Cartner, Michaela— Cardiac Surgery... then Cardiac Arrest
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1) The document provides guidance on assessing and treating deteriorating cardiac surgical patients in a safe and systematic way. 2) It emphasizes manipulating factors like heart rate, rhythm, preload, contractility, and afterload to optimize cardiac output and shock management in these patients. 3) For hemorrhage and cardiac tamponade, early recognition and reopening of the chest within 10 minutes of arrest can increase survival rates by over 50% for cardiac arrest patients after cardiac surgery.
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1. A brief history of key developments in cardiac surgery from 1896 to 1964.
2. The main purposes of cardiac surgery such as revascularization and valve repair/replacement.
3. Surgical approaches like open-heart, off-pump, and minimally invasive techniques.
4. Types of procedures including CABG, valve repair/replacement, and potential complications and nursing management in the postoperative phase.
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1) Minimally invasive cardiac surgery techniques have advanced with smaller cannulas, improved visualization tools, and robotic assistance, allowing for reduced trauma through smaller incisions.
2) Three case studies presented patients undergoing minimally invasive aortic valve replacement, mitral valve repair, and atrial septal defect repair who had short, uncomplicated hospital stays.
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Open heart surgery
Open heart surgery requires that the heart be still, dry, and relaxed. The basic steps involve opening the chest, placing the patient on bypass to circulate their blood, cooling and stopping the heart, performing the intracardiac operation, closing the heart, and weaning the patient off bypass. Key parts of the procedure include cannulating major vessels like the aorta and vena cavas to connect the patient to the bypass machine, delivering cardioplegia to arrest the heart, performing the necessary incisions and repairs on the heart, and closing the chest. Developing techniques have allowed some operations to be done without placing the patient on bypass.
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The major physiological effects of counterpulsation include:
A) increased coronary artery perfusion, increased preload, decreased after load, decreased myocardial oxygen consumption
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This document provides an overview of cardiac surgery, including:
1. A brief history of key developments in cardiac surgery from 1896 to 1964.
2. The main purposes of cardiac surgery such as revascularization and valve repair/replacement.
3. Surgical approaches like open-heart, off-pump, and minimally invasive techniques.
4. Types of procedures including CABG, valve repair/replacement, and potential complications and nursing management in the postoperative phase.
Op cab
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Transesophageal echocardiography
Trans-esophageal echocardiography (TEE) uses ultrasound to obtain high-quality images of the heart and surrounding structures. It involves inserting a probe with an ultrasound transducer at the tip through the mouth and esophagus. TEE provides clearer images than transthoracic echocardiography as the esophagus is directly behind the heart. A TEE exam involves systematically imaging the heart in various planes as the transducer is advanced and manipulated. Standard views include the mid-esophageal four-chamber, two-chamber, aortic, and RV inflow-outflow views. Real-time 3D TEE can provide en face views of structures.
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Point-of-care cardiac ultrasound, also known as focused cardiac ultrasound (FoCUS), can be performed at the bedside by any treating clinician to evaluate hypotensive patients. It uses 2D ultrasound to visualize the heart's size, function and anatomy without advanced training or technology. FoCUS can differentiate shock types and guide fluid resuscitation by examining the heart, lungs and IVC for signs of volume status. A normal, collapsing IVC suggests hypovolemia while B-lines in the lungs discourage further fluids for possible edema. RV size helps diagnose pulmonary embolism. This review discusses the clinical applications and techniques of FoCUS to rapidly diagnose and treat unstable patients.
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Coronary angiography is an x-ray examination of the heart's blood vessels. A small tube called a catheter is inserted into a blood vessel in the groin or arm and guided to the heart. A contrast dye is injected through the catheter to make the blood vessels visible on x-rays called angiograms. Preparation for coronary angiography involves explaining the procedure to the patient, obtaining consent, checking blood work and vital signs, preparing the insertion site, and providing psychological support and pre-medication. During the procedure, the patient's position and hemodynamics are monitored and contrast is injected to visualize the coronary arteries. Afterward, the sheath is removed, the site is dressed, and the patient is monitored
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Minimally invasive cardiac surgery
1) Minimally invasive cardiac surgery techniques have advanced with smaller cannulas, improved visualization tools, and robotic assistance, allowing for reduced trauma through smaller incisions.
