NeuroResus Review

Case study History with Interactive Questions  

Fundamentals  

• SAH Definition  
• Vascular Anatomy  
• Epidemiology  
• Risk Factors  
• Aetiology  
• Causes of Aneurysms  
• Locations of Aneurysms  
• Other causes of SAH  

Grading System  

• Modified Fisher Scale  
• World Federation of Neurosurgical (WFNS) scale  
• Pros and Cons of these systems  
• Hunt & Hess Grading systems  
• Interactive questions x3 

Resus and Investigations  

• Resus Priorities: Protect airway, stop more bleeding, stop Seizures & Treat Hydrocephalus  
• Early Investigations: 12 lead ECG, baseline bloods, urgent CT brain, lumbar Puncture?  
• Next Steps: Communicate + Refer, Obtain Further Access, Commence Nimodipine  

Definitive Aneurysm Management  

• When to secure an aneurysm  
• Endovascular bs surgical management  
• Clipping vs coiling  
• Endovascular adjuncts  
• How are Aneurysms clipped  

ICU Management  

• Essential supportive care in the ICU: Analgesia, sedation & anxiolysis, Feeding, Thromboprophylaxis, Positioning, stress ulcer prophylaxis, glycaemia control, anaemia, oxygenation, adjunct therapies and other considerations. 
• Targeted therapies: Nimodipine 
• Preventing complications: Give Nimodipine, control blood pressure, prevent hypovolemia, prevent hyponatremia, avoid fever, minimise risk of delirium, seizure prophylaxis, prevent rebleeding and control ICP. 
• Targeting complications: Radiological vasospasm, delayed cerebral ischemia, Hydrocephalus, ventriculitis, seizures and rebleed  

Outcomes and Follow Up  

• Patient outcomes  
• Factors associated with a poor prognosis  
• Residual deficits for survivors  
• Family screening and multiple aneurysms? 

Case study History with Interactive Questions   

Fundamentals  

• Definition  
• Epidemiology  
• Risk factors  
• ICH causes: Hypertensive Vasculopathy, Cerebral amyloid angiopathy, medication related, vascular structure lesions, systemic disease, undetermined and rarer causes  

Initial Management  

• Specific initial management required for ICH  
• Resus priorities: Airway + breathing, get a history, neuro exam, basics (bloods, lines, urine, ECG), CT ASAP, bedside investigations, reverse anticoagulation, BP mx, communicated + refer  

ICH in ICU  

• Key concepts: BP mx, coagulation ect 
• Intensive neurological monitoring  
• Monitoring  
• Control BP  
• Normalise coagulation  
• Seizures  
• Blood glucose  
• Temperature management  
• VTE prophylaxis  
• Establish the cause  
• Swallow assessment  
• ICH post thrombolysis  
• Role of surgery  
• Interactive question x1 

ICU Prognostication  

• Prognosis statistics   
• FUNC score  
• ICH score  

Case study History with Interactive Questions    

Fundamentals  

• Definition  
• Epidemiology  
• Clinically relevant anatomy: Cervical spine, overview, cross section, autonomic, breathing and decussation. 
• Clinically relevant pathophysiology: 1^st Injury & 2^nd Injury  

SCI Initial Management  

• Resus Priorities – in brief  
• Airway + breathing  
• Immobilise the neck  
• Manage shock  
• Protect the skin  
• Urinary catheter  
• Imaging  
• Steroids  
• Communicate + refer  

SCI Classification 

• Standardised ISNCSCI classification  
• Application of the ISNSCI: Sensation, motor, NLOI, Complete?, grade, ZPP, PITFALLS  
• SCI Syndromes: Central cord, Anterior cord, Brown-Sequard, Conus Medullaris & Cauda Equina  

SCI Intensive Care:  

• Reference to case study  
• Ward round checklist  
• Prevent secondary neurological injury  
• Respiratory management  
• Cardiovascular management  
• Venous thromboembolism  
• Gastrointestinal  
• Pain  
• Urinary tract  
• Skin care  
• Interactive question x1 

