Category: 3.6

Recognises and manages the patient with neurological impairment

Statins for Subarachnoid Haemorrhage

Statins for Subarachnoid Haemorrhage

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A 63 yr old woman collapsed at home and was brought into ED with a GCS of 3/15. She was a known hypertensive and hypercholesterolaemic. CT scan revealed a Fisher grade 3 subarachnoid haemorrhage. A ruptured middle cerebral artery was secured 24 hours later. She extubated on day 3 with a GCS of 13, but dropped her GCS to 10 on day 5 and was treated for vasospasm, which included continuing the nimodipine and simvastatin from her admission.

What is the evidence for ‘statins’ for the prevention of Vasospasm in Aneurysmal Subarachnoid Haemorrhage?Read More »

Delirium on the ICU

Delirium on the ICU

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A 67 year old with signficant cardiovascular comorbidities presented with a fractured neck of femur after a fall. She had a hemiarthroplasty performed under GA with fascia iliaca blocks, and went to HDU postoperatively. She became acutely confused during the first postoperative night with hallucinations and paranoia. She was CAM-ICU positive and was given haloperidol to control her agitation.

What is the optimum management of delirium on the ICU?Read More »

Therapeutic Hypothermia after Cardiac Arrest (Post-TTM)

Therapeutic Hypothermia after Cardiac Arrest (Post-TTM)

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A 55 year old presented to ED following a witnessed VF arrest. He received bystander CPR and several shocks from the ambulance crew. He was intubated at the scene, and transferred to ED with return of spontaneous circulation. He had primary PCI to LAD and was transferred to the ICU for therapeutic hypothermia. He was kept at 33 degrees for 24 hours, and rewarmed over 8 hours. He extubated 2 days late with no cognitive impairment, and mild weakness in one arm.

What is the evidence for and against Targeted Temperature Management (TTM) post cardiac arrest?Read More »

Botulism

Botulism

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A young female IV drug abuser presented with dysarthria, diplopia and weakness with loss of her gag reflex. She had recently had an abscess wound on her arm debrided. She was intubated for airway protection, and underwent early tracheostomy. She was treated with intravenous antibiotics and botulism antitoxin after electromyography and nerve conduction studies were consistent with a diagnosis of botulism. She was weaned from the ventilator within 2 weeks and the Health Protection Agency later confirmed the presence of botulism neurotoxin A from wound swabs.

What are the clinical features of Botulism and how is it managed?Read More »

Neuroprognostication after Cardiac Arrest

Neuroprognostication after Cardiac Arrest

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A 30 year old man suffered a 30 minute cardiorespiratory arrest secondary to an asthma attack. He was resuscitated, had his severe bronchospasm managed and he was treated with therapeutic hypothermia at 33 degrees. Once rewarmed, his neurology was assessed over several days. He was ventilated on a spontaneous mode, but his pupils remained fixed and dilated and there was no higher motor function seen. A CT brain was consistent with severe hypoxic ischaemic injury. After discussion with the family, treatment was withdrawn.

How reliable is neuroprognostication after cardiac arrest? What modalities are tested? Is there a difference in patients treated with therapeutic hypothermia?

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Therapeutic Hypothermia after Cardiac Arrest (Peri-TTM)

Therapeutic Hypothermia Post-Cardiac Arrest (Peri-TTM)

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An elderly man was resuscitated from out-of-hospital VF cardiac arrest. He remained deeply comatose post ROSC and was ventilated on the intensive care. His temperature control was not actively managed unless hyperthermia developed. 24 hours post admission he started to have myoclonic jerks and his pupils were fixed and dilated. CT brain showed evidence of severe hypoxic ischaemic injury. Treatment was withdrawn at 72 hours after discussion with family.

What is the rationale for the use of therapeutic hypothermia after cardiac arrest?Read More »

Management of Delirium

Management of Delirium

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A large 60 year old man developed septic shock and multiorgan failure secondary to a severe community acquired pneumonia. On the twelfth night of his ICU admission he became increasingly agitated and pulled out his vascath, NG tube and dislodged his tracheostomy. The resulting loss of airway led to a severe desaturation event before he was anaesthetised and reintubated, with loss of around 500ml blood from the haemofiltration circuit and vascath wound haemorrhage. He was commenced on regular haloperidol, but his CAM-ICU remained positive for 48 hours. Haloperidol was continued for 4 days, and he had a prolonged respiratory wean.

How is delirium best managed on the intensive care unit?Read More »

Hypertensive Reversible Posterior Leukoencephalopathy

Hypertensive Reversible Posterior Leukoencephalopathy

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A 65 year old chronic hypertensive man underwent a bone marrow transplant for acute myeloid leukaemia. He was subsequently treated for neutropaenic sepsis. He developed acute confusion and a subsequent drop in GCS requiring intubation. CT head and CSF investigation was normal. EEG was non-diagnostic. He was persistently hypertensive on the ICU. Review of notes showed that his anti-hypertensive medications had been omitted since admission, and that his ward blood pressures had been persistently elevated. Antihypertensives were established and the blood pressure improved. The neurological features improved with the blood pressure. A subsequent MRI confirmed the diagnosis.

What are the clinical features of Reversible Posterior Leukoencephalopathy Syndrome (RPLS)?Read More »

ICP Monitoring in Non-Traumatic Intracranial Haemorrhage

ICP Monitoring in Non-Traumatic Intracranial Haemorrhage

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A middle aged man had a sudden collapse with no precipitating features. His GCS on presentation was 3, with unequal but reactive pupils and CT brain showed a large subarachnoid bleed with midline shift. Neurosurgical opinion was to observe for clinical improvement, after which an intervention might be indicated. He was sedated on ICU and his MAP maintained above 80mmHg with noradrenaline. Nimodipine was commenced and mannitol was administered. After 24 hours he had a sedation hold and he began to localise and open eyes spontaneously. He was transferred to the neurosurgical unit.

Should all patients with non-traumatic intracranial haemorrhage have intracranial pressure (ICP) monitoring established?Read More »

Hepatic Encephalopathy in Acute Liver Failure

Management of Hepatic Encephalopathy in Acute Liver Failure

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A 30 year old woman with a background of substance abuse and deliberate self harm was found collapsed and semi-conscious following an overdose of co-codamol and was presenting late. It was possible that she had taken around 100g paracetamol. Her GCS was 11, and she had grade II/III hepatic encephalopathy. Her bilirubin was 60 and she had significant transaminitis with a lactic acidosis. . She was commenced on N-acetylcysteine despite undetectable paracetamol levels. Liver US was normal. Early repeat bloods showed worsening jaundice, transaminitis and rising INR. She was transferred to the regional liver unit initially for monitoring, but was subsequently admitted to the liver HDU. She did not require a liver transplant and recovered with conservative management.

What is the optimum management of hepatic encephalopathy in acute liver failure?Read More »