2) Three case studies presented patients undergoing minimally invasive aortic valve replacement, mitral valve repair, and atrial septal defect repair who had short, uncomplicated hospital stays.
3) The evidence shows minimally invasive mitral valve surgery has equal outcomes to sternotomy with less post-operative pain and faster recovery, though longer bypass times, with long-term results also equivalent. It is well-suited for high-risk and re-operative patients.
Heart valve replacement surgery procedure
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Cardiac surgeries
Cardiac surgeries can be open-heart or closed-heart depending on whether a heart-lung machine is used. Open-heart surgeries involve opening the chest wall to access the heart directly while closed-heart surgeries work on external structures. Common types of heart surgery include valvular surgeries to repair or replace faulty heart valves, coronary artery bypass grafting to reroute blood flow around blockages, and treatments for congenital defects. Valve repairs and replacements are the most common adult cardiac surgeries.
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Perioperative Management
Perioperative Care of the Cardiac Surgery Patient
This document outlines key aspects of perioperative care for cardiac surgery patients, including:
1) Preoperative evaluation to assess risk factors and optimize medical conditions;
2) Intraoperative management focusing on organ protection and hemodynamic optimization;
3) Postoperative care in the ICU addressing common complications like arrhythmias, bleeding, and pulmonary issues.
Nursing care of client with Coronary artery disease part 2 of 2
- Provide small frequent feedings
- Low calorie, low cholesterol, low sodium diet
- Avoid stimulants, hot/cold beverages, gas forming foods
- Use bedpan, avoid straining at stool
CLDomocmat 8/9/2012 50
Potential for Dysrhythmias
related to myocardial ischemia, infarction,
electrolyte imbalances, medications
1. Continuous cardiac monitoring
2. Check electrolytes and replace as needed
3. Administer antiarrhythmic medications as
ordered
4. Teach client and family about warning signs
and symptoms of dysrhythmias
5. Report any changes in cardiac rhythm to
physician
Scott Weingart Cutting Edge Intra-Arrest Care
This document provides guidance on advanced cardiac life support (ACLS) techniques for resuscitationists. It outlines steps for securing airways through intubation, optimizing breathing by connecting to ventilators, and improving circulation with high-quality chest compressions. It also recommends prioritizing coronary reperfusion for STEMI patients in cardiac arrest and using vasoactive drugs like epinephrine. The document stresses the importance of minimizing peri-shock pauses, dosing epinephrine by blood pressure, and considering techniques like extracorporeal cardiopulmonary resuscitation. It emphasizes addressing human factors like keeping interventions quiet and knowing when premorbid state or time of arrest impacts survival chances.
Could it be Poison? By Little
Mark Little builds a framework for the clinical approach to patients with suspected poisoning or envenomation. Particularly useful in a country where everything is trying to kill you.
Intraaortic Baloon Counterpulsation
A summary about how to use & interpret IABCP
To download send me an email to sherif_badrawy@yahoo.com
SMACC 2014 presentation
The document discusses various topics in neuroanatomy and neuroimaging for emergency medicine, including types of brain herniation, hydrocephalus, spinal injury classifications, vertebral artery dissection, and interpretations of common findings on CT scans such as subdural hematomas and hemorrhages in the basal ganglia. Diagrams and images are provided to illustrate anatomical structures and pathologies.
Bernard - Refractory Cardiac Arrest
Professor Stephen Bernard is an Intensive Care Physician at The Alfred Hospital and Medical Advisor to Ambulance Victoria. His research interests include the use of therapeutic hypothermia for the treatment of neurological injury after resuscitation from out-of hospital cardiac arrest. Here he provides a presentation on recent advances in the management of refractory cardiac arrest in the out of hospital setting.
Cardiac Surgery - What can go wrong?
Deirdre Murphy presents everything that can go wrong in cardiac surgery.
Deirdre reinforces that cardiac surgery is by no means a safe procedure! Murphy’s Law stipulates everything that can go wrong, will go wrong.
