SCCM Resource Library-Year in Review: Neurology

Video Transcription

So, thank you, and everyone here will give you a quick update on what's happening with neurocritical care as far as the testing and the ACGME transition.  And unfortunately, there is a lot of discussion going on at this meeting about what direction does critical care education need to go and what are kind of some standard aspects of  education. So, there is a session simultaneously going on right now that's having that discussion, and I have to run to that after this presentation. So, my apologies.  I will try to answer questions. So, a quick update. I have no disclosures except that I dread taking another test, just like all of you do, but we're all going to have to.  Everyone knows that the American Board of Psychiatry and Neurology announced in 2018 that it recognizes subspecialty certification, and the American Board of Medical Specialties  has recognized neurocritical care as of 2019. Background. So you all know this process has been long and coming. It started in 2016.  The initial groups that sponsored it were the American Board of Psychiatry and Neurology, American Board of Anesthesia, American Board of Emergency Medicine, and neurosurgery.  Recently, the American Board of Medical Specialties asked other medical boards if they wanted  to sponsor this, and both Internal Medicine, Surgery, and Pediatrics said not at that time, but they wanted to reserve the option that they might sign on later.  So, I have some updates for you on that. The idea of why we're doing this is to standardize training programs, to have uniformity in training  and skill sites, and to have a standardized assessment of competency and expertise. Sponsoring boards are working together. They have things in place.  They have committees working on this. We have practice and eligibility criteria developed for the new subspecialty board. The certification committee is formed.  They're actively working on test development, and the first exam will be in 2021, and what has recently come out is the deadline for you to apply for that test will be April 6th  of 2021, all right? And you would apply through your respective board, through EM, through psychiatry, neurology, through neurosurgery, or through anesthesia.  So that you should look for announcements in early 2021 to be able to apply for yet another exam for you to take, which means you will be writing another check.  The training guidelines and credentials for the training programs, a committee has been established for that through the American Board of Psychiatry and Neurology.  One of the members that's leading the test development is also on that group to develop the criteria for training programs, so that is moving forward.  Eligibility requirements, basically, you're going to have to have your primary boards in place before you take the test.  So if you're a neurologist, you're going to have to be certified in neurology to be able to take the neurocritical care exam.  If you're an anesthesiologist, you'll have to be certified in anesthesia, and we can go down the list. So you have to meet that criteria.  One thing that this is going to do, it is opening the grandfather period again, all right? And it will be a six-year time period of grandfathering in.  So those of us, I started this a long time ago, I did not do an official fellowship, I don't have a fellowship document saying that I did this, I went in through a practice  track initially, that will be available again for people. There's a lot of lists of how much time, it's time that you dedicate to neurocritical care,  and I'm happy to answer those later, but it's the usual 100% for one year, 50% for two years, and goes down the list.  There are, if you already have certification in neurocritical care, you do not have to use the practice track.  But that's one of the reasons, if your certification through UCNS is going to expire in 2020, you  may want to go ahead and take the UCNS test in 2020, so that you have your certification and don't have to go through a practice track course for 2021, which means you get to take  the test twice, okay? All right. Eligibility or requirements after the six-year grandfathering period will be for people from  backgrounds in neurology, anesthesia, or emergency medicine. They have to have done either a two-year accredited neurocritical care fellowship, or they do  one year of their surgical or anesthesia background, and then they do one additional year of neuro critical care.  Neurosurgery has a different path, because neurosurgery has such a long residency, they  can do an enfolded year, but you have to demonstrate dedicated time for neurocritical care training.  It can't be just part of their neurosurgical residency, they have a dedicated time period that they are doing only neurocritical care, and it has to be after their PGY3 year, okay?  As far as who's writing the examination, there's 13 members, a chair and vice chair, six of them are associated with the American Board of Psychiatry and Neurology, two from  each of the other sponsoring boards, anesthesia, neurosurgery, and emergency medicine, and one from the American Board of Directors. So there's representation from all groups.  Update on internal medicine. We have had advocates, whoever, those of you that are neurointensivists from IM backgrounds, your message was heard.  The American Board of Internal Medicine put together a group, and the critical care medicine  board of the American Board of Internal Medicine made a recommendation to the American Board  of Internal Medicine that they apply for co-certification status to be a co-sponsor of the neurocritical care certification exam.  So what this would mean, though, for internal medicine people, it's a tertiary process, though.  This is what they're gonna ask in the future, that you will do your internal medicine training,  you will do critical care training through internal medicine, and then you will do one additional year in neurocritical care, and it's a tertiary. So it's a very long process.  But with American Board of Internal Medicine signing on, that means they also will have the grandfather time period in, okay?  So if you are currently American Board of Internal Medicine, if ABIM does officially approve this, it's got one more step to be approved, then it will be available for people  from the IM background to take the certification exam, and we're hoping 2021. That's what they're planning.  