Jessica L White Kevin N Sheth Editors Neurocritical Care for the Advanced Practice Clinician 123 Neurocritical Care for the Advanced Practice Clinician Jessica L White • Kevin N Sheth Editors Neurocritical Care for the Advanced Practice Clinician Editors Jessica L White Neuroscience Intensive Care Unit Yale New Haven Hospital New Haven, Connecticut USA Kevin N Sheth Neurosciences Intensive Care Unit Yale School of Medicine New Haven, Connecticut USA ISBN 978-3-319-48667-3 ISBN 978-3-319-48669-7 (eBook) DOI 10.1007/978-3-319-48669-7 Library of Congress Control Number: 2017946839 © Springer International Publishing AG 2017 This work is subject to copyright All rights are reserved by the Publisher, whether the whole or part of the material is concerned, specifically the rights of translation, reprinting, reuse of illustrations, recitation, broadcasting, reproduction on microfilms or in any other physical way, and transmission or information storage and retrieval, electronic adaptation, computer software, or by similar or dissimilar methodology now known or hereafter developed The use of general descriptive names, registered names, trademarks, service marks, etc in this publication does not imply, even in the absence of a specific statement, that such names are exempt from the relevant protective laws and regulations and therefore free for general use The publisher, the authors and the editors are safe to assume that the advice and information in this book are believed to be true and accurate at the date of publication Neither the publisher nor the authors or the editors give a warranty, express or implied, with respect to the material contained herein or for any errors or omissions that may have been made The publisher remains neutral with regard to jurisdictional claims in published maps and institutional affiliations Printed on acid-free paper This Springer imprint is published by Springer Nature The registered company is Springer International Publishing AG The registered company address is: Gewerbestrasse 11, 6330 Cham, Switzerland Dedicated to our colleagues in the Neuro ICU – the nurses, physicians, and advanced practice clinicians who commit themselves to providing compassionate care for the neurologically ill And to our patients and their families – the practice and art of critical care neurology is our service to them Acknowledgment This project strives to highlight the professional collaboration between advanced practice clinicians and physicians as part of a multidisciplinary team We are grateful to our contributors for exemplifying this collaboration by generously sharing their expertise and experience in the field of neurocritical care We would like to thank the Yale University Neurocritical Care faculty and APC staff for their encouragement and feedback through this process And special thanks to Guido Falcone for his editorial assistance We are privileged to work everyday with such a phenomenal team vii Contents 1 The Role of Advanced Practice Clinicians in the Neuroscience ICU Jessica L White and Kevin N Sheth 2 Neuroanatomy Laura A Lambiase, Elizabeth M DiBella, and Bradford B Thompson 3 Neuroradiology 29 Susan Yeager, Mohit Datta, and Ajay Malhotra 4 Aneurysmal Subarachnoid Hemorrhage 55 Jessica L White and Charles Matouk 5 Intracerebral Hemorrhage 75 Devra Stevenson and Kevin N Sheth 6 Acute Ischemic Stroke 93 Karin Nyström and Joseph Schindler 7 Mechanical Thrombectomy for Acute Ischemic Stroke 117 Ketan R Bulsara, Jennifer L Dearborn, and Jessica L. White ix x Contents 8 Malignant Ischemic Stroke and Hemicraniectomy 137 Julian Bösel 9 Cerebral Venous Thrombosis 151 Gretchen Crabtree and Chad Miller 10 Traumatic Brain Injury 165 Megan T Moyer and Monisha A Kumar 11 Intracranial Pressure Management 183 Danielle Bajus and Lori Shutter 12 Seizures and Status Epilepticus 201 Catherine Harris and Emily Gilmore 13 Neurological Infections 223 Brian A Pongracz, Douglas Harwood, and Barnett R Nathan 14 Brain Tumors 251 Raoul J Aponte, Ankur R Patel, and Toral R Patel 15 Spinal Cord Injury 269 Jennifer Massetti and Deborah M Stein 16 Neuromuscular Disease 289 Peter Reuter and Alejandro Rabinstein 17 Hypoxic-Ischemic Injury After Cardiac Arrest 307 Jodi D Hellickson and Eelco F.M Wijdicks 18 Brain Death and Organ Donation 321 Dea Mahanes and David Greer Contents 19 Goals of Care and Difficult Conversations 343 Christine Hudoba and David Y Hwang 20 Multimodality Monitoring 363 Richard Cassa and Nils Petersen 21 Airway and Ventilation Management 387 Matthew Band and Evie Marcolini 22 Pharmacology 407 Kent A Owusu and Leslie Hamilton 23 Common Complications in the Neuro ICU 439 Jennifer L Moran and Matthew A Koenig 24 Helpful Links and Resources 467 David Tong and Jessica L White xi Chapter The Role of Advanced Practice Clinicians in the Neuroscience ICU Jessica L. White and Kevin N. Sheth The field of neurocritical care encompasses a broad range of neurological pathology and requires a multidisciplinary approach to provide best patient care At institutions across the country, physicians work alongside physician assistants and nurse practitioners to care for neurologically ill patients This collaborative relationship serves to provide an ideal complement of specialized medical knowledge and experienced bedside care Stemming from a historical genesis in primary care practice, the fundamental