NeuroResus Review
NeuroResus is a FOAMed educational resource which defines, describes and elaborates on the practical management of all neurological emergencies.
NeuroResus is designed and run by Dr Oliver Flower with content peer reviewed by Australian physicians and nurses with expertise in critical care specialties including intensive care, emergency medicine, neurology and neurosurgery. The passionate and dedicated creators of NeuroResus have a global focus of providing free and open access content.
What is NeuroResus and how does it work?
NeuroResus provides an interactive, education focused and practical series of evidence-based modules. Each of the 11 modules provides a fundamental overview of the condition, pathophysiology and diagnostic/grading criteria. Attention is maintained by enmeshing a case study with interactive questions and answers throughout the subject matter. The user is guided through the principals involved in the initial resuscitation, through to comprehensive and definitive management required in the intensive care unit.
Who is this designed for?
NeuroResus content is designed for all healthcare professionals involved in the management of critically unwell patients, experiencing neurological emergencies. The simple language and easy to access modules are perfect for all levels of education and learning from students and trainees to specialists. The content is practical and clinically relevant throughout.
Registration
NeuroResus provides the option to view all course content with or without registering a free account. Registration allows the user to complete a quiz at the completion of each module (>80% required to pass each module..) and save progress allowing the user to work through the course at their desired pace. At course completion, the registered user will receive a certificate of completion for CPE/CME purposes
Overall
I loved the interactive approach with videos, examples and case scenarios which I found highly engaging. Registering (for free) is encouraged as you are able to attack the modules at your own pace and order.
NeuroResus Module Structure
Here are the 11 modules with content structure and external links to NeuroResus to start your learning journey
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: 1st Injury & 2nd 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
- Bacterial meningitis: Definition, Epidemiology, Anatomy, Risk factors & The bugs
- Viral CNS infections: Definitions, Epidemiology, Anatomy and pathology, Risk factors & The bugs
- Nosocomial CNS infection: Intro to external ventricular drains, Ventriculostomy related infections, Ventriculoperitoneal shunt related infection & The bugs
- Brain abscess: Epidemiology, Pathology, Risk factors, Clinical presentation, Imaging & The bugs
- Subdural empyema: Definition, Epidemiology, Pathology, Clinical presentation, Imaging & The bugs
- 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
- External ventricular drain
- 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
Reference List:
- Flower O. NeuroResus. 2024
- Flower O. NeuroRuses Lecture series. LITFL 2024
neuroresus
RN, Sir Charles Gairdner Hospital. Coronary Care Unit // Emergency Department. Keen interest in critical and pre hospital care.