidence-based practices and innovative techniques to improve patient care and guide the future of emergency medicine.
The document discusses the importance of properly oxygenating, committing to, and confirming correct placement of an endotracheal tube during intubation. It notes that failure to do these three things can lead to "lethal airway sins" and references an airline crash caused by a pilot becoming incapacitated when no one confirmed correct placement of his oxygen mask. It advocates for checklists and protocols like RSI, RSA, DSI, NODESAT, and VORTEX to help avoid errors during intubation and proper oxygenation.
Deirdre talks ‘bad blood’ – the complex world of critical care haematology.
Critically ill patients frequently have activation of inflammatory and clotting pathways. These are likely adaptive responses in the human.
When they run riot, or the fine balance between pro- and anti-inflammatory states is shifted, there can be significant morbidity and mortality.
Deirdre presents three patients to highlight these issues and what you can do about it. This acronym-busting talk will focus on some acquired haematological disorders in critically ill patients.
Platelets make up a tiny percentage of blood – just 0.01%. However, they have a crucial role to play. A low platelet count can be due to reduced production or increased destruction.
Disseminated Intravascular Coagulation (DIC) is a clinical and laboratory diagnosis that affects about 1% of hospitalised patients. At the most severe end it is associated with bleeding and/or thrombotic complications. Disorders such as thrombotic thrombocytopenia purpura (TTP) and other forms of micro-angiopathic haemolytic anaemia (MAHA) will also be described including the role of ADAMST13.
The knowledge of what is what, is critical, as it will dictate treatment. Heparin-Induced Thrombocytopaenia (HIT) is an uncommon but important condition which is difficult to diagnose in a critically ill patient. It is a heparin dependent pro-thrombotic disorder. There is no good test for HIT.
Have you always wondered about NETs (neutrophil extracellular traps) and their importance? If so this whistle-stop tour of non-malignant hematology in the ICU is for you!
Deirdre drives home the message that low platelets are common in the critically ill and the causes are multifactorial.
Finally, for more like this head to our podcast page. #CodaPodcast
Forget ACLS Guidelines when dealing with PEA. Part1.Mario Rugna
This document discusses the differences between asystole, pulseless electrical activity (PEA), true PEA/electromechanical dissociation (EMD), and pseudo-PEA in cardiac arrest patients. While an algorithm may indicate the same treatment for asystole and PEA, they are clinically and therapeutically different conditions. The document recommends using central pulse palpation, EKG trace, end-tidal carbon dioxide, and point-of-care ultrasound to differentiate between these non-shockable rhythms and determine the appropriate treatment.
The document discusses Class IIa and IIb recommendations from the American Heart Association guidelines regarding resuscitation technology including impedance threshold devices, mechanical piston devices, and load distributing bands. It notes that incremental benefits of technologies are significant when combined, and that cooling unconscious adult patients with spontaneous circulation to 32-34°C for 12-24 hours may be beneficial if the initial rhythm was ventricular fibrillation. The American Heart Association does not endorse any particular products.
Stuart Lane on prognostication post out of hospital cardiac arrestSMACC Conference
Always controversial, always entertaining, the fearsome but loveable Geordie Stuart Lane gives an excellent summary of a core ICU topic: managing out of hospital cardiac arrests. Nearly at the end of the BCC3 series - and in only a month we're doing it all again, this time in tropical Cairns - come and join us.
This Talk is a Summary of:
1. Review the Importance of Quality in CPR
2. Discuss the Safety of “Hands-on” Defibrillation
3. Evaluate Manual vs Mechanical CPR
A presentation given by Luke Wainwright and myself about some of the trials and tribulations and eventual successes with integrating simulation into hospital education programs.
Sdc smacc educational leadership and subversion copySimon Carley
This document discusses educational leadership and questions whether it is needed. It considers what educational leadership might look like and what its goals should be. It references developing leadership qualities like responsibility, example, excellence, development and judgment. It questions whether copying traditional academic values is worthwhile and who should decide such issues. It concludes by suggesting educational leadership should support enthusiasts and evangelize to the unconverted, and that the wise can learn from others' mistakes.
This document summarizes research on intracranial pressure (ICP) monitoring in patients with severe traumatic brain injury. It discusses several key points:
1. While ICP monitoring is commonly recommended, the evidence from randomized controlled trials does not clearly support its use. One trial found no benefit to management guided by ICP monitoring over clinical exams and CT scans.