So they're gonna review the proposal, update on anticipation will be hopefully by fall of this year, and they also plan to participate in the very first exam in 2021, okay?  American Board of Surgery has also reviewed this and is opting to co-sponsor as well, but they're going, they may be taking a slightly different path in that they may be partnering  with anesthesia here. Details still need to be worked out. But the American Board of Surgery will offer certification option to surgical critical  care diplomats who are working in the field of neurocritical care for them to sit for the examination. They are also planning on having an examination available in 2021, okay?  So now all of them except PEDS. So diplomats from other specialties, American Board of Pediatrics at this time as of last  update is not gonna co-sponsor neurocritical care certification.  UCNS and maintenance of certification will be the only option available for pediatric diplomats at this time and for, well, and for people from American Osteopathic Association  certification or doctors of osteopathy. There's more details at the neurocritical care website. New UCNS eligibility though.  UCNS has also heard from doctors of osteopathy and they have added AOA equivalent certification as a appropriate eligibility criteria.  So people from, with certification by AOA will be able to sit for the UCNS exam and we'll have to see how this moves forward.  So this will go in fact for all UCNS recognized subspecialties beginning with the 2020 subspecialty exams. So people would be able to take the UCNS exam.  So at this point, what are the recommendations? We're still recommending that people maintain their UCNS exam until the first ACGME is available.  So until that transition is actually underway. And the UCNS is also moving more towards a maintenance of continuous certification. So some of you will be getting notices for that.  So that's kind of my updates. I'm happy to take any questions or comments from people quickly. And you can also reach out to me at any point.  And if I don't know the answer, people like Cheryl Lee Chang and Tom Bleck and other people, I will help get you in touch with them and find answers.  So I'll do anything I can answer right now for you. Great. Like I said, I'm available. I'm pretty easy to find my email. Contact me if you need to. Okay. Thanks.  Thank you, Dr. Shutter. Now, Dr. Hirsh will have her session highlighting the science from last year in neuroscience. Thank you.  All right. All the way from Silicon Valley, and I cannot figure out how to advance slides. I'm Karen Hirsh. I am a neurointensivist at Stanford.  I am neurology trained on to neurocritical care. So I decided to just highlight two trials for you today because I wanted to strike a  balance between actually having a little bit of time to discuss them, the pros and cons of them, but then also obviously covering what was important.  So without further ado, we're going to talk about two sort of key clinical problems or clinical areas that neurointensivists manage on a regular basis.  So one is status epilepticus, and the other is brain injury after cardiac arrest. I don't have any relevant disclosures, but we'll say I'm on the American Heart Association  Guidelines Writing Committee for Cardiac Arrest. And so if anyone wants to debate temperature management, I'll be happy to do that. So let me just dive in with ESET.  ESET was a trial that was run through the Neurologic Emergencies Treatment Trials Network. I'm going to present it to you in the form of a PICO, which I think is helpful for those  of you that are not familiar with PICOs. It stands for Population Intervention Control Outcome and then Timing.  It's a very helpful way to frame a question or to really summarize very quickly a clinical trial or a research trial.  And when people write guidelines, they write guidelines in the form of PICO questions and try to answer a specific PICO question.  And we encourage our trainees to do this for Journal Club as well, because it really helps you break down the trial in a very simple way.  So I'm going to present these two trials to you in the form of PICOs, and we'll go through them very quickly, as I said. So what was the population for ESET?  So this was a population that had a clinical definition of status epilepticus. This is relevant, because with more and more people having rapid EEG available to them,  it often begs the question of how we are defining a seizure. So for ESET, this was a clinical definition of convulsive status epilepticus.  And the patients had to be, quote, refractory to benzodiazepines. And so what that means is that there were varying doses, depending on which benzodiazepine  was being used, to be considered refractory. But if it was diazepan or midazolam, it was 10 milligrams. And if it was lorazepam, it was 4 milligrams.  So patients had to receive at least that much benzodiazepine before they, and still be clinically seizing before they were considered eligible for this trial.  For the pediatric patients, it was weight-based, and I will not pretend to try and tell you that I know those doses off the top of my head.  The intervention, and again, this is for all comers, regardless of age. So it was levotriacetam at a pretty high dose, 60 mg per kg.  This is, I would say, higher, oftentimes, than what we would use clinically, versus fosfenitoin at 20 mg per kg, versus valproate at 40 mg per kg.  There was no control, because the three arms were compared within each other. And the outcome was a clinical outcome.  So at 60 minutes, the investigators were at the bedside, and they were asked to fill out the case report form, and say, had seizures stopped, and was awareness improving?  And again, it was at 60 minutes. This was an interesting trial, because it was one of the first trials to go through the network with an adaptive design.  And so the simplest way that I can try to explain what adaptive design is, is that it's  an advanced statistical method that sees how the results are going, and changes the allocation to different arms, based on how the initial prelim data is looking.  So it doesn't start out and say, this many patients are in intervention A, this many are in B, and this many are in C. It says, we're going to do X number of patients, and  then we're going to look at the data. Obviously, the investigators aren't going to look, but the statistical team's going  to look at the data, and see which way the trends are going, and start to allocate patients to the arms that are looking most promising.  