Ooh, brain stuff. Hi, my name is Andrew. I'm a neuro-intensivist at Northwestern Medicine downtown. 49-year-old woman was admitted to the ICU two days ago for septic shock, second UTI. She's done well with antibiotics, been hemodynamically stable. They wanted to weather that she's appropriate for extubation. She had propofol, 60 mics per kick per minute, opens her eyes to voice, does not make eye contact. Which of the following drugs would be best to optimize the RAS for extubation? Is there an audience response for this one? Yeah, so if you just go right over here. And then you've just got to click this little thing. That's really cool. And then I think, do they have to scan this QR code? Yeah, so they'll have to scan this one. They'll scan this one. And then once you press Start, they can vote. So their voting will come up here. Every day's a school day. I know. And then if you click the black one, it's the show the right answer. Looks like everyone's done. Is everyone done? Everyone voted for propofol. Someone want to? Never mind, not everyone's done. I think this one should be valproate, really. No, this is propofol. They've not given you anything here about seizure. Lorazepam's hard to wean takes longer. Pentabarb is probably for status epileptic. If you don't want to wean the patient for several times, you'd like to call for the Trach and PEG. Propofol would probably be the best answer here. Since I know I have everything else to do and it's already 11, I'm going to try and keep us on time. Because I know that we are the last thing standing between you and lunch. And I'm a parent of a small child, I know everyone gets cranky. A 53-year-old presents the ED after a self-inflicted gunshot wound caused by hemispheric brain injury has an irreversible coma with no confounding variables, norm-intensive, on an FIO2 of 50% for the PEEP of 5, no brainstem reflexes, nor mothermic, nor manatremic. Each of the following would mean you have to do an ancillary test to meet the diagnosis of death by neurological criteria. There's no QR code on this slide. Did you do this, Darlene? Yeah. I did. Just leave it there. Okay. Perfect. Are the questions updated from the same QR code? Yeah. Okay. So which of the following means you have to do an ancillary study, like an NGO or a TCD? These have updated, these have changed, by the way, and I'll tell you more about them in the next hour. They've changed what are accepted ancillary tests in the last year. You know, brain stuff. We change it every couple of years, like the way the radiologists change the interpretation just to keep you on your toes. So for this one, requiring vasopressors is actually fine. You can require vasopressors. That's okay. You can make the patient normotent with vasopressors. That's okay. Absent corneal and pharyngeal reflexes is part of the definition of brain death. You're supposed to have that. And you can be mechanically ventilated with the PEEP of 5. That's totally fine. You can actually have someone mechanically ventilated on 15 of PEEP and 100 FiO2. That's okay. The correct answer was you have some instability where you can't actually perform an apnea test. You have to do the apnea test, and if you can't do the apnea test, then you have to do an ancillary study, and we'll talk in the next hour about which ancillary studies are considered acceptable in 2024. So you have to be able to get the systolic pressure to, I believe, 90 or 100. So you can use vasopressors. That's fine. They tell you in the question, this patient is hemodynamically stable and normotensive, but if he needed some phenylephrine, that's fine, you can do that. Sooner or later, everyone who is brain dead becomes plane dead because the hypothalamus stops working, they stop making catecholamines, and they eventually all get hypotensive and die. So that's fine. And that's it for a couple of days. All right. A 49-year-old woman is admitted to the ICU after a Whipple procedure for pancreatic cancer. She was extubated in the operating room and currently has severe pain and a moderate level of anxiety after awakening from anesthesia. Which of the following medication combinations is the most appropriate initial treatment? A, dexmedetomidine and haloperidol, B, fentanyl and midazolam, C, morphine and etomidate, D, catorlac and propofol, and E, fentanyl and dexmedetomidine. Wow, 100%, our first 100%, is that right? Way to go, my presentation was effective. Really proud of you guys. We're going to avoid benzos at all cost. Look at that, isn't that great? So, yeah, so we're avoiding benzos with the other answers and then, you know, we talked about how we don't really use atomidate infusions at all anymore, and then, you know, she's going to need some bigger pain relief than just some Catorlac and Propofol here. Propofol infusion syndrome is characterized by metabolic acidosis plus which of the following? Hypoglycemia, coagulopathy, and hepatic encephalopathy, or B, rhabdomyolysis, myocardial dysfunction, and renal insufficiency, C, hypotension, cardiac dysrhythmias, and status, and D, rhabdo, elevated temperature, and muscle rigidity. They love asking this question on the neurology boards, and they ask you the mechanism. Oh, I thought we were going to have another 100%. So close. All right, so the correct answer is B. So kind of talked about this in my talk, the rhabdo, myolysis, myocardial dysfunction, and renal insufficiency is part of the Propofol infusion syndrome. Looking at the other answers, the hypoglycemia, coagulopathy, and hepatic encephalopathy, it's a little bit more common with liver failure. The answer C, hypotension, cardiac dysrhythmias, and status is more consistent with a tricyclic antidepressant overdose. And D, the rhabdo, elevated temperature, and muscle rigidity is often on anesthesia boards, and that's more consistent with malignant hyperthermia. On the neuro boards, they show that, and they show you an electron micrograph of a cell, and they say which of these organelles is involved in Propofol infusion syndrome. They love that. It's mitochondria, by the way. 73-year-old presents the ED after being assaulted. He's struck innumerable times. The GCS is seven, otherwise stable. He's orotrically intubated. He has an open fracture, a small contusion, diffused subarachnoid hemorrhage, and a small liver lack, in addition to the use of septum, which is a relative indication for the placement of an ICP monitor. I'm going to say relative, because not everybody would do it in all situations. The fact that he has diffuse SAH, the fact that he's eligible for Medicare, the fact that he has a skull fracture, the fact that he's on the vent, or the non-operative liver lack. So this is a toughie. This is a question. The diffused subarachnoid