2. Guidelines set ICP thresholds for intervention but the optimal thresholds are unclear. Some studies found thresholds of 22 mmHg for mortality and functional outcomes.
3. Monitoring cerebral perfusion pressure (CPP) in addition to ICP may be important as outcomes improved with better adherence to CPP guidelines over time.
4. Effective treatments for elevated
1. The document discusses a symposium on the role of prasugrel in managing acute coronary syndrome patients undergoing percutaneous coronary intervention (ACS-PCI).
2. It summarizes results from the TRITON-TIMI 38 trial comparing prasugrel to clopidogrel in treating ACS-PCI patients. Prasugrel showed a statistically significant reduction in cardiovascular events compared to clopidogrel in all ACS-PCI patients and those with diabetes at 12 months.
3. In STEMI-PCI patients, prasugrel also reduced cardiovascular events compared to clopidogrel at 12 months, though the trial was not powered for this subgroup. Increased risks of bleeding were seen
1) The TRITON-TIMI 38 trial compared the antiplatelet drug prasugrel to clopidogrel in 13,608 patients with acute coronary syndrome undergoing percutaneous coronary intervention.
2) Prasugrel was found to significantly reduce the primary composite endpoint of cardiovascular death, myocardial infarction, or stroke compared to clopidogrel, from 12.1% to 9.9%. However, prasugrel was also associated with an increased risk of bleeding.
3) In the overall study population, the superior efficacy of prasugrel in reducing ischemic events outweighed the increased risk of bleeding, representing a net clinical benefit. However, prasugrel appeared to have less benefit or
Early Stage Nsclc The Role Of Chemotherapyfondas vakalis
- The document discusses the role of chemotherapy in early stage non-small cell lung cancer (NSCLC), including adjuvant and induction chemotherapy.
- Several studies on induction chemotherapy found it to be safe and feasible prior to surgery, with high rates of tumor response and similar postoperative complications compared to surgery alone. However, larger phase III studies are still ongoing.
- The optimal use of chemotherapy, whether adjuvant or induction, in early stage NSCLC remains unclear and requires completion of current clinical trials.
Lessons from the TTM trial and planning for the nexstscanFOAM
1) Detailed neurological examinations and blinded prognostication were conducted in the TTM trials to minimize bias in outcomes.
2) Follow-up assessments at 6 months in TTM1 found cognitive impairment, depression, and reduced quality of life in about one third of patients despite similar mortality between groups.
3) Extended cognitive testing in TTM1 at 6 months revealed memory, executive function, and processing speed impairments in about half of patients, more than in risk-factor matched controls, showing long-term cognitive consequences after cardiac arrest.
1) The document discusses several major trials related to decompressive craniectomy for traumatic brain injury. The DECRA and RESCUEicp trials investigated the effectiveness of early and late decompressive craniectomy, respectively, and found different outcomes.
2) Controversy remains around how to define "favorable" versus "unfavorable" outcomes. The Eurotherm3235 trial investigated the use of therapeutic hypothermia for TBI but results are still pending.
3) Ongoing trials like RESCUE-ASDH aim to provide more clarity on the optimal surgical management of specific traumatic brain injuries.
1) Hypothermia has been proposed as a treatment for traumatic brain injury (TBI) to help reduce secondary brain damage.
2) Previous studies on hypothermia for TBI have shown mixed results, with some trials finding benefits and others finding no effect.
3) The author conducted a randomized controlled trial of 107 patients with severe TBI to study the effects of progesterone, hypothermia, or their combination on outcomes.
4) The trial found the best outcomes based on Glasgow Outcome Scale at 6 months in the hypothermia group, followed by the progesterone group, though the combination did not provide additional benefit over hypothermia alone.
1) Hypothermia has been proposed as a treatment for traumatic brain injury (TBI) to help reduce secondary brain damage.
2) Previous studies on hypothermia for TBI have shown mixed results, with some trials finding benefits and others finding no effect.
3) The author conducted a randomized controlled trial of 107 patients with severe TBI to study the effects of progesterone, hypothermia, or their combination on outcomes.
4) The trial found the best outcomes based on Glasgow Outcome Scale at 6 months in the hypothermia group, followed by the progesterone group, though the combination did not provide additional benefit over hypothermia alone.