So what are the take-home messages from ESET? The picture here is from the publication. And you can basically see that this is the posterior probability.  So looking backwards, what was the probability that each drug would stop seizures? And all of them had essentially equal efficacy, and stopped seizures in approximately 50%  of patients. As far as adverse events are concerned, hypotension was numerically, but not significantly, more common seen with phosphonatone.  And that's a well-known problem, or a well-known side effect from phosphonatone that we're all aware of.  So when I think about trials, I think about what's good, and I think about what's bad. So I think that overall, the study design was very unique. It was clinically relevant.  It was comparing three drugs that we all use in clinical practice. And the fact that they define seizures clinically reflects real-world practice, and is very  helpful for those of us trying to take care of this patient population. However, we were an enrolling site.  And I can tell you, being on the phone calls and taking care of these patients myself, it was a muddy population.  If you had someone who had been seizing, and gotten benzos, and they still had a few twitches,  or maybe weren't necessarily responsive, did you consider that convulsive status epilepticus?  So I think there was broad variability, and probably variability across sites, and probably variability within sites, about how they defined persistent status epilepticus.  We know that 10% of the population went on to be diagnosed definitively with non-epileptic events, or psychogenic events.  And the dosing, as I said, probably reflects real-world practice, but the levator acetam dose was pretty high. So what are my take-home messages?  And we'll talk at the end about how to apply this to clinical practice. I think that any of those agents are reasonable second-line agents in patients that have failed  benzodiazepines for status epilepticus. And the good news is that all of them can be given safely.  Unfortunately, they only actually were effective in 50% of patients, which I found a bit surprising,  and generally think that these agents, previously reported data showed that these agents were more efficacious than that. All right, we'll wait till the end for questions.  We're going to shift gears now. As I said, we're going to fly through these two clinical trials.  So the next one is Hyperion, which was therapeutic hypothermia after cardiac arrest in non-shockable rhythms. Came out in the New England Journal just about six weeks ago.  So again, we'll go through the PICO, the relevant PICO question. So the population is patients who are comatose after resuscitation from cardiac arrest with a non-shockable rhythm.  These were out-of-hospital arrests, and the definition of coma was a GCS less than or equal to eight. This was only in adult patients.  The intervention was moderate hypothermia to 33 degrees, and the control was controlled normothermia.  I'll just point out that this is interesting that they chose this for the control arm. The previous TTM trial compared 36 to 33, so it's slightly different study design than  the TTM trial. And the argument for that, the ethical argument for that, is that there had previously really  not been any data showing that hypothermia in a prospective trial was good for non-shockable rhythms.  Outcome was a pretty standard outcome that we use in cardiac arrest, which was a cerebral performance scale score of 1 to 2, which basically means functional independence.  And it was assessed at 90 days post-arrest. It was open label, so the treatment teams knew which temperature target the patients were getting, but it was randomized and controlled.  So how did we do? Well interestingly, in the statistical design of the study, the investigators thought the  good outcome rates would be about 20% in the intervention group and about 14% in the control group.  And none of the groups achieved good outcome rates at that rate, but we did see a statistically  significant difference in good outcome with the patients receiving therapeutic hypothermia as more likely to have a good functional outcome at 90 days.  You can see the functional outcome bars here, so the CPC distribution. If you look here, the 1 and 2 is down here and down here in the intervention group.  And so I just put the numbers here for you since it's pretty hard to see. 10.2% good outcome in the intervention group versus 5.7% good outcome in the controlled normothermia group.  Obviously outcome measures are somewhat coarse, and it's just a scale. Many people may argue that a CPC of 3, which is essentially a conscious and interactive  treatment, but dependent for some care, would also be considered a good outcome based on the devastating insult that they go in with.  But for the purposes of the trial, a CPC of 1 to 2 is what was used. So what are my thumbs up and thumbs down on this trial?  So my thumbs up are that this is an important contribution to the post-arrest literature.  We've never had a prospective randomized trial for out-of-hospital arrest with non-shockable rhythms.  This is a big contrast with previous observational literature, which obviously has significant  limitations, but showing that perhaps in non-shockable rhythms, the benefit is not as robust.  Or even in some observational trials, that there is potential harm associated with cooling non-shockable rhythm patients.  The outcomes assessor was blinded, and they had somewhat standardized prognostication and care withdrawal.  So anyone who takes care of these patients post-cardiac arrest knows that one of the big key important things in taking care of them and important things for the clinical  trials is that prognostication is standardized, that it does not occur too early, and that it is accounted for in clinical trial design.  So this trial at least recommended algorithms for the sites and said that generally they were followed.  But on my thumbs down, we actually had somewhat limited information about what was driving the rationale for withdrawal of life-sustaining therapy.  They do note that it's due to neurologic prognosis, which is better than some trials, but we don't have a lot of detail about what those decisions were necessarily based on.  Thumbs down. Some differences, and not necessarily baseline characteristics, but between the two groups. Some of this is inevitable just because of the study design.  