Subsequently, Finagle’s corollary will tell us, it will be at the worst possible moment.
In this talk, Deirdre attempts to prove these theories in the world of cardiac surgery. Cardiac surgery can vary from being routine elective surgery to time-critical emergency surgery.
The term encompasses a broad range of procedures carried out on patients from neonates to nonagenarians.
In the 63 years since the first open heart surgery was performed using cardiopulmonary bypass, enormous advances have been made in the field. An average person presenting for coronary bypass grafting in 2016 can expect a very low chance of peri-operative morbidity or mortality.
When things go wrong however, they can go badly wrong and at the worst possible moment. The list of problems that occur is extensive.
Deidre steps through some of the more common issues that arise post cardiac surgery.
She describes pneumonia, mediastinitis, haemorrhage, ischaemia, and neurological issues, amongst others. Along the way she provides clinical pearls as to what to look for, what not to miss and what to do about it.
Through her extensive experience, Deidre has seen more than her fair share of post-cardiac surgery complications. She provides a number of clinical scenarios she has encountered, and in doing so gives useful insights to be aware of.
Her top tips are to prevent complications if possible. If not possible, recognise the complications early and finally train for ‘avalanches’ – those critical and scary situations that will put your patients at immediate risk of demise.
For more like this, head to our podcast page. #CodaPodcast
Jeremy Cohen - Raging Hormones and the Critically Ill
Jeremy Cohan took us on an Adrenal Function journey at SMACC Chicago with his talk Raging Hormones in Critical Care.
Cohan explores the natural roll of cortisol in the human body, various schools of thought and recent research in the areas of sepsis and cortisol resistance.
Ecmo Post Cardiac Surgery
This document discusses the use of ECMO (extracorporeal membrane oxygenation) after cardiac surgery. It outlines the indications for ECMO, including post-cardiotomy cardiogenic shock. Different cannulation strategies and their considerations are described. Monitoring patients on ECMO includes ensuring adequate oxygen delivery and preventing complications like bleeding, leg ischemia, and pulmonary edema. Myocardial stunning can lead to left ventricular overdistention, so decompression may be needed. Improving contractility may cause the harlequin phenomenon if lungs are not well ventilated. Outcome data shows a prevalence of 0.5-2.6% for post-cardiac surgery ECMO with in-hospital survival rates of
How to prepare a basic training module
This document provides guidance on preparing a basic training module. It discusses assessing learners' needs, designing the training to meet those needs, and developing the content and presentation. Key aspects include using the ADD concept of assessment, design, and development; considering learners' existing knowledge, needs, and expectations; and using effective presentation techniques like varying activities, using visuals, and practicing delivery. The goal is to create a simple, clear module that conveys the necessary information and skills to learners.
pulseless electrical activity bradycardia Nov 2014
PEA (pulseless electrical activity) and asystole represent the loss of cardiac contractility despite organized electrical activity in the heart. PEA and asystole indicate an advanced stage of shock. Treatment involves continuing CPR, addressing reversible causes like hypoxia, hypovolemia, cardiac tamponade, tension pneumothorax, hypothermia, pulmonary embolism, drug overdoses, and acidosis. Epinephrine may be administered but has limited benefit. The prognosis is generally poor for asystole and PEA that does not respond rapidly to treatment of reversible causes.
How To Prepare A Basic Training Module
This presentation is for those who are very new to Powerpoints and want to learn the art of making effective PPT's. Also the idea behind making a module, per say, is important and this PPT describes the parameters on which a Basic Training Module can be built. These parameters will help the new comers to get an Idea of how to prepare Training Modules
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Mechanical circulatory support (landes bioscience vademecum)
BCC4: Sharon Kay on Cardiac Crises Revealed in Echo
BCC4: Sharon Kay on Cardiac Crises Revealed in Echo
Nursing care of client with Coronary artery disease part 2 of 2
Nursing care of client with Coronary artery disease part 2 of 2
Jeremy Cohen - Raging Hormones and the Critically Ill
Jeremy Cohen - Raging Hormones and the Critically Ill
pulseless electrical activity bradycardia Nov 2014
pulseless electrical activity bradycardia Nov 2014
Similar to Cartner, Michaela— Cardiac Surgery... then Cardiac Arrest
Focused bedside Echocardiography
How to perform rapid focused bedside Echocardiography
Youtube lecture link:
https://youtu.be/_AHiQDfMo7k
CT EMS EXPO SCA SYSTEMS
This document discusses improving cardiac resuscitation systems of care. It describes how some systems achieve survival rates over 50% for cardiac arrests due to ventricular fibrillation through coordinated efforts including bystander CPR, public access defibrillators, EMS response times, and post-resuscitation care. The document outlines key components of model systems including establishing registries to measure performance, improving layperson and EMS involvement in CPR, and decreasing time to access emergency care. It emphasizes that the overall system of care, not individual components, determines survival rates.