This document summarizes a journal club discussion of a randomized trial comparing outcomes of intracranial pressure monitoring versus clinical examination alone for patients with severe traumatic brain injury. Key points included that the trial found similar outcomes between the two groups in composite endpoints and mortality. However, the intracranial pressure monitoring group received more aggressive treatments such as barbiturates. There was skepticism around applying the results to clinical practice in the US due to differences in pre-hospital care, rehabilitation standards, and treatment protocols between the study locations and the US.
Niklas Nielsen talks about the TTM trial as seen through a 2019 lens.
The video and references from the talk and all the rest of the goodness from The Big Sick 2019 in Zermatt is up at
https://scanfoam.org/
Research guru and PI for the ARISE study, college examiner and semi-professional forrest-based carpenter, Anthony always gives a fascinating talk. This time he gives an intelligent and considered breakdown on the nebulous topic of cerebral protection.
Pediatric Severe Traumatic Brain Injury-1.pptxzahramoukhader
- The document describes the case of a 6-month-old girl who presented with agitation, somnolence, spastic movements, and a history of head trauma after a fall.
- Initial workup revealed a Glasgow Coma Scale of 8, dilated pupils, and abnormal movements indicative of severe traumatic brain injury and possible intracranial bleed.
- She was admitted to the PICU for monitoring and treatment including anti-seizure medications, steroids, hydration, and head elevation. Her condition gradually improved over the following days.
Pre op planning Acromegaly.pptxxfffgbaCBcRAKESH KUMAR
This document contains a case presentation and pre-operative workup for a 45-year-old female patient presenting with signs and symptoms of acromegaly including headache, vision changes, coarse facial features, and enlarged hands and feet. Physical examination findings are consistent with acromegaly. Laboratory tests show elevated serum growth hormone and IGF-1 levels. Imaging reveals a pituitary adenoma. The patient is scheduled to undergo transnasal transsphenoidal excision of the pituitary adenoma to control her acromegaly.
Update on cardiac arrrest and post cardiac arrest management16 1-18Anand Tiwari
This document summarizes updates on cardiac arrest and post-cardiac arrest management. It discusses key changes including emphasizing high-quality CPR, early defibrillation, and targeted temperature management. Intubation is now de-emphasized as it can interrupt chest compressions and be associated with lower survival rates. Post-cardiac arrest care focuses on coronary angiography for suspected cardiac causes and targeted temperature management at 32-36°C for at least 24 hours. Multiple clinical exams, tests and biomarkers can help predict neurological outcomes but should be used together given limitations of individual methods.
Lapatinib is an oral tyrosine kinase inhibitor that is effective for HER2-positive breast cancer patients, including those with brain metastases. A phase II trial found that lapatinib led to partial responses in 6% of patients with HER2-positive breast cancer and brain metastases who progressed on prior trastuzumab therapy. Volumetric reductions of at least 20% in brain lesions on MRI were associated with improved progression-free survival. The most common adverse events were diarrhea and rash, which were primarily grades 1-2 in severity. Lapatinib is an important treatment option for HER2-positive breast cancer patients with brain metastases.
1) Oncologic emergencies can involve several body systems and include conditions like pericardial tamponade, superior vena cava syndrome, increased intracranial pressure, spinal cord compression, tumor lysis syndrome, sepsis, and symptomatic complications from the cancer or its treatment.
2) The case documents presented examples of patients presenting with pericardial tamponade, superior vena cava syndrome, increased intracranial pressure from brain metastases, and spinal cord compression from a plasmacytoma.
3) For each emergency, the document discussed diagnostic tests, treatment approaches like steroids, surgery, radiation, chemotherapy, and emphasized the importance of rapid diagnosis and management
Similar to Myburgh, John — Raised ICP: Keeping a Lid on It (20)
Systematic review of 26 studies with 55,792 patients found that dedicated neurocritical care (NCC) was associated with decreased risk of mortality (17% relative risk reduction) and decreased risk of poor functional outcomes (17% relative risk reduction) in critically ill brain-injured adults. A survey of Australian ICUs found limited availability of NCC, with only 4 centers specializing in it and 9 employing an intensivist subspecializing in NCC. Continuous EEG monitoring was found to have higher sensitivity for detecting nonconvulsive seizures than routine EEG monitoring, and was associated with reduced in-hospital mortality, though barriers to its universal use include infrastructure and personnel requirements.
