2007 TABLE OF CONTENTS Introduction ………………………..…………….………….... 3 Frequently called numbers …………………………………. ... 4 Department phone numbers ……….……………………….. ... 5 Dictation formats…………………………………………….... 6-7 PNS Anatomy………………………..…………………….. .... 8-20 Brain sections………………………………………................. 21-25 NIH stroke scale. …………………………………………....... 26-37 SAH classification …………………………………… …….... 38 Level of consciousness……………………………………....... 38 Motor Assessment scale ……………………………................ 38 Glasgow Outcome scale………………………………. ……... 38 Glasgow Coma scale ………………………………………. .... 39 rt-PA dose …………………………………………………. .... 40 Indications/Contraindications for rt-PA in stroke ……….. ….. 40-41 Acute Ischemic Stroke/TIA Clinical Guideline ……………. ... 42-43 Indications for Heparin therapy ……………………………. ... 44 Management of acute ischemic stroke …………………….. .... 45 Management of blood pressure in stroke ………………….. .... 46 Management of ischemic edema …………………………....... 46 Classification of aphasia ……………………………………. .. 47 Indications for CT Angiogram in ER ........................................ 48 Angiogram Orders …………………………………………..... 49 CSF Testing & Antibiotics used in Treatment of Bacterial Meningitis

……………………………………………………………….... 50-51 Antibiotic Therapy for Specific Bacterial Pathogens………. ... 52 Treatment of Herpes Encephalitis …………………………..... 52 Acute Multiple Sclerosis protocol …………………………..... 53 McDonald Criteria …………………………………............. ... 53 Dementia work-up …………………………………………. ... 54 Mini-Mental exam ..................................................................... 55 Alcohol Withdrawal Medications…………………… ……. .... 56 Different MR signals ………………………………………..... 57 Hemorrhage on MRI ………………………………………. .... 57 Management of Status Migrainosus ………………………...... 58 Drugs Used in Migraine & DHE Protocol ………………… ... 58-60 Side Effects of Antidepressants ………………………… ........ 61

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2007 Status Epilepticus Treatment for Adults ……………………. .. 62-66 Pentobarbital.............................................................................. 67 Standard Immunotherapy .......................................................... 68 IV immunoglobulin protocol .................................................... 69 Plasmapheresis protocol ............................................................ 69 Drugs that Increase Weakness in Myasthenia Gravis................ 70 Osserman’s Classification & Tensilon Test Protocol ................ 71 Orders for AIDP ........................................................................ 72 Diagram of Vital Capacities in Fatigue ..................................... 73 Algorithm for appearance of Dilated Pupils .............................. 74 Staging of Parkinson’s Disease ................................................. 75 Brain Death Protocol ................................................................. 76-77 Clinical References for Cerebrospinal Fluid Values.................. 78 Predicting Outcome from Hypoxic Ischemic Encephalopathy.. 79 Management of Concussion in Sports ....................................... 80-81 Prediction of Outcome in Comatose Survivors after Cardiopulmonary Resuscitation................................................. 82-85

.

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2007

Residents of Neurology: Welcome to the Department of Neurology Service. This book was designed to be a handy reference that will fit in the pocket of your white coat. It contains a variety of information, which we hope will be useful to you in caring for patients. Given that this is a continuous work in progress, if you have any corrections or suggestions for other topics that you think should be included, please let us know.

The Neurology Faculty

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2007 Frequently Called Numbers Admitting .............................................................................3881 Campus Police ......................................................................3770 CT Scan ...............................................................................4542 ER ……………………………………….............................3888 Heart Station …………………………….............................3925 Inpatient Transfer Line .........................................................3888 Laboratory ……………………………… ............................3470 Library …………………………………..............................4225 MRI …………………………………….. ............................3933 Med. Design …………………………… .............................5389 Medical Records ………………………...............................3754 Medicine………………………………. ..............................3685 Neurodiagnostic (EEG,EO,IOM)………..............................3931 Neurology Outpatient Clinic …………. ...............................3760-3787 Neurology Secretary……………………..............................3544 Neuropsychology …………………….... .............................5679 Neurosurgery …………………………................................3547 Pain Center …………………………….. .............................3666 Pharmacy ………………………………..............................3898 Psychiatry ……………………………….............................5695 PT, OT, Speech Pathology …………….. .............................5040 Stroke beeper …………………………................................444-1302 Activation ……………………........................................ 9999 Cancellation …………………… .................................... 0000 Standby ……………………….. ..................................... 5555

Surgical Pathology …………………….. .............................3485 Transcranial Doppler …………………................................3544 Vascular laboratory ……………………. .............................3935 2-Surgical ICU ………………………… .............................4987 3A- ICCU ……………………………… .............................4981 3B- ICCU ……………………………….. ...........................4975 3C- ICCU ……………………………… .............................4900 3D- MCCU ……………………………...............................4980 3D- Neuro ICU ………………………….............................4955 4AB- Medicine/Surgery ……………….. .............................4961 4CD – Ortho/Renal ...............................................................3731 5A- Surgery/Step down ………………………….. ..............4928 5B – Medicine/Surgery.........................................................4943 5CD- Neurology/Stroke Unit ………... ................................4950 6A – Geri Psych....................................................................6767 6B ICCU overflow................................................................4930 6CD- Rehab …………………………..................................6805

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2007 Department of Neurology Academic Secretaries.............................................. 3544, 6187 Clinic ...................................................................... 3760, 6015 EEG Lab ................................................................ 3931 EMG Lab ............................................................... 4379 Epilepsy Center....................................................... 6783 FAX ........................................................................ 3093 Residents’ Library .................................................. 3972 Residents’ Room..................................................... 3843, 3848

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2007 Dictation Formats What to dictate for Admission History& Physical Chief complaint & reason for admission to the hospital. History of Present Illness including these elements: Location of problem Quality of problem Severity of problem (scale of 1-10) Duration of problem Timing of problem Context of problem Modifying factors (exacerbating or relieving factors) Associated signs and symptoms Past Medical History Social History Review of Systems- include each category: Constitutional Eyes Ears, Nose, Mouth, Throat Cardiovascular Respiratory Gastrointestinal Genitourinary Integumentary Musculoskeletal Neurological Hematologic/Lymphatic Allergic/Immunologic Psychiatric Endocrine

General physical Exam (body areas): Head, including face Neck Chest, including breast and axillae Abdomen Genitalia, groin, buttocks Back, including spine Each extremity Specific Organ Systems: Constitutional Eyes Ears, nose mouth, throat Cardiovascular Respiratory Gastrointestinal Musculoskeletal Skin Neurological Psychiatric Hematologic Lymphatic Immunologic Review the number of diagnoses or treatment options. Discuss the amount and/or the complexity of the data to be reviewed. State the orders, tests, and plans, for the patient while hospitalized.