So sedation duration was obviously much longer in the group that was undergoing hypothermia. Temperature management duration was also longer in the intervention arm.  So in the control arm, they had 48 hours, and in the intervention arm, they went out to almost three days of temperature management. The control group did have some fever.  The goal was to obviously prevent fever and keep them right at 37 degrees, but there is significant debate in the field about whether or not fever prevention versus hypothermia  is really the important message here. But nonetheless, I think hopefully that this shows us that hypothermia is the benefit.  So my take-home message, in comatose survivors of cardiac arrest, out of hospital cardiac arrest from non-trackable rhythms, a higher percentage of patients had a good outcome  in the therapeutic hypothermia arm. That good outcome, again, was a CPC score of 1 to 2 in 90 days. So taking a pause, how do I think about how to apply these in clinical practice?  When I think about ESET, I think that it's a relevant question that all of us face in critical care. So the study was obviously done in an emergency setting.  It was not done in a critical care setting. But I think that it gives us important information. It's perhaps indirect information, but it's still important information.  I feel safe using any of those three options. I would say at our institution, we oftentimes reach for levotiracetam and never previously had a lot of data to back that up.  But the reason we reach for it is that it has a cleaner side effect profile and seems to be a better option in our critically ill patients with multi-organ failure and many  other concomitant diseases. I now finally feel safe doing that, whereas previously we would often say, if you think  they're really having bad seizures, maybe stay away from levotiracetam and use phenytoin or valproate. I think this trial now supports us in reaching for any of those three agents.  Obviously consider the side effect profile and the underlying disease. Valproate had significant restrictions in the clinical trial that are all the ones that  would be relevant in clinical practice. Malignant hypothermia, inborn errors of metabolism, et cetera. Switching gears to cardiac arrest, how do I apply these results?  I will say our institution, we were still cooling non-shockable out-of-hospital cardiac arrests. So I feel that, in a way, this gives us some good data to support that.  But I acknowledge that it's only a single prospective randomized trial. The fragility index, which basically evaluates how robust the results are, was high, meaning  that if one patient basically had switched over to not having a good outcome, the results would be non-significant. However, I think we don't put too much stock in that.  And we actually look at just the functional outcomes distribution. And you can see that, clearly, the functional outcomes are better in the hypothermia group.  So I think for out-of-hospital cardiac arrest, we still don't know what temperature to pick. But based on the data, 33 degrees is appropriate.  When I say we don't know which temperature to pick, I mean, is 33 versus 34 versus 36 better? We don't know.  But we certainly know that hypothermia to 33 degrees is better than controlled normothermia. So I will stop there. We're going to take questions at the end? Yeah. OK.  I'll stop there and look forward to talking about this further. Thanks, Dr. Hirsch. Next, Dr. Agapian will be talking about etiologies of the unconscious patient and approaches  different hospital models of how to respond to them. All right. Good morning. It's always a lot of pressure being the only thing between you guys and lunch.  But we'll make this a nice interactive session. And then we'll have questions towards the end for the earlier speeches.  Just by a show of hands, to poll the audience, how many neurologists do we have in the room?  Okay, so many of you guys are familiar with code strokes. Do we have any surgeons or neurosurgeons in the room? Okay, I see a few hands there as well.  And initially the way this talk was designed, it was designed in the model of the flipped classroom, or the reverse classroom type model.  And there were some questions that were made available. If you haven't had a chance to see them, we'll just walk through them as we go along. We have like six objectives here  that we'd like to try to cover. And the first and foremost would be recognizing and identifying the different ideologies for the unconscious patient.  Because how many people take ER call or are on call for their hospitals?  Okay, many times you'll get a call saying this patient is unconscious or was found down. We're not sure if they're having a stroke. And I remember a few years back  when Congress was in San Antonio, I had the privilege to have dinner with Dr. Rincon, who is the chair of the section. And he had to step away for a few minutes  because he had a teleconference with the robot. They were holding the robot in front of the patient's face and evaluating to see if the patient actually had a stroke or not.  So that's gonna be one of the differentials that we're gonna be discussing. The next one, and the next implication of identifying correctly what the ideology would be  is to know who to like call. So if you're in the ER, for example, and you're an ER physician and you're dealt with this situation, do you activate a trauma?  Do you call a code stroke and have the on-call neurologist get paged and put a robot in front of the patient?  We learned about cooling patients.  Is this a cardiac arrest, a STEMI? Do we need to like call the cooling team and the code team to do the angio?  Because the needle, door to needle times are closely monitored. So those are the implications of correctly identifying why this patient was found down.  Every institution has its own set of codes. Some hospitals are designated trauma centers. Other centers are designated stroke centers of excellence. Other centers are STEMI centers.  So as far as the field paramedics go, they have to have a general idea what this patient is undergoing to know where to deliver the patient to.  Each institution has specific teams and codes in play.  And after this little discussion, hopefully you can take that back to your institutions and see how to incorporate what we learned here  into hospital policies at your own home institutions.  