CORTICAL SPREADING DEPOLARISATION IN NEUROLOGICAL DISEASE – AN INTRODUCTION
By Toby Jeffcote
Cortical spreading depolarization (CSD) is a spreading loss of ion homeostasis, altered vascular response, change in synaptic architecture, and subsequent depression in electrical activity following an inciting neurological injury.
It was first described by Leão in 1944, a disturbance in neuronal electrophysiology has since been demonstrated in a number of animal studies, and recently a few human studies that examine the occurrence of this depolarizing phenomenon in the setting of a variety of pathological states, including migraines, cerebrovascular accidents, epilepsy, intracranial hemorrhages, and traumatic brain injuries. The onset of CSD has been demonstrated experimentally following a disruption in the neuronal environment leading to glutamate-induced toxicity. This initial event leads to pathological changes in the activity of ion channels that maintain membrane potential. Recovery mechanisms such as sodium-potassium pumps that aim to restore homeostasis fail, leading to osmolar shifts of fluid, swelling of the neuron, and ultimately a measurable depression in cortical activity that spreads in the order of millimeters per minute. Equally important is the resulting change in vascular response. In healthy tissue, increased electrical activity is coupled with release of vasodilatory factors such as nitric oxide and arachidonic acid metabolites that increase local blood flow to meet increased energy expenditure. In damaged tissue, not only is the restorative vascular response lacking but a vasoconstrictive response is promoted and the ischemia that follows adds to the severity of the initial injury. Tissue threatened by this ischemic response is then at elevated risk for CSD propagation and falls into a vicious cycle of electrical and hemodynamic disturbance. Efforts have been made to halt this spreading cortical depression using N-methyl-D-aspartate receptor antagonists and other ion channel blockers to minimize the damaging effects of CSD that can persist long after the triggering insult.
Celia Bradford takes us through the latest on the management of subdural haemorrhage (SDH). She covers acute SDH, chronic SDH and middle meningeal artery embolisation, a novel treatment for chronic SDH management in certain circumstances.
Andy Neill - More neuroanatomy pearls for neurocritical careSMACC Conference
Andy Neill shares some more neuroanatomy wisdom that's highly practical for anyone working with neuro emergencies. This time he covers brain herniation syndromes, hydrocephalus, extradural vs subdural haematomas, cervical spinal imaging, vertebral artery dissection and "things you read on CT reports but don't know what they mean"!
Andrew Udy talks about Brain Tissue Oxygen Monitoring:
It’s Not What You’ve Got It’s What You Do With It
The BONANZA Trial
Andrew Udy talks about the ongoing BONANZA Trial which is assessing whether an algorithm that incorporates both ICP and brain tissue oxygen (PbTO2) can improve outcomes after traumatic brain injury (TBI). Like with all monitoring, how the PbTO2 is interpreted and managed is critical and the devil is in the detail!