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2007 What to Dictate for Discharge Summary: 1.

Identify yourself.

2.

Patient name, please spell.

3.

Patient unit number (6 digit # in the upper right corner of face sheet).

4.

Discharge date- IMPORTANT.

5.

Narrative summary (clinical resume of significant findings and events of hospitalization) to include: a. Reason for admission b. Pertinent findings c. What was done d. Condition on discharge, to include (2-3 sentence synopsis): i. Why patient was admitted ii. What was done iii. Result of treatments

6.

Hospital complications.

7.

Consultations obtained.

8.

Disposition (home, transfer to another facility, or expired).

9.

Recommendations on discharge: a. Discharge instructions b. Medication changes since admission c. Diet d. Activity e. Follow-up (who to follow-up with and when).

Make sure a copy of the Discharge Summary goes to any treating physician or referring doctor.

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2007 Dermatomes

-8-

2007 Dermatomes

-9-

2007 Brachial Plexus

- 10 -

2007 Median Nerve

- 11 -

2007 Median Nerve

- 12 -

2007 Ulnar Nerve

- 13 -

2007 Musculocutaneous (A) and Ulnar (B) Nerve

- 14 -

2007 Ulnar Nerve

- 15 -

2007 Sciatic Nerve

- 16 -

2007 Peroneal Nerve

- 17 -

2007 Tibial Nerve

- 18 -

2007 Myotomes (arm) C5 C6 Anterior Primary Rami

C7

C8

T1

C7

C8

T1

ROXIMAL NERVES Rhomboid Major/Minor (Dorsal Scapular)

Supra/Infra Spinatus (Suprascapular) Deltoid (Axillary) Biceps Brachii (Musculocutaneous)

RADIAL NERVES Triceps Anconeus Brachioradialis Extensor Carpi Radialis Extensor Digitorum Communis Extensor Carpi Ulnaris Extensor Pollicis Brevis Externsor Indicis Proprius

MEDIAN NERVES Pronator Teres Flexor Carpi Radialis Flexor Pollicis Longus Pronator Quadratus Abductor Pollicis Brevis

ULNAR NERVES Flexor Capri Ulnaris Flexor Digitorum Profundus Med) Abductor Digiti Minimi Adductor Pollicis First Dorsal Interosseus

Posterior Primary Rami

C5

Cervical Paraspinals High Thoracic Paraspinals

- 19 -

C6

2007 Myotomes (leg) PROXIMAL NERVES L2 L3 L4 L5 S1 S2 Iliacus Adductor Longus (Obturator) Vastus Laterlais/Medials (Femoral) Rectus Femoris (Femoral) Tensor Fascia Lata (Gluteal) Gluteus Medius (Gluteal) Gluteus Maximus (Gluteal)

SCIATIC NERVES Semi Tendinosus/Membranosus (Tibial)

Biceps Femors (SHT.HD) (Peroneal) Biceps Femoris (Long HD) (Tibial)

PERONEAL NERVES Tibialis Anterior Extensor Hallucis Peroneal Longus Extensor Digitorum Brevis

TIBIAL NERVES Tibialis Posterior Flexor Digitorum Longus Gastrocnemius Lateral Gastrocnemius Medial Soleus Abductor Hallucis Abductor Digiti Quinti Pedis

POSTERIOR PRIMARY RAMI L2 L3 L4 L5 S1 S2 Lumbar Paraspinalis High Sacral Paraspinals

- 20 -

2007 Localization in Clinical Neurology

- 21 -

2007 Cross Section of the Brain

- 22 -

2007 Cross Section of the Brain

- 23 -

2007 The cerebellum

- 24 -

2007 Course of Cerebellar Arteries

- 25 -

2007 NIH Stroke Scale NIH Stroke Scale Items Function 1a. Level of Consciousness (Alert, drowsy, etc.)

Alert Drowsy Stuportous (requires repeated stimuli) Comatose 1b. LOC Questions Both correct (Month, age) One Correct Incorrect Normal 2. Best Gaze Partial glaze palsy (Eyes open-patient follows Forces Deviation examiner’s finger or face) Normal 3. Visual (introduce visual stimulus/ threa Motor asymmetry Partial to patient’s visual field Complete questions) Normal 4. Facial Palsy (Show teeth, raise eyebrows & Motor asymmetry Partial squeeze eyes shut) Complete No drift 5a. Motor Arm Left (elevate extremity 90° score Drift Some effort against gravity drift/movement) No effort against gravity No movement Amputation No drift 5b. Motor Arm Right (elevate extremity 90° score Drift Some effort against gravity drift/movement) No effort against gravity No movement Amputation

- 26 -

Score Exam 0 1 2 3 0 1 2 0 1 2 0 1 2 3 0 1 2 3 0 1 2 3 4 9 0 1 2 3 4 9

2007 NIH Stroke Scale Items

Function

No drift Drift Some effort against gravity No effort against gravity No movement Amputation 6b. Motor Leg Right No drift (elevate extremity 30° Drift score drift/movement) Some effort against gravity No effort against gravity No movement Amputation 7. Limb Ataxia Absent (Finger-nose, heal down shin) Present in upper or lower Present in Both 8. Sensory Normal (Pin prick to face, arm trunk, & Partial loss leg- compare side to side) Dense loss 9. Best Language No aphasia (Name items, describe a picture Mild-moderate aphasia & read sentences) Severe Mute 10. Dysarthria Normal articulation (Evaluate speech clarity by Mild-moderate slurring patient repeating listed words) Severe, nearly unintelligible or worse 11. Extinction & Inattention No neglect ( Use of information from prior testing to Partial neglect identify neglect or double simultaneous Profound neglect 6a. Motor Leg Left (elevate extremity 30° score drift/movement)

testing)

NIH Stroke Scale TOTAL: - 27 -

Score Exam 0 1 2 3 4 9 0 1 2 3 4 9 0 1 2 0 1 2 0 1 2 3 0 1 2 0 1 2

2007 NIH Stroke Scale

- 28 -

2007 NIH Stroke Scale

- 29 -

2007 NIH Stroke Scale

- 30 -

2007 NIH Stroke Scale

- 31 -

2007 NIH Stroke Scale

- 32 -

2007 NIH Stroke Scale

- 33 -

2007

- 34 -

2007

MAMA TIP-TOP FIFTY-FIFTY THANKS HUCKLEBERRY BASEBALL PLAYER

- 35 -

2007

You know how. Down to earth. I got home from work. Near the table in the dining room. They heard him speak on the radio last night.