education of nurse practitioners and physician assistants is general by design, including basic principles of medical science and clinical management This educational foundation offers the benefit of professional flexibility and the ability to adapt to a myriad of subspecialties; however, such adaptation requires continued focused learning when entering a subspecialty to acquire advanced understanding of patient care Recognizing this challenge, we embarked on a J.L White, PA-C (*) • K.N Sheth, MD Yale University, New Haven, CT, USA e-mail: Jessica.white@yale.edu; Kevin.sheth@yale.edu © Springer International Publishing AG 2017 J.L White, K.N Sheth (eds.), Neurocritical Care for the Advanced Practice Clinician, DOI 10.1007/978-3-319-48669-7_1 456 J.L Moran and M.A Koenig of urine output is measured each hour and then replaced with saline during the following hour This process can be labor intensive and requires strict monitoring of the intake and output, especially in subarachnoid hemorrhage patients who may be awake and able to swallow oral fluids In addition to fluid balance, obtaining daily weights and trending the central venous pressure are useful to determine when a patient needs more volume replacement Volume contraction from CSW may lead to strokes due to cerebral hypoperfusion in the setting of cerebral vasospasm in patients with aneurysmal subarachnoid hemorrhage With CSW, the subarachnoid hemorrhage patient can quickly become volume depleted, greatly increasing the risk for development of symptomatic vasospasm and cerebral ischemia [25] 23.8.4 Special Case: Triphasic Sodium Response Patients who undergo neurosurgical procedures for pituitary tumors may develop postoperative DI that quickly progresses to SIADH and then returns to a state of DI. Wide variations in sodium and osmotic shifts put the patient at risk for osmotic demyelination, seizures, and cerebral edema Close postoperative monitoring with serial sodium checks and strict fluid balance monitoring are needed This triphasic response occurs when there is transient dysfunction of the pituitary stalk or hypothalamus during the immediate postoperative period, followed by recovery Phase one is a polyuric phase due to injury of the pituitary stalk or hypothalamus during which DI is caused by a decline in ADH secretion In the second phase, excess ADH is released from the damaged hypothalamic-pituitary axis until the stores of ADH are depleted This is followed by return of polyuria due to DI, which occurs after the reserves of ADH are depleted [20] 23 Common Complications in the Neuro ICU 457 23.9 P revention and Treatment of Venous Thromboembolism Complications related to venous thromboembolism (VTE) – deep venous thrombosis (DVT) and pulmonary embolus (PE) – are the third leading cause of death in the USA, and VTE is especially common in ICU patients Patients in the neurocritical care unit have significant risk of VTE related to immobilization from paralysis and sedation, delayed initiation of chemoprophylactic agents in patients with brain and spinal cord hemorrhages, delayed mobilization of patients with paralysis or intracranial hypertension, and underlying neurological conditions that lead to systemic prothrombotic states Depending on the underlying neurological condition, the incidence of VTE has been reported as high as 40–80% in patients in the neurocritical care unit with the highest incidence reported in patients with quadriplegia due to spinal cord injury and in patients with high-grade malignant brain tumors with paralysis [19] VTE has been shown to increase mortality, morbidity, and length of stay in the neurocritical care unit The most common signs of DVT include unilateral limb edema, fever, and limb pain, but these signs are frequently overlooked or obscured in neurologically ill patients For high-risk conditions like spinal cord injury, some institutions perform routine duplex ultrasonography to screen for DVT, but the cost- effectiveness of this approach has not been studied Common strategies for the prevention of VTE include early mobilization of patients, passive range of motion and massage, intermittent pneumatic compression (IPC), compression stockings (CS), and chemoprophylaxis with anticoagulant medications CS are not currently recommended for DVT prevention due to poor reported efficacy and high incidence of skin injury in recent clinical trials Chemoprophylactic agents include subcutaneous 458 J.L Moran and M.A Koenig unfractionated heparin (UH), low molecular weight heparin (LMWH), and the factor Xa inhibitor fondaparinux UH can be administered every or 12 h, and LMWH can be administered daily or twice daily with dose adjustments based on renal clearance, weight, and VTE risk Patients with impaired renal function who are receiving LMWH should undergo periodic testing with anti-factor Xa assays to monitor systemic anticoagulation Inferior vena cava (IVC) filters are not currently recommended for prevention of PE in patients without known DVT, even among patients who are quadriplegic due to spinal cord injury Because many neurocritical care conditions increase the risk of brain and spinal cord hemorrhage, the timing of initiation of anticoagulant chemoprophylactic medications has been controversial, and practices vary among institutions and providers A recent meta-analysis of TBI patients found that early (