More on BONANZA here
More on BOOST3 here
R. Loch Macdonald, M.D., Ph.D.
Community Neurosciences Institute
Fresno, California, USA
Angiographic vasospasm and more accurately, delayed cerebral ischemia, continue to contribute to morbidity and mortality in patients with aneurysmal subarachnoid hemorrhage (SAH). It is known that angiographic vasospasm is common after SAH, occurring in two-thirds of patients. Cerebral infarctions that developed days after the SAH have been attributed to angiographic vasospasm, occuring in about a third of patients, although this has always been controversial. Angiographic vasospasm theoretically can only damage the brain by restricting blood flow but there is no easy, accurate, widely available method to measure cerebral blood flow and this is not the measurement we need. Blood flow depends on metabolic demand so what we need to know to determine if angiographic vasospasm is causing ischemia is oxygen extraction fraction in the brain tissue supplied the the spastic artery. Without this measurement, the attribution of ischemia to vasospasm is subjective. Since angiographic vasospasm is essentially the only detectable delayed phenomenon after SAH, we focus on it and apply tremendous resources to preventing or reversing the vasospasm. Undoubtedly angiographic vasospasm can cause cerebral infarctions, but it has to be severe and flow limiting. But SAH is a complex disease. There are many other causes for cerebral infarctions after SAH, the most common being due to the aneurysm repair procedure. And a given degree of vasospasm may cause infarction in a volume-depleted patient with poor collateral blood supply but not in a patient without these things. There also are hypodense brain lesions after SAH that are due to intracerebral hemorrhages. There can be hypodensities in the brain directly under usually thick SAH where the brain dies. This observation in particular supports a role for cortical spreading depolarizations/ischemia as a cause of infarction after SAH. Other macromolecular processes that are hypothesized to cause brain damage after SAH include microthromboembolism, changes in the microcirculation, delayed brain cell apoptosis and capillary transit time heterogeneity. Determining the importance of these things is hindered by the lack of an easy way to detect them in patients. It is also known that poor grade patients, who presumably have more early brain injury and ischemia than good grade patients, are more prone to delayed cerebral ischemia, suggesting increased sensitivity to secondary insults of the already injured brain. We also assume delayed neurological deterioration when attributed to vasospasm or delayed cerebral ischemia, is purely due to ischemia. While knowledge about what happens pathophysiologically after SAH is increasing, management of delayed cerebral ischemia still focuses on detecting angiographic vasospasm and then augmenting the blood pressure to improve cerebral blood flow or dilating the spastic arteries with balloons or drugs.
By Catherine Bell and Andrew Udy
Catherine Bell takes us through how to troubleshoot problems commonly encountered when looking after patients who have an external ventricular drain (EVD) in situ. Issues with using brain tissue oxygen monitors are also discussed. A highly practical session aimed at bedside clinicians.
There is no such thing as mild, moderate and severe TBI - by Andrew UdySMACC Conference
Part 2 of a debate over the classification of TBI. Andrew Udy then argues that this classification is fundamentally flawed. He discusses the issues with the Glasgow Coma Scale, and therefore the follow-on issues in TBI classification, including all the confounders to the GCS, the issues with timing of the score as well as GCS not taking baseline function or specifics subtypes of TBI into account. He makes teh argument that biomarkers may better categorise the diffuse entity we call TBI.
TBI Debate - Mild, moderate and severe categories workSMACC Conference
Andrew Chow, Intensivist with a neurosurgical background, argues that the current categorisation system for traumatic brain injury (TBI) works, and makes sense! He tackles us through the history of this system, and why it’s important to differentiate different types of TBI. The arguments in favour of this categorisation include the consistency and benefits of a universal language, the implications for triage and management, and the fact that this system has been endorsed by all major organisations
Dr Nick Little is an experienced Neurosurgeon who's looked after patients with traumatic brain injury for his whole career. Here he discusses the difficulties of prognostication following traumatic brain injury (TBI). He talks about the statistics of outcomes following mild, moderate and severe TBI and then goes on to tackle the harder topic of how we try to work out what an individual would want if they knew the spectrum of outcomes that they may face. The issues with the clinical examination findings we use to prognosticate are covered, as well as which imaging findings he finds most helpful. He also mentions the difficulties with current prognostic calculators.
Historically, when it came to brain injury, ketamine had a bad rap. Much of that dogma was dispelled in the last decade, and ketamine is now frequently used as an induction agent in acute brain injury, especially traumatic brain injury, due to it’s favorable effects on haemodynamics.
However a new application of ketamine is now being explored - whether ketamine may be able to reduce secondary brain injury.
Managing Complications of Chronic SCI by Bonne LeeSMACC Conference
20 million people around the world are living with a spinal cord injury (SCI). The medical issues they develop over the years differ to any other patient cohort.
These complications include autonomic dysreflexia, management of pressure areas, specific infections, nuanced peri-operative care and highly specific issues such as baclofen pump management and syringomyelia
Do look at the NeuroResus section on this and listen to Spinal Rehab Specialist Bonne Lee talk about this side of SCI care.
Keywords
SCI, spinal, spinal cord injury, autonomic dysreflexia, pressure areas, infection, peri-operative care, baclofen pump, syringomyelia, chronic SCI, spinal trauma, spinal rehab, incomplete SCI
Tania is a neurologist and epileptologist with expertise in continuous EEG (cEEG) and status epilepticus (SE). This talk covers what a seizure is, what status is, including focal and generalised status epilepticus.
So why do we do cEEGs for patients with suspected SE?