- 36 -

2007

- 37 -

2007 HUNT-HESS CLASSIFICATION OF SAH 0 1 1a 2 3 4 5

Unruptured aneurysm Asymptomatic, or mild headache, & slight nuchal rigidity No acute meningeal/brain reaction, but with fixed neuro-deficit Moderate to severe headache3, nuchal rigidity; or cranial nerve palsy Lethargy or confusion; mild focal deficit Stupor, moderate to severe hemiparesis Deep coma, decerebrate rigidity

LEVEL OF CONSIOUSNESS 1 2 3 4

Alert Drowsy Stuporous Comatose

MOTOR ASSESSMENT- MRC SCALE 5 4+ 4 43 2 1 0

Normal strength Slightly less than full power against strong resistance Able to overcome moderate resistance Able to overcome mild resistance Able to accomplish full range of motion against gravity only Able to accomplish full range of motion when gravity eliminated Only trace muscle contraction; may only be palpable Flaccid

GLASGOW OUTCOME SCALE 1 2 3 4 5

Good recovery, fully independent Moderately disabled, impaired but independent Severely disabled, totally dependent Vegetative survival Dead

- 38 -

2007 GLASGOW COMA SCALE

MOTOR 6 Obeys verbal commands 4 Localizes to noxious stimuli 3 Decorticate posturing 2 Decerebate posturing 1 No response Verbal 5 Fully oriented 4 Disoriented, converses 3 Inappropriate words 2 Incomprehensive sounds 1 No vocalization Eye Opening 4 Opens eyes spontaneously 3 Opens eyes verbal commands 2 Opens eyes noxious stimuli 1 No eye opening

- 39 -

2007 rt-PA for Acute Ischemic Stroke Dose is .9 mg/kg, maximum 90 mg 10% of dose will be given IVP over 1 min., the rest is infused over 1 hour.

Indications for rt-PA therapy 1 2

3 4

Age > 18 Clinical diagnosis of ischemic stroke with a measurable deficit as impairment of language, motor function, cognition and/or gaze, vision, neglect Time of onset well established to be less than 3 hours CT performed and read

Contraindications for rt-PA 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18

Evidence of ICH on pre-treatment evaluation Clinical suspicion of SAH Minor stroke or symptoms rapidly improving by the time of onset of treatment Recent intracranial surgery or serious head trauma Intracranial neoplasm, AVM, or aneurysm History of stroke in the previous 3 months Major surgery or serious trauma in the previous 14 days Arterial puncture at the non-compressible site or a lumbar puncture in the previous 7 days 3 Known bleeding diathesis, e.g.: platelet count < 100,00/mm Current us of oral anticoagulant with a PT > 15 sec. Administration of heparin within 48 hours preceding the onset of stroke, with an elevated PTT on presentation Serious medical illness that outweighs treatment benefit Seizure at onset of stroke Active internal bleeding or history of GI or urinary tract hemorrhage in the previous 21 days Uncontrolled hypertension at the time of treatment (systolic BP > 185 or diastolic BP> 110 mmHg) Clinical presentation consistent with acute MI or post myocardial infarction pericarditis. Blood glucose of 400 mg /dl Pregnant/lactating patients

- 40 -

2007 Management of Suspected Intracranial Hemorrhage Suspicion of intracranial hemorrhage prompted by: Neurologic deterioration, new headache, acute hypertension, nausea, vomiting IF intracranial hemorrhage is the presumed diagnosis: ƒ Discontinue rt-PA infusion ƒ Obtain an immediate CT scan ƒ Draw blood; PT, aPTT, platelet count, fibrinogen ƒ Prepare to give fibrinogen 6-8 U and cryoprecipitate containing Factor VIII ƒ Prepare to give platelets 6-8 U ƒ IF intracranial hemorrhage is not present on CT scan: end algorithm IF intracranial hemorrhage is present on CT scan: ƒ Evaluate laboratory results; fibrinogen, PT, aPTT ƒ Consider alerting and consulting neurosurgeon ƒ Consider altering and consulting hematologist ƒ Consider second CT scan to assess size change Consensus decision: Plan surgical and medical therapy

- 41 -

2007 ACUTE ISCHEMIC STROKE Clinical Protocol Expected LOS: 3-5 days (check box to initiate order) ORDERS (*) ARE 24 HOUR ORDERS AND MUST BE ASSESSED DAILY

Addressograph Admission Day: Day 1 Date: ADMIT TO

ICU

Time:

Unit_____________________

Tag/Order Clinical Practice Guideline “Acute Ischemic Stroke” in

Care Manager Patient not appropriate for Clinical Practice Protocol because:____________________ ATTENDING PHYSICIAN DIAGNOSIS CONDITION OF PATIENT CATEGORY OF CARE ALLERGIES * NUTRITION (24 hour order) * ACTIVITY(24 hour order)

CONSULTS

Dr:________________________________ Admitting Resident:_______________ _____ Pager#________________ Ischemic Stroke Good

Fair

Full Support

Critical

Other___________________

Category of Care Order Form (Total support except Advanced Life support, DNRCC-Arrest, DNRCC)

NKA

_______________________________________

NPO completely

Nurse to complete “Nursing Swallowing Screen” prior to oral medications or diet

Complete bed rest (elevate head of bed 30˚), reposition q 2 hours if needed Speech Therapy for bedside dysphagia screening exam