Cardiopulmonary Resusitation (CPR- AHA 2015)
Dr Saeid Safari
Anesthesiologist
Pre CPR
CPR (BLS - ALS)
Post CPR
AHA 2015
Iranian Anesthesiology Network
Cardiopulmonary Resuscitation (CPR- AHA 2015)
PreCPR,
CPR (BLS, ALS) ,
Post CPR
احیا قلبی عروقی
طبق گایدلاین 2015
از سری اسلایدهای آماده شده برای شبکه آنستزیولوژی ایران
ECPR by Vincent Pellegrino 2016
Slides for a talk by Vincent Pellegrino (ECMO Director at The Alfred ICU) on ECPR. For videocast and audio only versions of this talk go to the RAGE podcast (http://ragepodcast.com/ecpr-vincent-pellegrino/) or The Alfred ICU's INTENSIVE blog (http://intensiveblog.com/ecpr-vin-pellegrino/).
acls/blsCARDIO PULMONARY RESUSITATION.pptx
CPR is used to treat cardiac arrest and cardiopulmonary resuscitation. It involves chest compressions, rescue breathing, and defibrillation to restore normal heart rhythm. The chain of survival includes early recognition, CPR, defibrillation, and advanced life support. When encountering cardiac arrest, one should ensure safety, check response, call for help, perform high-quality chest compressions and rescue breathing, and use an AED if available. Post-resuscitation care focuses on managing airway, oxygenation, circulation, glucose, temperature, and determining neurological prognosis. Acting quickly with BLS can make the difference between life and death.
ECMO for Cardiac Arrest
This document describes the case of a 29-year-old male who suffered an out-of-hospital cardiac arrest. He was brought to the emergency department still in pulseless electrical activity. The document discusses considering extracorporeal membrane oxygenation (ECMO) for the patient and summarizes the steps taken to initiate venoarterial ECMO. It provides an overview of ECMO and the evidence from the CHEER trial showing improved survival rates for cardiac arrest patients treated with ECMO, hypothermia, and early reperfusion. The patient in this case survived and was discharged with no neurological deficits.
new cocepts in cpr
The document discusses new concepts in CPR including continuous chest compression CPR (CC CPR) and cardio cerebral resuscitation (CCR). CC CPR emphasizes fast, uninterrupted chest compressions for lay rescuers while CCR, used by healthcare providers, adds defibrillation and medications. Studies at the University of Arizona and pilot programs in Tucson and other Arizona cities found that CCR increased survival rates for sudden cardiac arrest from less than 3% to 33% in Gilbert. The presentation includes demonstrations of CC CPR and CCR techniques.
CABG on CARDIOPULMONARY BYPASS
1) Coronary artery bypass grafting (CABG) is performed to improve quality of life and reduce mortality for patients with coronary artery disease.
2) Anesthesia for CABG involves monitoring the patient throughout various stages including pre-bypass, maintenance on bypass, and weaning from bypass.
3) Key aspects include induction, myocardial protection through hypothermia and cardioplegia, and monitoring the patient closely during and after coming off bypass.
Treadmill stress testing
This document provides information about treadmill exercise stress testing. It discusses the indications, protocols, measurements, and interpretation of treadmill stress tests. Key points include: treadmill stress testing evaluates the cardiovascular system's response to exercise; the Bruce and modified Bruce protocols are most commonly used; measurements include ECG changes, symptoms, heart rate and blood pressure response, and functional capacity; ST segment depression greater than 1mm is considered abnormal.