Next would be to predict which service the patient will actually belong to. So if you're a neurologist, you don't wanna admit a patient who doesn't even have a stroke  and now it becomes a placement issue, discharge, hospital length of stay, and the patient never even had a stroke. So what service they belong to or they get admitted to  will have implications. And the last two would be the guidelines. Each institution has different guidelines as to how to admit these patients and how to manage them.  And then how to manage these patients once they get admitted to a different service. So I gave a little survey of why somebody might be down. It could be, the most common ones  would be metabolic disarray. And how many people, as Dr. Sutter had talked to us about the upcoming ABS subspecialty certification  for neurocritical care, how many have actually participated in the SCCM critical care practice question thing.  Are you guys familiar with that one? Has anyone done that one?  I know we have it available in the bookstore here, but you could get the book or online. This is actually, there was actually a question relating to this,  and this was in the discussion. They talked about the differentials for that. One was certainly metabolic disarrays. Others were overdoses, poisonings, vascular disease.  So you could have different ideologies for like TIAs or other vascular ideologies.  And finally, infection, sepsis, and then somebody could have had a seizure and they're just postictal.  Okay, for the sake of our discussion here though, we're gonna mainly talk about strokes  because that's something we're all very familiar with. And for the few trauma surgeons or the neurosurgeons in the audience, traumas, you know, I won't spend as much time on that.  So we talked about what the implications are. So depending on what the hospital is and what services are available, it determines the level of expertise  and the resources you might have available. So if a patient is actually having a stroke but gets sent to a hospital that's just the trauma center  and they don't have a stroke center for excellence, you know, that's gonna do the patient more harm  because now you're in a facility that can't really attend to that. And you have to do inner ER to ER transfers. So depending on what facility you're at,  you're gonna have like a set of resources available. So that's gonna be important to have the patient arrive at the right hospital from the beginning.  These might have life or death circumstances  based on, you know, how and where they end up. Also allocation of public funding because many of these designated centers, you know, if it's a trauma center, for example,  county budgets help fund local hospitals to have trauma centers running. You know, same with like STEMI centers and code stroke centers of excellence.  So that has implications of funding and quality metrics as well. So as I'll go through some of the later slides, for example, STEMI centers,  they have quality metrics that they have to report back to like what the time from the patient's initial presentation to the emergency department,  all the way to the time of the first needle stick in the groin for an angio. So those are time metrics, for example, that get very closely followed  and your level of quality is determined by how compliant or how closely you comply with these quality metrics. Same with strokes, for example. Okay, and then all these patients  then get registered into a national database. For example, in trauma, there's like the T-QIP. For surgery, there's NISQIP. And certainly for stroke and for cardiac STEMIs,  they have national databases that each of the participating hospitals then report back to.  Just by way of example, you know, STEMI would be the first one that we'll quickly talk about.  As I mentioned, there are databases. This one's the National Cardiovascular Data Registry for Acute Coronary Treatment Interventions Outcome.  I'm not gonna get into the details of it, but just by way of illustration, I wanna point out that these are heavily studied and published and followed guidelines.  So that's one example of a patient who's found down and depending on what their ideology is and how they get worked up, they have all the quality metrics  and resources to follow through with. Okay, so something we're more familiar with or bread and butter stuff is the code stroke.  And we're all familiar with the landmark trials out there, starting TPA, how and when to start it. So patient comes in, they get a CT at the head, and this is what you see.  Is there any question what you're gonna do next other than ask them how long they've been down for and what the window is?  Okay, so as far as time to TPA,  let me get a poll from the audience. What do most people think is the outer limit of how long somebody can be before they could be a candidate for TPA?  Anybody wanna throw an answer out there?  Say that again.  Okay, four and a half hours. And a lot of times people will be like, oh, it's been more than four and a half hours, they're not eligible. But I think some of the centers  are pushing that envelope out further, if I'm not mistaken, right? You will need to use technology to push the envelope. Okay. But the... Standard? Yeah, it's 4.5.  We recommend, okay, so 4.5. And that's why time is critical and making a correct diagnosis initially will allow you to fit into these windows.  Here's a slide that just talks about how to dose the TPA. This is something probably we do for day in and day out. We could do this in our sleep. So this is just to put it out there  that it actually is a code stroke. We know what to do. And these are the contraindications for strokes  starting TPA.  And then I'll finish the talk off and allow for questions at the end now. Trauma activation. So I work at a trauma center. My disclosure is I'm a trauma surgeon.  So part of my inspiration to have a discussion about this is that pretty much anybody that comes into the emergency department that was found down  ends up being a trauma activation because due to gravity, if you're gonna lose consciousness and you're gonna be on the ground, that's a fall, so it's a trauma.  So we spend the whole activation, all the resources scrambled under the ER. They get CAT scans, x-rays, lines, million dollar workup. And then you get a CAT scan  and then you might see something like this. So what do you do now? Is this a stroke? Is this a trauma? How many people think this should now be a code stroke instead?  