To confirm the diagnosis
To see if patient just post ictal or still seizing
To establish that the clinical and electric seizures have stopped
To see if burst suppression is achieved
To exclude other differential diagnoses
She makes a good argument for why cEEG is such an important tool in managing SE.
In the questions after the talk, the issue of availability of cEEG in the Australian setting was discussed. Limited montage EEGs are discussed including their pros and cons.
Stuart Browne is a Neuro Rehab specialist from Sydney. These slides accompany a talk he gave at the Brian Symposium in 2023. He discusses what "severe disability" really means.
Severe disability is more common than many realise - about 6% of the Australian population.
Stuart discusses how health is more than simply physical recovery and how it is a multidimensional construct. He covers how permanent disability doesn't necessarily equate to a poor quality of life. He also discusses the long timespan of recovery, which is often much longer than appreciated.
He specifically discusses "Locked-in Syndrome" and how the survivors have surprisingly positive self-reported health-related quality of life and well-being.
Stuart also covers how severely disabled people face various forms of discrimination.
Shree Basu is a Paediatirc Intensivist in Sydney. These slides from the Brain Symposium 2023 accompany the talk she gave. She discusses how Paediatric stroke presents, what neuroimaging is required and what interventions are available, including thrombolysis and the role of endovascular thrombectomy.
Hypertensing Spinal Cord Injury - gold standard or wacky?SMACC Conference
This document discusses the concept of maintaining higher blood pressure levels, known as hypertension, after a spinal cord injury to improve spinal cord perfusion pressure and reduce secondary injury. It notes that while animal studies and some human trials have shown improved neurological outcomes, the evidence is still limited. It calls for larger randomized controlled trials in humans that also incorporate multi-modal monitoring and standardized outcome measures to further evaluate if inducing hypertension after spinal cord injury should be considered the gold standard of care.
Mark Weedon takes us through the increasingly utilised concept of an optimal cerebral perfusion pressure (CPPopt) for each unique patient. He discusses the background to CPPopt, including intrcranial pressure (ICP), the Monroe Kelly hypothesis, neurovascular coupling, and cerebral autoregulation in health and following brain injury. He shows how intracranial pressure is affected by intracranial compliance and how this affects ICP waveforms. Cerebral perfusion pressure in relation to the Brain Trauma Foundation guidelines is covered including management of elevated ICP (EICP). The currently recommended tiered approach to managing cerebral perfusion pressure and EICP is mentioned citing recent guidelines. He uses a clinical case of a TBI to illustrate how the CPPopt can be ascertained and used to guide therapy, including the easy to perform “MAP Challenge”. Mark also describes the Pressure Reactivity Index (PRx) and how it can be used as a target for therapy. Finally, he covers the exciting results of the preliminary COGiTATE pilot study.
Social Worker Victoria Whitfield and Bereavement councilor Louise Sayers discuss the power of words when health professionals are communicating topics around of death and serious injury with relatives and patients in critical care. They use role plays to bring theories to life.
Sepsis and Antimicrobial Stewardship - Two Sides of the Same CoinSMACC Conference
Undertreatment of sepsis can lead to mortality, while overdiagnosis and overtreatment can increase future risk of antimicrobial resistance. Antimicrobial stewardship aims to balance these risks by prioritizing patient safety and appropriate antimicrobial use. Data shows variability in appropriateness of antimicrobial prescribing between different types of hospitals. Embedding antimicrobial stewardship principles throughout sepsis diagnosis and treatment, from initial microbiology testing to post-treatment review, can help standardize care and optimize outcomes.
Being able to prognosticate in the aftermath of a traumatic brain injury (TBI) is important as it assists with counselling patients and families. Moreover, it helps rationally allocate healthcare resources.
However, due to the heterogenous nature of TBI and variable pre brain injury patient factors and post brain injury course, this has proven to be a difficult task.
Large cohort studies have enabled improved accuracy in the prediction of 6 month mortality and unfavourable outcome.
Furthermore, many of the factors that contribute to long-term outcome have also emerged. However, it is not yet possible to use them in prediction algorithms or mathematical models.
There is emerging evidence that pre injury psychosocial and demographic factors may be of more relevance than injury severity. Moreover, that 'outcome' becomes increasingly subjective and complex as the post injury duration increases.
We end with three brief vignettes which highlight the fraught nature of long term outcome prediction.