Presentation on mi
A 55-year-old male smoker and alcoholic presented with chest pain and was diagnosed with a myocardial infarction based on electrocardiogram and cardiac enzyme changes. He received treatment including aspirin, nitroglycerin, morphine, and streptokinase thrombolysis and was admitted to the intensive care unit. Nursing care focused on monitoring, providing pain relief, and health teaching prior to discharge.
Cardiac Arrest Rhythm.pdf
This document provides information on analyzing cardiac rhythms from an electrocardiogram (ECG) and determining appropriate treatment. It discusses normal sinus rhythm and defines shockable and non-shockable rhythms. Shockable rhythms include ventricular fibrillation (VF) and ventricular tachycardia (VT), which appear as irregular waveforms without discernible QRS complexes for VF or rapid heart rates over 150 bpm for VT. Non-shockable rhythms are pulseless electrical activity (PEA) and asystole, which show weak or absent electrical activity. The document outlines steps for systematically analyzing an ECG and determining treatment, which is defibrillation for shockable rhythms and CPR plus medication for
The next generation in managing emergency department patients
The Next Generation in Managing Emergency Department Patients: Non-Invasive Cardiac Output.
Jennifer Williams, MSN, RN, ACNS-BC, CEN, Clinical Nurse Specialist, Barnes-Jewish Hospital. Emergency Services
Acute Medicine Skills Part One
Dr Ashling Lillis, National Director's Clinical Fellow Macmillan Support, final year trainee in Acute Oncology
Dr Clare Philliskirk, Trainee in Acute Medicine, West Midlands
Dr Sarbit Clare, Acute Medical Consultant, Sandwell and West Birmingham Hospitals
Rescuscitation principles
This document provides guidelines for cardiac resuscitation and emergency cardiovascular care. It outlines objectives such as performing BLS procedures, using an AED, and diagnosing death. It also discusses the chain of survival, including factors like bystander CPR and early defibrillation that impact outcomes. Procedures covered include airway management, IV access, monitoring, and treating reversible causes of cardiac arrest like hypoxia, hypothermia, and electrolyte abnormalities. Indications for starting and stopping CPR are also reviewed.
CARDIO PULMONARY RESUSITATION.pptx
This document discusses cardiopulmonary resuscitation (CPR). It begins by defining CPR and noting that cardiac arrest affects approximately 700,000 people per year. Early recognition and treatment, including CPR, can lead to survival rates over 60%. The document then outlines the steps of CPR, including chest compressions, rescue breathing, use of an automated external defibrillator, and advanced cardiac life support. It emphasizes the importance of high-quality, coordinated care throughout and after resuscitation to optimize outcomes for cardiac arrest patients.
Mass casualty management
This document discusses mass casualty management and disaster preparedness for hospitals. It provides data on road traffic accidents in Nepal and describes key aspects of managing mass casualty incidents, including establishing triage, conducting primary and secondary surveys, and activating disaster plans. The main points are:
1) Triage is crucial to prioritize patients and direct them to the appropriate level of care. The START method is described.
2) During primary survey, life threats like airway, breathing, and circulation are addressed within 2-5 minutes.
3) Secondary survey thoroughly examines all body systems to identify minor injuries.
4) Hospitals must have clear disaster plans, adequate staff and supplies, and policies to handle surges
Extracorporeal membrane oxygenation.
Cardiogenic shock has high mortality that can be addressed with mechanical circulatory support (MCS) such as extracorporeal membrane oxygenation (ECMO). ECMO provides effective cardiac and respiratory support, bridging patients to recovery, transplant, or long-term devices. While associated with risks like bleeding and limb ischemia, studies demonstrate improved survival in cardiogenic shock with ECMO compared to medical management alone. ECMO also shows promise as a strategy for refractory out-of-hospital cardiac arrest when combined with mechanical CPR, hypothermia, and early cardiac catheterization.