Chronic SCI Critical Care  

• The beginning is not the end  
• Interactive question x1  
• Physiology to expect  
• Autonomic dysreflexia  
• Pressure areas  
• Infections  
• Syringomyelia  
• Peri-op care  

SCI Outcomes 

• Patient outcomes  
• Factors predicative of higher mortality  
• Predicting neurological outcome 
• Imaging and prognosis  

Case study History with Interactive Questions  

Fundamentals 

• Definition 
• Epidemiology  
• Incidence  
• Clinically relevant anatomy: Overview, imaging, ACA/MCA, PCA, P COMM, LACUNAR, Territories, 3D model  
• Clinically relevant pathophysiology  

Initial Managment  

• Stroke resus priorities summary  
• Airway and breathing  
• Circulation  
• History  
• Examination  
• Exclude stroke mimics  
• Early investigations: Baseline bloods, urgent (CT, CTA, CTP) and 12 lead ECG 
• Next steps: Communicate & refer, obtain more IV access and keep NBM 

Stroke Examination  

• How to examine a patient with suspected stroke  
• NIHSS video + calculator  
• Visual aids  
• Interactive question x1 
• Stroke syndromes: MCA, ACA, AChA, PCA, BASILAR, AICA, PICA, LACUNAR 

Treatment Options  

• Treatment criteria diagram  
• Thrombolysis: Edibility, Section, Onset < 3Hrs exclusion criteria, onset 3-4.5hr exclusion criteria, onset 4.5-24 hr & how to thrombolyse  
• BP control  
• ECR: Eligibility, Onset 0-6hr, onset 6-24hr, onset 24-48hr and what is ECR 
• TIA’s: Definition, ABCD2 score, ABCD2 0-3 low risk TIA & ABCD2 3-8 High risk TIA  
• Interactive question x1 

Critical Care Management  

• Key concepts 
• More detail: Intensive neurological monitoring, monitioring, control blood pressure, groin + limb, blood glucose, temperature management, If Lysis given, VTE prophylaxis, neuroimaging, stroke workup, anticoagulation, swallow assessment & management of complications  

Case study History with Interactive Questions  

Fundamentals  

• Pathophysiology  
• Overview video  
• Interactive question x2 

Emergency Management of Seizures:  

• Goals  
• Why is time critical?  
• 0–5-minute standard care  
• Specific treatments  
• 0–20-minute tier 1 therapies  
• 20-40-minute tier 2 therapies  
• Still fitting? Tier 3 therapies  
• Still fitting? Tier 4 options  
• Still fitting? Tier 5 options  
• Other emergency management: The differential, airway, circulation, physical exam and initial investigation  

Anti-seizure Medications 

• Commonest ASMS 
• Tier 1 ASMS: Benzodiazepines, Midazolam, Lorazepam, Diazepam & clonazepam  
• Tier 2 ASMA: Levetiracetam, Phenytoin & Valproate  
• Tier 3 ASMS: Propofol, Lacosamide  
• Tier 4 ASMS: Ketamine, Thiopentone  
• Interactive question x1 

ICU Management 

• Priorities in ICU  
• EEG  
• Supportive ICU care  
• Find and treat the cause  
• Super refectory status epilepticus  
• Treatments and consequences  
• Interactive question x2 

Outcomes  

• Patient outcome statistics  
• Factors predictive of higher mortality  
• Outcomes from SRSE  

Case study History with Interactive Questions  

Fundamentals  

• Definition  
• Other disorders of consciousness  
• Pathophysiology of consciousness  
• Causes of structural coma: Bilateral cortical injury, bilateral Diencephalon injury & Ascending Arousal System injury  
• Classification  

Initial Management 

• Resus priorities  
• Airway + breathing  
• Get a collateral history  
• Coma neuro exam  
• Naloxone  
• Thiamine  
• Bedside investigations  
• CT  
• LP  
• Communicate + refer  
• Interactive question x1  

ICU Management  

• Supportive care  
• More history  
• EEG 
• MRI  
• Do the basics well  
• Specific situations  
• Persistent coma  
• Interactive question x1 

The Future  

• Prognostication in coma  
• Is coma curable?  