I see a few hands in the audience. How many people say just keep it as a trauma, this isn't a code stroke?  Is there anybody out there that doesn't think there should be a code stroke and it should just stay as a trauma?  I think some would argue that if you look at the, I mean, everybody thinks, everybody just looking at it, I'm talking to a room of neurology experts. Everybody would agree  that this isn't a normal CT of the brain. The question then would be, is this like an acute event? Is this a chronic event? Is this acute on chronic?  How many people think this is an acute event?  Okay, I see a lot of hands out there. Okay, how many people think this is just a chronic event?  Okay, how many people think this might be acute on chronic based on the densities of the thing? Okay, more people say that. Okay, so to that end, at least in my institution,  our neurology program is less robust. So I think the one neurologist who does take call would probably say, I don't think this is a stroke  or just keep it on the trauma service, call neurosurgery. But therein lies the question. Certainly if they're out of the window, if it's more than four hours, certainly five hours,  then they're not a candidate for TPA anyway. So in that sense, it's less of a discussion point. So I'll wrap it up by just reminding everybody  that there's a broad extensive differential for the patient found down. It could be anywhere from a drug overdose to just maybe a homeless guy taking a nap on the ground  to somebody actually having a heart attack or somebody who actually got knocked out and now may have intracranial hemorrhage. So it's a unanswerable question maybe.  And the best we could do is adapt with change and follow the workup and see where that takes us. So that has implications of how and where the patients end up, who admits them,  which facilities they get transported to. And this will have like ramifications of like patient outcomes, quality metrics that get reported and life and death survivability.  So thank you very much. And we'll open it up for questions now. Thank you, Dr. Agapian. Any questions?  So before you go, I want to go back to the extension of window for TPA. I think that there are two instances that will be probably a new indication for TPA.  I'm talking about intravenous TPA. The first one, the American Heart Association, American Stroke Association published updated guidelines last year  and is for the inclusion of patients with wake-up strokes. The technology that I was mentioning in terms of decision-making involves the use of MRI.  So you will see more and more protocols being changed in terms of allowing intravenous thrombolysis for patients that wake up with a stroke. And the biology is sort of like simple.  You sort of like think about this when patients come in, you don't really know what time it occurred, but most likely it occurred before they woke up.  So what you're doing with the MRIs are like identifying the type of stroke that may qualify for intravenous thrombolysis with minimal risk of hemorrhagic conversion. So that's one.  And at my institution, we started already  editing of our protocols and we will include now a pathway for wake-up strokes using MR technology. And then the second group of patients  are patients where you know the last time of onset, but they are beyond the 4.5 hour window. There was a study published in the England Journal last year as well, called Xtend.  It was a non-American based study, primarily UK and Australia, I think,  where they actually tested the safety and feasibility  of using TPA beyond 4.5 up to nine hours, I'm sorry, using CT perfusion and on the basis of the ratio between penumbra and core or stroke infarct size,  they were able to thrombolyze patients up to nine hours with a reasonable efficacy and limited complications.  So those are the two groups that I think you will see more data coming up. I don't know, Dr. Hirsch, do you have any comments? Yeah, I agree. I would just add that I think the field  for intravenous thrombolysis is moving towards tissue-based diagnosis and not time-based diagnosis, right? And so using imaging to guide patient selection,  not just using time since last known normal. So I think we'll see a lot of that. There's a lot of clinical trials currently looking at extended window IV thrombolysis  with other agents as well. So more to come, but I think in general, four and a half hours for your average center that cannot rapidly get patients to MRI. All right.  We have two questions here.  Azar Ali, I'm an intensivist in AdventHealth Tampa. The question is for Dr. Hirsch. In the hypothermia, therapeutic hypothermia clinical trial,  was sedation used in that clinical trial? And my next question would be, what's your current practice at your institution regarding use of sedation in hypothermia?  Yeah, so the question was about sedation protocols  and Hyperion and then what we do. So I think it's a great question. Obviously, it's a very important question. So the objectives for sedating patients post-cardiac arrest  are to make sure that they're comfortable while they're undergoing therapeutic hypothermia, and also to facilitate temperature management to avoid shivering.  The sort of the converse to that is that these medications have prolonged clearance in patients that are getting hypothermia or patients with post-cardiac arrest  multi-organ dysfunction. And therefore, that has significant implications as well for time to awakening and also confounding neurologic prognosis. So in the Hyperion trial,  they basically said that they followed the quote guidelines but it was done in Europe, it was done in France. So they followed ILCOR, International Liaison Committee  on Resuscitation Guidelines for this. They basically, in the normothermia arms, sedated patients for the first 12 hours using a standard approach with benzodiazepines  and opiates for analgesia. In the temperature to 33 degree arm, they were sedated the entire time that they were at a reduced temperature  until they were re-warmed to normothermia. So they had significantly longer durations of sedation. They used the same approach. They basically said it was at the discretion  of the treating sites, which agent they would pick, but they used sedation plus analgesia with opiates and then used neuromuscular blockade as needed  in order to achieve temperature management and prevent shivering. So what do we do? I would say it's an evolving target and there's been a lot of discussion about this.  