Other ____

Other __________

Speech Therapy for Speech& Language

Evaluation & Treatment Physical Therapy Evaluation and Treatment (ROM)

NURSING

*Cardiac monitor

*Continuous pulse ox, call if Sp O2 < 94

Seizure precautions I&O

Occupational Therapy Evaluation and Treatment

DBP > 105 or < 60 Pulse < 50 or > 120 RR > 30

*No invasive procedures except venous blood draws for 24 hours

until__________________________(date/time) if given tPA. EPC cuffs

Call MD immediately for: SBP > 185 or < 120

*No lifting or pulling of limbs on affected side

ROM q 4 hours

Other______

5000 units Heparin subcutaneous every 12 hours

Vital signs and neurological assessments q 30 min x 6 hours, then

T > 101˚F / 38.5˚C È neurological status change in mental status headache, vomiting evidence of bleeding µ language or motor deficit

q 1 hour x 16 hours, then q 4 hours ( Recommended for patients post tPA) OR Vital signs and neurological assessments q 2 hours x 8 hours, then q 4 hours

* Foley to dependent drainage

Evaluate stool, urine, emesis or other secretions for signs of blood. Hemoccult testing if there is evidence of bleeding (Recommended for patients post tPA)

Weight on admission

O2 @ 2L per minute per NC

SIGNATURE MD/DO (PRINT NAME)

Protocols do not replace clinical judgment and should be modified according to individual patient needs.

- 42 -

2007 ACUTE ISCHEMIC STROKE Clinical Protocol Expected LOS: 3-5 days (check box to initiate order) ORDERS (*) ARE 24 HOUR ORDERS AND MUST BE ASSESSED DAILY Admission Day: Day 1 Date:

LABS

IV MEDICATIONS CARE COORDINATION

Addressograph

Time:

CBC in a.m. X 1 * Glucose finger stick q 6 hours Fasting Lipid Profile in a.m. X 1 Other __________________________ ______________________________ __________________________ _______________________________ IV 0.45% NaCl @ _________ ml/hr IV Other _______________________________

Stroke Prevention Medications (if no tPA) & other medications should be ordered below.

Contact Care Coordinator for discharge planning

PATIENT

Stroke Education Folder, Specific material as needed Education Record – Patient/Caregiver – Stroke/TIA Form#49812 (Please include in medical record) EDUCATION The Brain at Risk, Stroke (Story of Treatment and Recovery) ADDITIONS/CHANGES – PLEASE NOTE: ASA, antiplatelet agents, Coumadin or heparin not recommended for 24 hours if tPA was given. Date & Time such medications can be started:_____________

FAMILY

TIME

ORDER

SIGNATURE MD/DO (PRINT NAME)

Protocols do not replace clinical judgment and should be modified according to individual patient needs.

Rev: 08/2005 PS0146

Page 2 of 2

- 43 -

2007 Indications for Heparin Therapy

I.

II.

Cluster or crescendo TIAs defined as 3 TIAs in the last 24-48 hrs. IV heparin 15-18 units/kg/hr or 700-1000 units/hr. Stroke-in-evolution, defined as appearance of new deficits within 2 hours, or fluctuation of neurological symptoms, unless there is evidence of i. Ischemic edema ii. Fluctuation in blood pressure iii. Acute metabolic or hypoxic metabolic abnormalities

III. IV. V. IV.

Ischemic stroke attributed to cardiogenic embolism Dissection of carotid arteries Cortical vein thrombosis No Loading Suspicion of basilar artery thrombosis • Draw platelet count, PT & PTT prior to initiation of heparin therapy. • PT & PTT stat q 6 h till achieving therapeutic aPTT (aPTT 1.4-2.0 x control), 6 hrs. after dosage change, and then daily • Platelet count, Hbb, Hst q 4 days • Check for signs of bleeding daily • When switching to Coumadin or ASA, begin these agents then taper heparin before D/C to rebound hypercoagulability.

- 44 -

2007 Management of acute ischemic stroke 1. Avoid intubation and hyperventilation 2. Cardiac monitoring for 24-48 hours 3. Monitor blood pressure and neurochecking q1h for 6 hrs, then q2 hrs for 8 hrs, then q4hrs 4. Start IV 50 cc/h of .45 NSS 5. Draw blood for CBC, diff, platelets, CHEM 20, VDRL 6. Consider blood for ANA, ESR, RF, ACL, protein C, protein S, antithrombin III, APC resistance, & toxicology mainly in patients 185 OR Diastolic > 110 Labetalol 10-20 mg IV over 1-2 min, may repeat once OR Nicardipine 5 mg/h IV infusion as initial dose and titrate to desired effect by increasing by 2.5 mg/h every 5 min to a max of 15 mg/h If blood pressure remain >185 /110 do not administer tPA If “NOT” eligible for tPA / thrombolytic therapy Check BP every 10 -15 min If Systolic > 220 OR Diastolic > 120 Labetalol 10-20 mg IV over 1 – 2 min May repeat or double dose every 10 – 20 min (max dose 150 mg) OR Nicardipine 5 mg/h IV as initial dose; titrate to desired effect by increasing by 2.5 mg/h every 5 min, max 15mg/h Aim for a 10-15%reduction in blood pressure If Diastolic > 140 Nitroprusside 0.5 – 1.0 mcg/kg/min Monitor BP q15 min, and avoid rapid fall of BP or hypotension Management of ischemic edema (in cases of impending herniation or progressive cerebral edema) 1. Mannitol* 1g/kg IV over 12 minutes, then .25 g/kg IVP a 4 h for 3-4 days, then taper over 2-3 days 2. Monitor serum osmolality ½ hr following each dose of Mannitol for first 24 hrs, then daily in am 3. Monitor electrolytes, intake/output 4. Maintain serum osmolality ~ 310-315 mosm/l * Dose should be reduced in patients with renal insufficiency