hemorrhage, I actually didn't know about that. I thought it would have been the age greater than 65. The skull fracture is not an indication. The need for mechanical ventricular support, that's okay. We put ICP monitors in patients for mechanical ventricular support all the time. The non-liver lack, the diffused subarachnoid hemorrhage suggests that he's more likely to have ICP, although not everyone puts these in all the time. It actually depends a lot on where you train. There's a controversy as to whether or not it's the elevated ICP or the brain oxygen tension that matters most, how well brain is oxygenating. So I'm here at a site that's doing BOOST3. There's a clinical trial ongoing run by the SIREN network called BOOST3, which is looking at a probe that the Lycox that has a brain oxygen tension monitor in it to see if brain oxygen tension, attention to normalizing brain oxygen tension improves outcomes more than ICP alone. So this was a tricky question, a lot of controversy about it. BOOST3 will answer this one way or the other in the next couple of years, at which point we will update the question. Forty-one-year-old admitted to the ICU with severe TBI, GCS of four, a motor vehicle accident eight hours ago, ejected through the windshield. His temperature is a little bit febrile, heart rate is 56, rate is 14, norm of intensive is ICP is 16. Which of the following should you do prophylactically? Crani, methylprednisolone, cooling, or sequential compression devices? Okay. The answer is SCDs. Decompressive craniae, actually the data on this are quite mixed, and a couple of prospective randomized trials of prophylactic decompressive craniae have shown harm for three-month outcome, not benefits. I asked one of my neurosurgery buddies why I said the New England Journal of Medicine hates surgery. Well, maybe, but that's not why they published the trial. Methylprednisolone, that doesn't work. We thought it would all work. It's one of the great stories of animal models not translating to human research. Hypothermia. I'll say it. Does that still work for anything? Do we still use that for... Does that still work? That works. We don't use that... Do we still use that in cardiac arrest? We still do. We do? Really? Okay. Not to 36, not 35? It says 35. Oh, gotcha. So, cranial decompression devices prevent DVTs. He's likely... He's at very, very high risk for having deep venous thrombosis. All right, an 86-year-old woman with ventilator-associated pneumonia necessitating mechanical ventilation has consistently received a score of 4 on the intensive care delirium screening checklist, meaning that she has delirium. Currently, she is receiving lorazepam for sedation at 2 mg per hour. Which of the following is the best course of action given the above information? A, continue the lorazepam at 2 and titrate the dose down as possible. B, add fentanyl to decrease the lorazepam. C, transition from lorazepam to dexmedetomidine. D, discontinue lorazepam infusion and initiate midazolam infusion at 2. Get ready to vote. All right, we're gonna stamp out delirium by getting rid of the benzos So we're gonna transition from the lorazepam to dexmedetomidine as a more appropriate sedative in this situation So, yeah, I'm looking at the other answers here So continue it we hate benzos. We're not going to continue it add fentanyl and keep it. We hate benzos. We're not going to do that and then Discontinue and start midazolam. We hate benzo. So we're not going to do that one. All right Okay, 72 year old man has just undergone a partial lung resection for squamous cell carcinoma Four hours after admission to the ICU from the post anesthesia care unit. He becomes uptunded with partial airway obstruction Respiratory rate of four breaths per minute and falling arterial oxygen saturation by pulse oximetry He received six milligrams of epidural morphine and a hundred and fifty mikes of epidural fentanyl via lumbar epidural catheter approximately eight hours before ICU admission Underlying conditions include COPD and coronary artery disease with stable angina. Which of the following interventions is most appropriate a Immediate nasotracheal intubation to protect airway patency and provide ventilatory assistance B immediate oral tracheal intubation to protect airway patency and provide ventilatory assistance C immediate effective ventilatory support via bag mask while 80 mikes of naloxone is administered via the epidural catheter D immediate naloxone point four milligrams IV push Oh It's going all over the place All right, the audience is torn here Okay Drumroll, please. Correct answer is D We're gonna give some immediate naloxone so, um You know, there's a long explanation here. So the patient is breathing all although not very vigorously I think going right to intubation, you know, there's You know pros and cons can be cons too if he has a difficult airway whatever I think answer C was was Intriguing to me, but we don't really give naloxone and epidural catheters. So I took that one out right away So, I think it's one of those things you can, you know kind of support the patient get the naloxone immediately Maybe you do need to think about bag mask ventilator, but we're not going to give naloxone in the epidural catheter 19-year-olds admitted to the ICU for urinary sepsis and has a witnessed seizure. After convulsions ended, she has a one-hour post-icto period where she's confused. Later in the day, she is back to normal. On visit to the exam, it is normal. Which is the best characterization of her seizures? So it's a semiology question Has a seizure, is confused, then looks better I did. Nobody wants to vote because it's brain stuff Also, I didn't get to give a lecture first I'm actually not going to talk about this. No one cares about seizure semiology in the ICU actually So They, I see what you might think, it is a generalized seizure But they don't give you a prodrome. A prodrome is a funny feeling, an abdominal sensation, the sense that it's happening They didn't give you a prodrome in this story It's not convulsive status because she didn't seize continually for minutes at a time Complex partial means there's some focal seizure activity with some impairment of consciousness. They gave you a story for generalized Most seizures in the hospital are focal seizures And then they quickly generalize, like embolic strokes Perturbs a part of the brain as it goes through a large vessel, bonks against the brain, and then it secondarily generalizes That's the end of the questions and now I'll tell you all the brain stuff you might have wished you'd known before we did the questions

neuro-intensivist

neurological conditions

brain death diagnosis

Propofol infusion syndrome

opioid overdose treatment