1. Raised intracranial pressure:
keeping a lid on it
UNSW
John Myburgh
MBBCh PhD FCICM
The George Institute for Global Health
St George Clinical School, University of New South Wales
5. Neuroprotective trials
Maas: Neurosurgery 1999
HIT I (n=351)
HIT II (n=852)
HIT III (n=123)
PEGSOD (n=463)
Tirilizad (n=1128)
Triamcinolone (n=396)
HIT II tSAH
Tirilizad tSAH
Triamcinolone GCS 8
+focal lesion
Neuroprotective agents
All steroids
mean = 435
6. Rat / human model 20th century
Take a young male rat.
Infuse alcohol or speed until intoxicated.
Throw rat at high speed into brick wall
Break its femur and pelvis.
Leave it lying in the corner for 1 hour.
Get resident to resuscitate it using albumin
Include an oesophageal intubation and hypoxia for 20m.
Get orthopod to fix femur and lose 20% blood volume.
Do a CT head, but don’t tell the researcher the results.
Get a resident to put in ICP monitor 6-36 hours after injury.
Do the intervention.
Random use of mannitol, hyperventilation, hypothermia, barbs
Count how many rats are dead after 1 week.
10. Rat / human model 21th century
Take a rat of any age.
If young, infuse alcohol or speed until intoxicated.
If old, give warfarin and aspirin
Early intubation and resuscitation
Pan-scan and damage control surgery
Standardise ICP monitoring
Do the intervention.
Flog CPP with noradrenaline
Use hypothermia, barbiturates to keep ICP<20
Decompressive craniectomy if these don’t work
Keep going until the rat’s family tells you when to stop
Count how many rats are dead after 6 months.
14. Decompressive craniectomy
Indication
Age
Diffuse vs mass lesion
Traumatic vs non-traumatic
Timing
Pre-emptive
Rescue
Trigger
CT / clinical
ICP
Technique
Bifrontal vs unilateral
Dura open vs closed
Outcome
Physiological
Death / functional outcome
16. Jiang:J Neurotrauma: 2005
Multicentred RCT, blinded outcome adjudication
1998 – 2001
n=486
Age < 70
Clinical / CT triggers for decompression
Primary outcome: 6m GOS
Standard Limited
17. Jiang:J Neurotrauma: 2005
GR / MD SD / PVS Dead
0
10
20
30
40
50
Standard DC (n=241))
Limited DC (n=245)
6m GOS
%
0
10
20
30
40
50
Day
ICP(mmHg)
Pre DC 1 day 3 days 7 days
Standard DC (n=36)
Limited DC (n=47)
p=0.03
18. Cooper: New Eng J Med 2011
Multicentred RCT, blinded outcome adjudication
2002-2011
N=155 (age <60)
Age < 60; < 72h post injury
CT trigger: Diffuse injury
ICP trigger: >20 mmHg
Primary outcome: 6m GOS
vs Medical therapy
19. Cooper: New Eng J Med 2011
Unfavourable Favourable
70% 51%
OR: 2.21 95%CI 1.14 to 4.26; P=0.02
20.
21. www.rescueicp.com
Multi-centre RCT, blinded outcome adjudication
366/400 patients recruited
Age 18-65
ICP>25 mmHg
Refractory to medical therapy (2nd tier)
Included evacuated mass lesions
Clinically directed decompression
Primary outcome: Discharge + 6m GOSE
22. Honeybul: Brian inj 2013
Decompression for TBI
Survivors with unfavourable outcomes
Survivors with favourable outcomes
Survivors with favourable outcomes
29. Chesnut: NEJM 2012
ICP monitoring group
Imaging/exam group
P=0.60
ICP
(n=157)
ICE
(n=167)
OR (95%CI) p
CFOS 56 (22-37) 53 (21-76) 1.09 (0.74 to 1.58) 0.49
Death 56/144 (39%) 67 (41%) 1.10 (0.77 to 1.57) 0.60
30. T H Huxley
1825 - 1895
m
“That the great tragedy of
Science is the slaying of a
beautiful hypothesis with an
ugly fact”
31. Some concluding thoughts
Outcome from ABI is primarily determined by geography…
… and genetics
ICP is primarily an indicator of severity of injury
Treating ICP comes at a cost …
… saving the head, but killing the body…
… and those who care for the patient