- 46 -

Classification of aphasia

2007 Type of Aphasia

Intact

↓

↓

↓

↓

↓

↓

↓

↓

Intact

↓

↓

Fluency Comprehension Repetition Naming

↓ Good

Broca’s Wernicke’s

Good

↓

Conduction

Global

Intact or ↓

Logorrheir

Intact

↓

Intact Intact

Intact

↓

↓ Good

Good

Intact

Good

Intact Intact

Transcortical Motor Sensory

Good

↓

Anomic

Atypical Good Basal ganglia Thalmic Good

↓

Other Signs

Frontoperietal operculum

Lesion location

Massive perisylvian

Posterior or inferior temporal Posterior perisylvian

Right Hemiparesis

----Right hemiplegia

Anterior or superior frontal temporoparietal,

thalamus

Depends on type

Anerolateral thalamus

Right Head of caudate, hemiparesis, anterior limb of capsule dysrthria Attention & Memory deficit

- 47 -

2007 INDICATIONS FOR CT – ANGIOGRAM IN THE EMERGENCY ROOM First 0 to 6 hours of stroke symptom onset • Young (1 mo)

Adults

Penicillin G

50,000 U/kg q 4h

304 M U q4h

Ampicillin

75-100 mg/kg q6h

2g q4h

Cefotaxime

50 mg/kg q6h

2-3 g q6h

Ceftriaxone

50 mg/kg q12h

2-3 g qd

Ceftizoxime

50 mg/kg q6h

4g q8h

Naficillin

50 mg/kg q6h

1.5 g q4h

Chloramphenicol

25 mg/kg q6h

1.5 g q6h

Vancomycin

10 mg/kg q6h

0.5 g q6h

Trimethoprim-

5/25 mg/kg q6h

5/25 mg/kg q6h

Sulfamethoxazole Important reference – Wood AJJ. Treatment of bacterial meningitis.N. Engl J Med 1997; 336-708-716

- 50 -

2007 Antibiotics Recommended for Empirical therapy in Patients with Suspected Bacterial Meningitis Who Have a Non-Diagnostic Gram’s Stain of Cerebrospinal Fluid

Group of Patients

Likely Pathogen

Choice of Antibiotic

Age < 3 mo*

S. agalciae, E coli, or L. momocytogenes

Ampicillin† plus broadspectrum cephalosporin‡

Age 3 mo to 50 yr With impaired Cellular immunity With head trauma, Neurosurgery, or Cerebrospinal fluid Shunt

* Specific recommendations depend on the age as well as the condition of the infant. In pre-term, low birth-weight infants less than one month old, Vancomycin (15 mg/kg of body weight intravenously every 6 hours), plus ceftazidime (50-100 mg/kg intravenously every 8 hours) is recommended because of the higher risk of nosocomial infection with staphylococci or gram-negative bacilli. † The preferred dose is 100 mg/kg intravenously every 8 hours ‡ The preferred dose of Cefotaxine is 50 mg/kg intravenously every 6 hours; that of Ceftriaxone is 50-100 mg/kg intravenously every 12 hours. § The preferred dose of Cefotaxime is 2 g intravenously every 6 hours that of cefriaxone is 2 g intravenously every 12 hours. ¶ The preferred doe is 2 g intravenously every 4 hours; if penicillin G is given, the preferred dose is 4 million units intravenously every 4 hours.

- 51 -

2007 Antibiotic Therapy for Specific Bacterial Pathogens Organism Antibiotics* H. influenzae Third-generation cephalosporin, Ampicillin (if sensitive); (if not sensitive), chloramphenicol† Penicillin G, third-generation cephalosporin Chloramphenicol Reduced penicillin-sensitive Third-generation cephalosporin Penicillin resistant Third-generation cephalosporin

S. pneumoniae

N. meningitidis

Penicillin G, chloramphenicol l†

S. agalactiae

Penicillin G or Ampicillin

L. monocytogenes

Ampicillin (plus Aminoglycoside) or Sulfamethoxazole

Enterobacteriaceae

Third- generation cephalosporin with or without Aminoglycoside Ceftazidime plus Aminoglycoside or Fluoroquinolone (e.g., ciprofloxacin)

P. aeruginosa

S. aureus Nafcillin * Third-generation cephalosporins: Cefotaxime, Ceftriaxone, Ceftizoxime. † For penicliin-allergic patients. Management of Herpes encephalitis 1. EEG, MRI of brain with out and with Gladolenium 2. Lumbar puncture: routine testing and PCR for Herpes viral antigen. 3. Acyclovir 10.0-12.5 mg/kg IV q8h. Lower does should be considered in older patients and in renal insufficiency. 4. IV NSS or 0.45 NSS at a rate of 75 cc/hr. 5. If there is a suspicion of a seizure, start phenytoin 12-18 mg/kg IV drip in NSS, maximum rate of 50 mg/min.

- 52 -

2007 Treatment of Acute Multiple Sclerosis Exacerbation 1.

IV NSS or .45 NSS at a rate of 50-75 cc/hr.

2.

Methylprednisolone 1 gm qd for 3-4 days.

3.

Patient will be discharged on prednisone 60 mg po daily, to be tapered by 10 mg q 2 days over 2 weeks.

4.

As an alternative, patient can be discharged without above Prednisone taper.

5.

Carafate 1 gm po q 8 hrs.

McDonald Criteria •

•

• •

•

•

2 or more attacks; objective clinical evidence of 2 or more lesions o No additional data needed 2 or more attacks; objective clinical evidence of 1 lesion; plus o Dissemination in space, demonstrated by: ƒ MRI, or ƒ 2 or more MRI-detected lesions consistent with MS plus positive CSF, or ƒ Further clinical attack implicating a different site. 1 attack; objective clinical evidence of 2 or more lesions; plus o Dissemination in time (demonstrated by MRI). 1 attack; objective clinical evidence of 1 lesion (monosymptomatic presentation, clinically isolated syndrome); plus o Dissemination in space, demonstrated by: ƒ MRI, or ƒ 2 or more MRI-detected lesions consistent with MS plus positive CSF, and o Dissemination in time, demonstrated by: ƒ MRI or ƒ Second clinical attack. Insidious neurological progression suggestive of MS; plus o Positive CSF, and o Dissemination in space, demonstrated by: ƒ 9 or more T2 lesions in brain, or ƒ 2 or more lesions in spinal cord, or ƒ 4-8 brain lesions plus 1 spinal cord lesion, or ƒ abnormal VEP associated with 4-8 brain lesions, or ƒ abnormal VEP with fewer than 4 brain lesions plus 1 spinal cord lesion; and Dissemination in time, demonstrated by: o MRI, or o Continued progression for 1 year.

