Transcript Common Neuro Admissions

Common Neuro
Admissions
Intern Lecture Series
Shane M Garon, MD
PGY II
TIA/CVA
• Code Purple – CVA
• Level 1 Code Purple – CVA eligible for TPA (time limit
dependent, need to review criteria)
• CT Head STAT, if no hemorrhage, give Heparin 1mg/kg loading
dose
• Tele, Coagulation studies, ECHO (thrombus), Carotid Duplex
scan, Coronary risk profile, need to be on statin therapy, SS
Consult for rehab, NPO until swallow eval done, NIHSS checks,
Consult the Hajmurad
CVA
• ICU admit/NIHSS/Tele/NPO Bedside Swallow/MBS if severe
impairment/Code status?
• Tx: ASA/PRN Hydralazine/Labetalol/(Cardene drip if severe
HTN)  Keep BP <180s/110s (Hem), <220/130 (ischemic)
• Labs: CBC/CMP/Coags/ABG/CT Head w/o/MRI/Duplex
Carotid/TTE/TEE/EKG/Coronary Risk panel/Statin
• Consult Neuro/NSGY if hemorrhagic
SAH
• ICU Admit/NPO/Swallow Eval/SS Consult/Neuro consult/NSGY
Consult/CVC/Art Line/Intubate w/ Vent if unstable
• Orders: CBC/CMP/Coags/ABG/CE/CK/EKG/ECHO/Duplex/CT Head
w/o, restraints/Coronary Risk/TSH/UDS
• Tx: NPO, ElHOB, Albumin 25% 15gQ8 (HHH)/ Nimodipine 60Q4 via NGT,
BP systolic <160, Seizure PPX (Ativan/Keppra)/Statin
• If Imaging shows Cerebral Edema: Decadron IV 10mgx1 loading dose  8mg
Q8hr
• Since NPO: D5NS/LR/Normosol-M +/- Procalamine
• F/U: CT Head/MRI Q3-4 Days
• PRN: Cardene Drip, Labetalol/Hydralazine (Avoid Nitroprusside Inc ICP)/Zofran
(Phen)/Tylenol/protonix/Pain (Dilaudid/Morphine)
Seizures
• ICU Admit if unstable, if stable admit to Tele/NPO/Swallow
Eval/Neuro consult/aspiration precautions
• Orders: CBC/CMP/Coags/ABG/CE/CK/EKG/ECHO/CT Head
w/o, restraints/TSH/UDS/UA/Drug levels/**CBS/Myco/FluA/B,
+/-LP if above labs nonspecific (Meningitis panel)
• Tx: NPO, swallow eval/Keppra/Dilantin (Neuro will give rec)
• If on dilantin, get dilantin level, ***Make sure to correct for low albumin
• D5 IVF
• F/U: Neuro recs
Migraine
• Treat it like a Rule out
TIA/CVA & Meningitis
AMS
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Admit to floor if stable/Hold all meds especially benzos/barbs/psych/etc.
Place PRNs in
NPO, swallow eval, PRN haldol/geodone, IVF hydration
CBS**/CBC/CMP/CK/ABG (TCA
OD)/UA/UDS***/EKG/CE/Blood/Urine/Sputum Cx (Common cause in
elderly)/CXR (r/o aspiration)
• Proceed to do workup for
CVA/TIA/Drugs/Infection/NSTEMI/STEMI/Seizure
Fall
• Admit, Head CT, CBC CMP Coags, eval if fall accidental of
neurocardigenic, if so CE, EKG, ECHO, Cardio consult, If fall simple, no
bleed, no Neuro consult needed.
• Watch overnight, repeat clinical exam, if good, d/c with close f/u within one
week .
Hypertensive Urgency/Emergency
• Admit to ICU, Start either Cardene Drip, Nipride Drip, or Labetalol drip.
• Don’t give clonidine. Can give PRN doses of hydralazine/Labetalol
Enalaprilit
• Don’t lower fast, don’t lower slow. 160s/90-100s
• Treat pain to exclude false elevations: Morphine PRN
• NIHSS checks, watch for metabolic encephalopathy
• ACEi/BB/CCB (Procardia XL works well)
• **Personal experience – Aldactazide 25/25 BID works well if all else seems to
fail
• CT Head, Renal scan
fasthugs
• Feeds/IVF: NGT (PEG if 2 weeks w/o ability to eat PO)/D5Normosol-M until
feeds began/Procalamine <7 days IV until dietary/swallow eval/MBS
• Analgesia/Antiemetics: Dilaudid (S)/Morphine (M)/Tylenol,
Zofran/Phen/Compazine
• Sedation: Propfol (watch for elevated TG/Pancreatitis & Infusion syndrome), can
dual with Ativan drip (If w/drawl from EtOH/benzos)/Pain med drip
• Thromboembolic PPX: SCDs/Lovenox
• HOB El/Hardcore Abx Stewardship: None unless indicated. Get Pan cultures Q5
days for surveillence
• Ulcer PPX: IV Protonix/Famotidine BID
• Good Glycemic Control: ICU has HSSI protocol
• Scoring: APACHE II/SAPS/CHADS
• PRN: Cardene Drip, Labetalol/Hydralazine (Avoid Nitroprusside Inc ICP)/Zofran
(Phen)/Tylenol/protonix/Pain (Dilaudid/Morphine)
PRNS and (Not so)Common Sense things to
watch out for
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Vascular:
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Lung: RTQ4PRN Duonebs (If tachy/afiby Xopenex), Mucomyst/Budesonide Q8H staggered for
secretions, if Brady + Secretions = Robinul
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CXR Daily for first week, if lungs unchanged and in top shape, change to Q2 days if clinical exam is benign
ABG daily, same as above.
Calculate the PaO2:FiO2 ratio daily
Liver: Watch for shock liver/med side effects/biliary stasis
Kidney/GU: Monitor Cr/UOP/ Check the Foley bag, change foley Qweek ***Day X/7 foley.
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BP Control:Cardene Drip, Labetalol/Hydralazine (Avoid Nitroprusside Inc ICP).
If CVC/Art/Peripheral: Day inserted/Day to change***
If meds cause anticholincergic sxs  Flomax trial
GI: Zofran/Phen/Compazine//Protonix/Famotidine, if severe diarrhea/hyperdefecation/buttock ulcer 
BMS/Rectal Tube
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If worry abt increase intraabdominal pressure (cirrhosis/ischemia) place foley with intraabdominal pressure
monitoring//if poikilothermia place foley with temp measurement
If PEG/Trach or trauma  Be weary of perforation, it will happen when you least expect it.
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Skin: Decubitis ulcers
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Pain: Dilaudid/Morphine/Tylenol (IV/PO), can do patches/PO/PPEG meds too