The Neurocritical Care Society and American Heart Association are actually putting out a statement that should come out in the fall  about the critical care management of post-arrest patients. Basically addressing many of these questions because we don't have prospective randomized controlled data  about these topics. So that we put together a consensus conference of 25 experts and are going to be commenting on this. I can tell you though that basically it says  use the minimum amount necessary, target it obviously to signs of patient discomfort in an unconscious patient and try to reserve neuromuscular blockade  as a sort of as needed medication and not necessarily as a this is everybody continuous dose neuromuscular blockade. Does that answer the question?  Go ahead. Hi, I'm Chris Winterbottom from Bridgeport Hospital. I have a question about TTM also. In our health system we use an arctic sun, we will cool people to 36,  we will allow people to warm to 33 and if people come in between we will keep them at that temperature. When we talked about the Hyperion trial at a system level  we felt like keeping people kind of close to 37 with cooling blankets didn't sufficiently reflect what our current practice was to abandon TTM in favor of hypothermia.  I'm wondering if other people in the room here have done that. If we think that this trial is enough to think that therapeutic temperature management  is inappropriate and we should be cooling people and my question to the panelists is whether you think that we should.  I'll go first. I think that the data shows that after the TTM trial came out there was a lot of creep. So people thought oh, 36 and 33 have equal efficacy  and therefore we don't need to do hypothermia and then that translated into oh, we don't really have to do closed loop temperature management either.  And so that's not what the guidelines say. The guidelines actually say that in cardiac arrest patients you should do closed loop management. So arctic sun, control it,  really be aggressive about maintaining the temperature post cardiac arrest. But I certainly agree that there has been significant creep  and there's data to support that many, many centers have gotten away from this significantly.  As I said, I don't think that we know what the right temperature is because those trials have not been done. The trials by design have to pick temperatures for intervention arms  and that's just how the trials are designed. So we only know data from the trials where they had very specific temperature targets. There is a clinical trial coming.  It all goes to 33 degrees but it goes for different durations too and that's called ice cap. So I would simply say we don't know for sure  what the duration of temperature management should be and we don't know what the target temperature should be. But based on the data that we have,  I would suggest that any comatose cardiac arrest survivor should be managed with a closed loop system with a target temperature between 33 and 36 degrees  and that my suggestion is 33, understanding the resources. I suspect you'll get very different answers if you pull the room and- No, I actually agree with you.  I think that the bottom line is that you have to pick a dose. You have to pick a target for your patients and just take it from there. There is a phenomenon that you see a lot  which is fever post rewarming and that's just another kind of worms out there. But as long as you're doing 33 to 36 right now for basically every survivor of cardiac arrest  is the way to go. And then we have TTM2 also coming up, right? 33 versus 37, which is real normothermia. And we're expecting those results and see if there's any difference.  Hi, this is Dr. Ntimba from SSM DePaul Health Center. I'm an intensivist. I'm also certified in neoclinical care. My question is about the ESSET study  and maybe also about your experiences. One of the biggest reasons I find patients coming to the ICU with quote-unquote status epilepticus is inadequate dosing of the benzodiazepines  and they're giving like measly doses, like one milligram or they're widely spaced.  What has been your experience with this matter? And also in this article, were they able to exclude that factor in those patients who are termed refractory? Yep.  Yeah, so the question was about the ESSET trial and just in general, what's adequate benzo dosing.  As first-line agents for status. So I can tell you, there was a lot of discussion and controversy about this when the trial was coming out. People felt like, yes, of course,  we wanna achieve quote adequate benzodiazepines. The concern with the doses that they were mandating in the trial was that airway protection would be compromised and or the patients  would just take a very long time to wake up. Because again, it was 10 milligrams for the diazepam and midazolam groups or four milligrams total.  And the way that they actually recommended you dose them was five milligrams followed by another five if seizures were continuing for just like five minutes,  five to 10 minutes or two initial dose of two milligrams of lorazepam followed very quickly by another two. So that's what they defined as adequate benzos. I would say that agree,  our institution does not always do that. I would say I'm a little more comfortable now using those bigger doses after the trial because they did not see a lot of adverse effects  from the doses.  They did not see increasing rates of intubation, but that said every patient in that trial had to have those doses. So I think going hard and fast with your benzodiazepines  for status is probably the way to go, but obviously you need to do it in a place where you are able to watch the patient closely and make sure they have airway protection.  I don't know if Dr. Rincon, if you, what you all do, but there's a lot of variability. Yeah, I agree. You have to go through the full dose of benzodiazepine.  It's supported by all studies as well.  And the failure on a second or third agent  may be related to the fact that you're not loading up front the right dose of benzodiazepine. Yeah, I can tell you the one milligram of Ativan  and the gram of Keppra is sort of standard. Well, they got a gram of Ativan and a gram of Keppra, so it's prevalent. So I think re-education about what adequate dosing is  is important. Thank you very much. Well, I think we are done, so let's go have lunch. Thank you very much for your attention. Thank you.