- 53 -

2007 Dementia Work-up:

1. History of hypertension, renal or hepatic disease, drug abuse, history of GI surgeries, family history 2. Blood work including B12, folate, niacin levels, heavy metal screening, thyroid function tests (TSH, T3, T4) 3. CSF analysis, including VDRL 4. EEG: for prion diseases such as Cruetzfeldt-Jacob 5. MRI: look for NPH, Binswanger’s, multi-infarcts, tumors, PML, demyelination, atrophy 6. Neuropsychological testing

- 54 -

2007

- 55 -

2007 ALCOHOL WITHDRAWAL MEDICATIONS

Thiamine

100 mg IM or IV Before IV glucose, then 100 mg po qd x 5 days. Prophylaxis for Wernicke-Korskoff Syndrome

Cholordiazepoxide (Librium)

Until behavior and vital signs normalize 25-50 mg po q2h prn Hold if sleepy or lethargic 10 mg IV q 5 min prn

Diazepam (Valium)

Until behavior & vital signs normalize 10-30 mg po q2h prn Hold if sleepy or lethargic

Lorazepam (Ativan)

Until behavior and vital signs normalize 2-5 mg po q 2 hr prn Hold if sleepy or lethargic

Phenobarbital

Until behavior and vital signs normalize 60-120 mg po/im q2h prn Hold if sleepy or lethargic 20 mg IV q5 min

Propranolol (Inderal)

Use to control tachycardia, hypertension,

10-20 mg po 6 h prn tremor. Will not prevent withdrawal seizures.

Clonidine (Catapress)

Use to control hypertension 0.05-0.1 mg po q 1 h prn Will not prevent withdrawal seizures.

Nifedipine (Procardia)

Use to control hypertension 10mg sl q 20 min prn

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2007 DIFFERENT MR SIGNALS

MRI-T1 Dense bone Air Fat Water Brain

Dark Dark Bright Dark 3”anatomic”

MRI-T2 Dark Dark Bright Bright Intermediate

XRAY-CT2 Bright Dark Bright Dark Intermediate

Bright means high signal intensity, dark means low, and intermediate means intermediate 2 Bright means high density/high attenuation of x-rays, dark means low 3 Gray matter appears grey, white matter white 1

EVOLUTION OF INTRACRANIAL HEMORRHAGE ON MRI Component Hgb state T1WI T2WI Clinical Time phase Hyperacute Immediate Intracellular Oxy-hemolobin Iso-to↑ hypointense Acute 5 hrs Intracellular Deoxy-Hgb Iso-to slight ↓ Very ↓ 1-5 days Extracellular Deoxy-Hbg Very ↑ Very ↓ Subacute Early >5 days Intracellular Met-Hemoglobin Very ↑ Met-Hemoglobin Very ↑ Late Extracellular Chronic > 15 days Center Extracellular Hemichrome → Rim Intercellular Hemosiderin Very ↓ ↑ Hyperintense ↓ Hypointense → Isotense

- 57 -

Very ↓ Very ↑ Slight ↑ Very ↓

2007 MANAGEMENT OF STATUS MIGRAINOSUS IV DHE Protocol 1 2 3 4 5

Admit to quiet room IV fluid; NSS rate of75-100 cc.hr. Reglan 10 mg IM 10 min. Prior to each DHE dose Lomotil 5 cc po bid prn for diarrhea DHE 0.5 mg IV drip in 100 cc NS over 15 min. Q 8 hrs for 6 doses If headache persists, and no nausea, increase does of 0.75 mg q 8 hrs Dose can be increased to 1 mg q 8 hrs If patient develops severe nausea, decrease dose of DHE of 0.3 mg q 8 hrs

Or DHE 1 mg in 250 cc NS slow IV drip over 8 hrs; q8 hrs x 3 days *Maximum dose of DHE should not exceed 3 mg/day 7.

Vital signs (BP, P, RR) prior to and at the end of each DHE dose *Warning: Parethesia in extremities, tachycardia, elevation, in blood pressure, chest pain, limb cyanosis.

Toradol- Ketorolac 1. 30 – 60 mg IM 2. Pretreat with 10 mg Reglan IM Intravenous phenothiazines Chlorpromazine 5 mg IVP q 10 min. prn up to 25 mg of Prochlorperazine 2 mg IVP q min prn up to 10 mg (mix 1 cc of the drug in 4 cc of NSS and inject 1 cc at a time over 1 min). Warning: orthostatic hypotension; extrapyrmidal manifestations; drowsiness Morphine sulfate pump in individual cases Droperidol- Inapsine

DRUGS USED FOR MIGRAINE HEADACHE Abortive Tylenol (acetaminophen); 650 mg at onset, then 650 mg q 4h prn NSAIDs: Anaprox, Naprelan, Aleve (naproxen sodium): 550-1100 mg at onset, then 275-550 mg q4-6h prn

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2007 Drugs used for Migraine Headaches (Continued) Imtrex (sumatriptan): Tablets: 25-50 mg at onset, then 25-50 mg q2 hrs prn, total 300 mg/d & 600 mg/week Injections: 6 mg sc at onset, then in 1 hr prn, total of 2 doses a day or 4 doses/week Nasal spray: 20 mg intranasal, 1 q hr, max 2 doses a day or 4/week Zomig (Zolmitripitan): 2.5 or 5 mg tab, q 2 hrs, max 10 mg/day or 20 /week Amerge (Nortriptan): 5 mg tab q2 hrs, max 2/day or 4/week Maxalt: 10 mg tablet, dissolved in mouth q 4, max 2/day, 4/week Warning: avoid in heart disease, hypertension, bailar migraine, allergy to sumatriptan, or within 24 hrs of use of DHE or ergotamine; watch for serotonin syndrome DHE: Sc: 0.5 mg at onset, may increase or repeat in 1-2 hrs, total 2 mg/day, and 6 mg/week IV: 0.5-1.0 mg IV in 100 cc NSS over 10-15 min + 10 mg of Reglan (see DHE protocol) Nasal spry (Migranal): 1 spray in each nostril, to be repeated in 15 min, max 2 mg/day, 4 mg/week Warning: heart disease, HTN paresthesia in extremities or cyanosis