Princip cardsurg lect copy
Cardiac surgery is more difficult than other types of surgery due to the moving heart organ containing blood which is vital with no room for mistakes. Historical milestones like the heart-lung machine in 1937 and first coronary artery bypass graft in 1958 allowed cardiac surgery to become viable. Indications for cardiac surgery include CABG, valve repair/replacement, arrhythmia management, and congenital heart defects. Preop preparation assesses patient risk factors. During surgery, a heart-lung machine is used to bypass the heart and oxygenate blood while the surgeon operates. Common procedures like CABG graft arteries to improve blood flow. Postop care focuses on complications like hypothermia, bleeding, and low blood pressure.
2020 high performance cpr v0.1
This document discusses high performance CPR techniques to improve outcomes for cardiac arrest patients. It provides 7 mantras of quality resuscitation and discusses key aspects of effective CPR including maintaining a rate of 100-120 compressions per minute, compressing at least 2 inches deep, fully releasing pressure between compressions, minimizing interruptions, and limiting ventilations to 6-10 per minute. The document outlines Ada County's model for high performance CPR using defined roles and positions to focus on continuous, high-quality chest compressions. It also reviews the science demonstrating improved perfusion and survival rates associated with minimizing interruptions and maintaining coronary and cerebral perfusion pressures.
Similar to Cartner, Michaela— Cardiac Surgery... then Cardiac Arrest (20)
The next generation in managing emergency department patients
The next generation in managing emergency department patients
More from SMACC Conference
Precision Medicine in Acute Brain Injury
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.
CSD by Jeffcote Coda 22.pdf
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.
Subdural Haemorrhage and MMA embolisation
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 care
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"!
The BONANZA Trial and PbTO2 Monitoring
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
Dilating the Dogma of Vasospasm
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.
EVD Tips and Tricks
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 Udy
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 work
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
TBI: when to stop and when to give time
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.
Ketamine in Brain Injury by Toby Jeffcote
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 Lee
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
EEG and Status Eplilepticus by Tania Farrar
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.
Browne Neuro symposium.pptx
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.
Paediatric Stroke by Shree Basu
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?
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.
Optimal Cerebral Perfusion Pressure
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.
The Power of Words - Death and Language.ppt
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 Coin
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.
Brain injury outcomes and predictors
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.
More from SMACC Conference (20)
Andy Neill - More neuroanatomy pearls for neurocritical care
Andy Neill - More neuroanatomy pearls for neurocritical care
There is no such thing as mild, moderate and severe TBI - by Andrew Udy
There is no such thing as mild, moderate and severe TBI - by Andrew Udy
TBI Debate - Mild, moderate and severe categories work
TBI Debate - Mild, moderate and severe categories work
Managing Complications of Chronic SCI by Bonne Lee
Managing Complications of Chronic SCI by Bonne Lee
Hypertensing Spinal Cord Injury - gold standard or wacky?
Hypertensing Spinal Cord Injury - gold standard or wacky?
Sepsis and Antimicrobial Stewardship - Two Sides of the Same Coin
Sepsis and Antimicrobial Stewardship - Two Sides of the Same Coin
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Overall life span (LS) was 1671.7±1721.6 days and cumulative 5YS reached 62.4%, 10 years – 50.4%, 20 years – 44.6%. 94 LCP lived more than 5 years without cancer (LS=2958.6±1723.6 days), 22 – more than 10 years (LS=5571±1841.8 days). 67 LCP died because of LC (LS=471.9±344 days). AT significantly improved 5YS (68% vs. 53.7%) (P=0.028 by log-rank test). Cox modeling displayed that 5YS of LCP significantly depended on: N0-N12, T3-4, blood cell circuit, cell ratio factors (ratio between cancer cells-CC and blood cells subpopulations), LC cell dynamics, recalcification time, heparin tolerance, prothrombin index, protein, AT, procedure type (P=0.000-0.031). Neural networks, genetic algorithm selection and bootstrap simulation revealed relationships between 5YS and N0-12 (rank=1), thrombocytes/CC (rank=2), segmented neutrophils/CC (3), eosinophils/CC (4), erythrocytes/CC (5), healthy cells/CC (6), lymphocytes/CC (7), stick neutrophils/CC (8), leucocytes/CC (9), monocytes/CC (10). Correct prediction of 5YS was 100% by neural networks computing (error=0.000; area under ROC curve=1.0).