Video Summary

The speakers discussed the importance of correctly identifying the etiology of an unconscious patient in order to determine the appropriate course of action. They emphasized that different hospital models and resources are available to handle different medical emergencies, such as stroke, trauma, or cardiac arrest. It was noted that the field of neurology is moving towards tissue-based diagnosis rather than time-based diagnosis. For example, there is growing evidence to support the use of intravenous thrombolysis in patients with wake-up strokes and patients who are beyond the traditional time window for treatment. The speakers also emphasized the importance of adherence to sedation protocols in post-cardiac arrest patients who are undergoing therapeutic hypothermia. They highlighted the need to use the minimum amount of sedation necessary and to reserve neuromuscular blockade as a last resort. Overall, the speakers emphasized the need for ongoing research and consensus in order to improve the care and treatment of unconscious patients.

Asset Subtitle

Neuroscience, 2020

Asset Caption

The Society of Critical Care Medicine's Critical Care Congress features internationally renowned faculty and content sessions highlighting the most up-to-date, evidence-based developments in critical care medicine. This is a presentation from the 2020 Critical Care Congress held February 16-19, 2020, in Orlando, Florida, USA.

Learning Objectives

Interpret the National Board of Medical Examiners' guidelines and identify how to prepare for the neurocritical care certification examination
Identify leading trials in neurocritical care and assess practical applications from trial findings
Recognize different etiologies for the unconscious patient and give examples of different hospital response codes that may be activated

NBME Update on Neurocritical Care Board Certification

Lori A. Shutter

Review of Recent Clinical Trials in Neurocritical Care 2020

Karen G. Hirsch

Code "Found Down"

John V. Agapian

Meta Tag

Content Type Presentation

Knowledge Area Neuroscience

Knowledge Level Intermediate

Knowledge Level Advanced

Membership Level Select

Membership Level Professional

Membership Level Associate

Tag Seizure

Tag Stroke

Year 2020

Keywords

etiology

unconscious patient

appropriate course of action

medical emergencies

neurology

tissue-based diagnosis

intravenous thrombolysis

sedation protocols

therapeutic hypothermia

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