Lidocaine: 4 % intranasally, 0.5cc in one or both nostrils to be repeated in 2 min for 2 does. Give with head hyperextended and flexed to side of headache. Compazine: (prochlorperazine) or Thorazine (chlorpromazine): 25-50 mg supp or tabe at onset, then q8h prn, total 3 days/week. 25 mg IM can be used Reglan (metaclopramide): 10-20mg tabs/supp at onset qoh prn, up to 60 mg/week Midrin (isometheptene/acetaminophen [65-325]): 1-2 cps at onset, then 1 q1h up to 5/day and 10/week Cafergot (ergotamine/caffeine): 1-2 (1-2 mg) onset, then 1 q ½ h prn, total 5/day & 10/week 1/2-1 supp at onset, then ½ - 1 supp q1h prn, up to 2/day, or 5/week

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2007 Drugs used for Migraine Headaches (Continued) Prophylactic B-blockers: Inderal (propranolo): 80 mg LA p to 240 mg/day warning: asthma, CHF, hypotension, bradycardia AEDs: Depokote (Valproic acid): 250-500 mg po bid- qid warning: liver failure, pancreatitis, pregnancy, tremor, alopecia Neurontin (gabapentin): Warning: drowsiness, leg edema

300 mg big- 1200 mg

Topamax (topiramate) 25 mg bid- 100 mg –bid Warning: drowsiness, weight loss, mood changes TCA’s Elavil (amitriptyline) 25 mg- woo mg qhs Pamelor (nortriptyline): 25-75 mg qhs Warning: orthostatic hypotension, glaucoma, prostatic hypertrophy, tremor, arrhythmias Calcium channel blockers Calan (verapamil): 80 mf tid-qid, or long acting 240 mg/day Warning: sick sinus syndrome, CHF, hypotension SSRIs: Prozac (fluoxetine): Zoloft (sertaline): Warning: serotonin syndrome

20-80 mg qhs 50-150 mg qhs

Sasert (methysergide): 4-8 mg/day Warning: retroperitoneal & organ fibrosis; patients need to be taken off the medication for at least one month after a 6-month use, with yearly CXR, echocardiogram, & Ct of abdomen. Periactin (cyproheptadine): Warning: drowsiness Steroids:

8-16 mg/day 60 mg for 5 days, then taper gradually over 2 wks

Lithium carbonate: 300 mg tid-qid Warning: thyroid dysfunction, renal failure, tremor

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- 61 -

+1 +3 +1 +2 +/0 +/0

Desipramine (Norpramin

Amitriptyline (Elevil)

Nortriptyline (pamelor)

Doxepin (Sinequan)

Amoxipine (Asendin)

Maprotiline (Ludiomil)

Reference Agent

Atropine (belladonna alkaloid) +4

0

+/0

Fluoxeline (Prozac)

Bupropolon (Wellbutrin)

0

Trazodone (Desyrel)

Non-tricyclics

+2

Cholinergic (muscarinic) • blured vision • dry mouth • sinu tachycardia • constipation • urinary retention • memory dysfunction

Imipramine (Tofranil )

Tetra- & tricyclics

Receptor: Potential side effects caused by blockade

Diphenhyframine (Benadryl) +2

+/0

+/0

+1

+3

+2

+4

+1

+3

+1

+2

Histminergic • sedation, drowsiness • weight gain • hypotension • potentiaion of CNS depressants

Phentolamine (Reglitine) +4

+/0

+/0

+4

+3

+3

+4

+3

+4

+2

+3

α1 adrenergic • postural hypotension • dizziness • freflex • tachycardia • additive w/ antihypertensive prazosin

Phentolamine (Relitine) +3

0

+/0

+2

+/0

+/0

+2

+1

+2

+/0

+1

α2 adrenergic • block antthypertensive effects of clonidine, gauanabenz, and methyldopa • priapism

Haloperidol (Hadol) +4

0

+1

+1

+1

+1

+1

+1

+1

+1

+1

Doaminergic • extrapyrmidal movement disorders • endocrine changes (pro-lactin elevation)

Receptor Blockade of Antidepressants & Related Side Effects

2007

2007

- 62 -

2007 AED

Initial dose

Maintenance daily dose

Common Adverse Effects

Phenytoin

15-20 mg/kg

4-7 mg/kg/day (adults) 5-10 mg/kg/day (pediatric) once a day dosing

Phenobarbital

Load only in status epilepticus with 20 mg/kg, requires respiratory & cardiovascular support

60-240 mg (adults) 3-7 mg/kg/day (pediatrics 95% hepatic W/ induction 60 14-23 60% hepatic 5-7 12-60* >90% hepatic, no induction 19-25 30% hepatic, no induction 5-13

8-10† >90% hepatic, mild induction

Valproate

Ethosuximide

Felbamate

Gabapentint

Lamotrigine

Topiramte

Tiagabine

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Oxcarbazepine

NE= Not established * Varies widely depending on coadministered drugs. metabolite, active metabolite. >65% renal excretion >70% hepatic, no induction

6-8 63

Levetiracelam

Zonisamide

>90% hepatic, no induction

>95% renal

65% hepatic no induction

> 90% hepatic W/ induction

5-45 10-40

100-400

10-35

NE

4-10

2-16

4-16

20-140

40-100

50-120

1-14

8-12

1-7

1-7

7-14

28-42

28-42

28-42

1-7

7-14

7-14

7-14

45

7-14

1-7

(days)

(mg/day)

10-20

Titration Time to Minimum Effective Dose

Usual Effective Plasma Concentration

1000-3000

600-1,800

100-500

750-1,500

1,000-3,000

15-40

800-1.600

Phenobarbital

> 90% hepatic W/ induction

8-22

300-100

Carbamasepine

> 90% hepatic W/ induction

(mg/day)

Usual Adult Dose

22

(hrs)

Metabolism

PHARMACOKINETICS OF ANTICONVULSANT DRUGS

Phenytoin

Drug

HalfLife

40

1 year), EEG (for brain death), or Technetium-99m Brain Scan A. Procedure:_________________ _________________________ ___________________________ Date & Time________________ _________________________ ____________________________ Results _________________ _________________________ ___________________________

IV.