Case study History with Interactive Questions  

Fundamentals  

1. Bacterial meningitis: Definition, Epidemiology, Anatomy, Risk factors & The bugs

2. Viral CNS infections: Definitions, Epidemiology, Anatomy and pathology, Risk factors & The bugs

3. Nosocomial CNS infection: Intro to external ventricular drains, Ventriculostomy related infections, Ventriculoperitoneal shunt related infection & The bugs  

4. Brain abscess: Epidemiology, Pathology, Risk factors, Clinical presentation, Imaging & The bugs  

5. Subdural empyema: Definition, Epidemiology, Pathology, Clinical presentation, Imaging & The bugs  

6. Epidural abscess: Definition, Epidemiology, Pathology, Risk factors, Clinical presentation, Imaging & The bugs  

Initial Management  

• Resus priorities  
• Think of the diagnosis  
• Droplet precautions  
• Really think it could be meningitis or encephalitis  
• Non con CTB  
• LP tips  
• When to intubate  
• Aim MAP >80 MMHG 
• Brain abscesses and subdural empyema  
• Fever and back pain  

ICU Management  

• Interpreting CSF: Approach, normal, bacterial, viral and TB/fungal  
• Ventriculostomy related infections  
• ICP management  
• MAP and ICP targets  
• Avoid fever  
• Seizures and ASM’s 
• MRI  
• Spinal cord injury  
• Scenario test question x1 

Outcomes  

• Bacterial meningitis outcomes  
• Viral meningitis outcomes 
• Fungal CNS infection outcomes 
• TB meningitis outcomes 
• Brain abscess outcomes 
• Subdural empyema outcomes 
• Spinal epidural abscess outcomes 

Case study History with Interactive Questions  

Fundamentals  

• Definition  
• Epidemiology  
• Classification: Severity, mechanism of injury, pathoanatomic & pathophysiology  
• Clinically relevant pathophysiology: Inflammation, cerebral perfusion, energy crisis, CSD & genetics  

Anatomy of TBI 

• Anatomy overview: Skull, Meninges, Ventricles, Brain, blood supply and cranial nerves  
• Anatomy of TBI symptoms: Fixed dilated pupils, coma, decerebrate posture, decorticate posture & post traumatic headache  
• Brain herniation  

Initial Management  

• Resus priories  
• Protect the neck  
• Protect airway  
• Breathing  
• Circulation  
• History  
• Examination  
• Treat suspected EICP  
• Seizure prophylaxis  
• Early investigations: baseline bloods, urgent CT brain  
• Next steps: communicate + refer  
• Interactive question x1  

Specific Management  

• Patterns and their management: EDH, SDH, TICH, TSAH, TIVH, DAI 
• Herniation syndromes: Overview video, subfalcine hernination, uncal herniation & Tonsillar herniation  

ICU Management  

• Supportive care in the ICU  
• Monitoring
• Analgesia and sedation
• Manage EICP
• Fluids
• Ventilation
• Avoid further bleeding
• Patient position
• Nutrition
• Avoid fever
• Seizure prophylaxis
• Thromboprophylaxis
• Stress ulcer prohpylaxis
• Glycaemic control
• Anaemia
• Trial eligibility
• Family updates and goals of care
• Multi-modal monitoring: ICP monitioring, brain tissue oxygenation monitoirng, cerebral microdialysis, continous EEG and PRX  
• Interactive question x1  

Prognostication and Outcomes  

• Outcome statistics  
• Prognostication  
• Calculations  

Case study History with Interactive Questions    

Fundamentals  

• Causes of increased cerebral blood volume  
• Normative: Cerebral blood flow, Intracranial pressure, cerebral perfusion pressure, CSF 
• Importance of monitoring and treating ICP  
• Monroe Kellie Hypothesis  
• Interactive question x1 