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Cartner, Michaela— Cardiac Surgery... then Cardiac Arrest
- 1. SMACC Gold 2014 Michaela Cartner MBBS FACEM FCICM PG Dip Echo Crit Care Cardiac Surgery … then Cardiac Arrest….
- 2. OR • The Approach to the Deteriorating Cardiac Surgical Patient
- 3. My Aim: • To give you a safe systematic way to treat and assess the post op cardiac patient • To show you the subtle differences in this subgroup that are practice altering • And yeah Yeah YEAH!!!!!
- 5. My Aim: • To give you a safe systematic way to treat and assess the post op cardiac patient • To show you the subtle differences in this subgroup that are practice altering • To make you safer when you leave the room than when you entered it
- 6. Shock is still Shock.
- 7. A and B still come first
- 8. But C is the key = SV x HR run thru twice as the body has two pumps Co
- 9. Co = SV x HR is easy to manipulate Rate Rhythm
- 10. Rate Rhythm Uppers Adrenaline Isoprenaline Atropine Pacing Downers BB Ca CB cardioversion Overdrive pacing ALL PURPOSE DETERGENT Amiodarone HR is easy to manipulate
- 11. Co = SV x HR run thru twice as the body has two pumps Rate Rhythm
- 12. Co = SV x HR run thru twice as the body has two pumps Rate Rhythm Preload Contractility Afterload
- 13. SV Afterload Right Heart • hypoxia/hypercarbia/acid osis • atelectasis (PEEP ?) • Pulm Vasodilators -Nox - PC - SNP - Phosphodiesterase IIIi Left Heart
- 14. SV Afterload Left Heart • Uppers- – Adrenaline – Norad • PEEP • Downers – Db – Milrinone – GTN – SNP Left Heart
- 16. Cardiogenic Shock..pump broken.. Muscle Pipes Valves Augment the Muscle Adrenaline Milrinone Dobutamine Dopamine iABP VAD L, R, Bi ECMO Unblock the pipe Return to theatre Cath lab Replace the valve Return to theatre Echo/TOE Milieu Ph Ca++ Stop Shivering Temperature BSL
- 17. Co = SV x HR run thru twice as the body has two pumps Rate Rhythm Preload Contractility Afterload
- 18. Preload: Hemorrhage 3-8% return to theatre for reopen.
- 19. SV PRELOAD Definition: • >500ml/hr for first hours • > 800ml in first 2 hours • > 900ml in first 3 hours > 100 in first 4 Or cardiac tamponade Kristensen KL, Rauer LJ Reoperation for bleeding in cardiac surgery Interactive Vascular and Cardiac Surgery 14 (2012) 709-713
- 20. Risk factors • Patient – Low BMI – Co-morbidities DM, low EF, CRF • Operation • Long pump time • Multiple grafts • Failed off pump
- 21. Medical or Surgical? Kristensen KL, Rauer LJ Reoperation for bleeding in cardiac surgery Interactive Vascular and Cardiac Surgery 14 (2012) 709-713
- 23. Your approach is fine….
- 24. Cardiac arrest post surgery Guideline for resusitation in cardiac arrest after cardiac surgery European Journal of cardiothoracc surgery 2009
- 25. Survival rate • 17-79% 50% survival if reopen within 24 hours surgery and within 10 mins of arrest time. VF most common Bleeding/tamponade • ERC 2009 Guidelines
- 29. When to think about ICM and reopen? - before 10 mins of CPR - Aim for s60 mmHg
- 30. Gown and glove Don’t worry about hand washing ERC guidelines 2009
- 32. Mackay JH, et al Six Year prospective audit of chest reopening after cardia arrest. European Journal of Cardio-thoracic Surgery 22 ( 2002) 421-425
- 33. Video
- 34. My Aim: • To give you a safe systematic way to treat and assess the post op cardiac patient • To show you the subtle differences in this subgroup that are practice altering • To make you safer when you leave the room than when you entered it
- 35. Thank you.