Clinical Features of EICP include:  

• Decreased level of consciousness  
• Third cranial nerve lesions  
• Cushing’s triad  
• Papilloedema  
• Nausea/vomiting  
• Seizures  
• ICP waveform  
• ECG changed  
• Top clinical signs of ECPI  
• The potential radiological features of raised ICP on non-contrast CT brain  
• Herniation syndromes: Uncal Transtentorial, Central Transtentorial, Subfalcine, “Upward” Transtenorial and Tonsillar Herniation  

Measuring ICP  

1. External ventricular drain  

2. Fiberoptic monitors  

• Considerations for options of ICP monitors  
• Components of the EVD setup  
• Setting the height of the EVD  
• Potential sources of error in ICP measurement with EVD  
• EVD waveforms  

Management  

• Standard care  
• Teir 1 management  
• Teir 2 management  
• Teir 3 management  
• Improving venous drainage  
• Sedation and analgesia  
• Osmotherapy  
• Hyperventilation  
• Neuromuscular blockade  
• Thiopentone  
• Decompressive craniectomy  

EICP Management  

Case study History with Interactive Questions    

Fundamentals  

• Epidemiology  
• Resus statistics  
• Aetiology: Causes and reversible causes  
• Arrest statistics  
• Brain injury post cardiac arrest: Primary vs secondary 

Emergency Management  

• Case study interactive question  
• Resus priorities  
• ECMO  
• Prepare for re-arrest  
• Respiratory support  
• Prevent further arrythmias  
• Maintain cerebral perfusion  
• ?PCI  
• Investigate the cause  
• Targeted temperature management  
• Communicate + refer  

ICU Management  

• ICU specific management requirements  
• Targeted temperature management  
• Respiratory management  
• Cardiovascular management  
• Sedation strategy  
• Stress ulcers  
• Nutrition  
• Blood glucose management  
• Seizures  
• VTE prophylaxis  
• Interactive question x1 

Neurological prognostication  

• Investigations used to aid prognostication  
• Clinical examination  
• The four score  
• EEG 
• CT brain  
• MRI brain  
• SSEP  
• NSE  
• The TTM2 method  
• Interactive question x1 

Extra Resources  

• Major guidelines  
• Talks  
• Major trials  

RCA Test  

Case study History with Interactive Questions    

Death Fundamentals  

• Death definition  
• History of death  
• Final causes of death: Circulatory and neurological determination of death  
• Organ donation: Definition and when is it considered?  

End of Life Care  

• What is end of life care  
• What is considered a ‘Good Death’  
• Who is it for?  
• When does it start?  
• Consideration of organ donation  
• Breaking bad news to families  
• Ethics and law 
• Not for resuscitation  
• Analgesia and sedation in EOL care  
• Other medications  
• Invasive lines and tubes  
• Non-essential treatments and monitoring  
• Checklist  
• Care of the family  

Death and Organ Donation  

Neurological Determination of Death  

• When is it considered  
• The clinical exam  
• Cerebral blood flow investigations: Digital subtraction angiography, Radionuclide imaging and CT angiography 
• Documenting brain death  
• What happens if investigations don’t prove brain death  
• Care of the brain death patient: diagnostic criteria, general ICU care, respiratory support, CVS support & fluid and metabolic management  

Circulatory Determination of Death  

• When is it considered  
• Why does time matter  
• How is DCCS actually done?  
• Coronial referral  
• Donor assessment process  
• Coordination meeting  
• Where to withdraw life support  
• Analgesia and sedation in DCDD 
• How are the transplant retrieval team involved  
• Certification of death in DCDD 
• Documenting DCDD 
• What happens if a patient doesn’t die within the time limit  

After Death  

• Death in the ICU: How staff core, memory making, bereavement support, for families of organ donors  
• Practical aspects: Communicate, coronial referral, death certificate, cremation certificate, tissue donation and for families of organ donors