CLINICAL CONFIRMATION OF DEATH BY BRAIN CRITERIA

A. Neurological/Neurosurgical Consultant B. ICU consultant (if applicable) C. Attending Physician 1. Signature _____________________ 1. Signature _________________________ 1.Signature ___________________ 2. Date & time _____________________2. Date & Time _________________________ 2. Date & Time _____________________

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2007 DETERMINATION OF DEATH BY BRAIN CRITERIA INSTRUCTIONS FOR ADULTS AND CHILDREN 1 YEAR OF AGE OR OLDER I. CLINICAL EXAMINATION The attending service should complete section I, the first exam of section II, and the apnea oxygenation test. When these are completed, the attending service is encouraged to call the Neurology/Neurosurgery consultant. All items I and II require a “Yes” response. Attending to attending communication is always important. Repeat of the clinical examination will be done at different intervals depending on the use of a optional confirmatory laboratory procedures. If confirmatory test is consistent with brain death, then no further observation period is needed before 2nd clinical exam. If no confirming laboratory test is used, the period of observation should be 6 hours. IT IS CRITICAL TO PERFORM A THOROUGH CLINICAL EVALUATION AND APPROPRIATE DIAGNOSTIC TESTING TO EXCLUDE REVERSIBLE OR TREATABLE CONDITIONS. II.

ICE WATER CALORIC STIMULATION 1. 2. 3. 4.

III.

Check auditory canals for obstruction. Flex head to 30 above horizontal with patient supine. Irrigate external auditory canal with 40 ml. of ice water. Observe for tonic deviation of eyes.

APNEIC OXYGENATION TEST: Performance of the Apneic Oxygenation Test should be requested from Respiratory Therapy. The examining physician must be present during the Test to insure patient safety and to witness the Test. The Apneic Oxygenation Test is carried out as follows: 1. 2. 3. 4. 5

IV.

Ventilation on 100% oxygen for 20 minutes Draw blood for determination of arterial blood gases Insertion of a catheter via the endotracheal tube into the trachea above the carina for insufflation with 100% 02 at 6L/min long enough for a rise in pCO2 to 20 points above baseline or a total of 60, or a maximum of 10 minutes while the ventilator is turned off Repeat blood draw for determination of blood gases Removal of catheter and resumption of ventilation

LABORATORY CONFIRMATION OF DEATH BY BRAIN CRITERIA MAY BE USED TO SHORTEN THE PERIOD OF OBSERVATION. A cerebral angiography to demonstrate absence of cerebral blood flow, EEG (to demonstrate electrical cerebral silence) or Technetium-99m Brain Scan may be considered.

V.

CLINICAL CONFIRMATION BY A NEUROLOGICAL/NEUROSURGICAL CONSULTANT, THE ICU CONSULTANT IF APPLICABLE AND THE ATTENDING PHYSICIAN OR DESIGNATED ATTENDING ARE REQUIRED. If neurosurgery or neurology is attending service, opposite service must be consulted. If there is agreement that the brain criteria of death are met, any of the above physicians will write a concluding note in the progress notes stating that Death by Brain Criteria exists in this patient. A physician will then declare the patient dead and any life support systems may be withdrawn. MCO Form #278-B(Adult)

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2007 CLINICAL REFERENCES FOR CEREBROSPINAL FLUID VALUES Normal and Abnormal Values of Cerebrospinal Fluid (CSF) Pressure Color White blood Red blood Glucose cell count cell count (mm H2O) (per mm3) (per mm3)

Normal

70-190

Acute bacterial Meningitis

250-800

Aseptic Meningitis

slight increase

Viral Slight Encephalitis increase

Clear & Colorless usually cloudy yellow or or white Because of Puss clear

clear & colorless

0-3

0-5

60-80 mg/100ml greatly reduced, sometimes to 0

100’s to 10,000’s, nearly all

0-5

50-500, mostly Lymphocytes

0-5

Normal

30-400

0-5

Normal

Cerebroup to 500 bloody Vascular Accident (hemorrhagic into ventricles or subarachnoid space)

Normal

Protein 15-45 mg/100ml Greatly increased, as high as 400-500 mg/100mL slight increase(up to around 100 mg /100mL) Slight increase (rarely above 100mg/100ml Normal

Remarks 1. If manometer reads pressure of 300 mg H2O or more, remove it at once and use fluid init do a microscopic reading. 2. To differentiate between a traumatic tapp and blood in the CSF due to subarachnoid hemorrhage, centrifuge the CSF. In a traumatic tap the supernatant is clear; in a subarachnoid hemorrhage the supernatant will be yellowish. 3. A fall in the chloride level of the CSF is characteristic of tuberculous meningitis. 4. In infants younger than 1 year, the most common organism to cause acute meningitis is Gram-negative Escherichia coli; in children it is Hemophilus influenzae; in adults it is Gram-negative Neisseria meningitidis.

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2007

- 79 -

2007

PRACTICE PARAMETER: THE MANAGEMENT OF CONCUSSION IN SPORTS The usefulness of a grading scale has been well established in sports medicine to determine the severity of a concussion. This practice parameter presents the following grading scale arrived at by a consensus of experts who reviewed all existing scales, including the recommendations in the Colorado Medical Society Guidelines. Grade 1: 1. 2. 3.

Transient confusion No loss of consciousness Concussion symptoms or mental status abnormalities on examination resolve in less than 15 minutes

Grade 1 concussion is the most common yet the most difficult form to recognize. The athlete is not rendered unconscious and suffers only momentary confusion (e.g., inattention, poor concentration, inability to process information or sequence tasks) or mental status alternations. Players commonly refer to this state as having been “dinged” or having their “bell rung.” Grade 2: 1. 2. 3.

Transient confusion No loss of consciousness Concussion symptoms or mental status abnormalities on examination last more than 15 minutes

With Grade 2 concussion, the athlete is not rendered unconscious but experiences symptoms or exhibits signs of concussion or mental status abnormalities on examination that last longer than 15 minutes (e.g., poor concentration or post-traumatic amnesia). Any persistent Grade 2 symptoms (greater than 1 hour) warrant medical observation.

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2007 Grade 3: 1.

Any loss of consciousness, either brief (seconds) or prolonged (minutes)

Grade 3 concussion is usually easy to recognize – the athlete is unconscious for any period of time. Timing of initial management and return to play are outlined in tables 1 and 2. Table 4 Initial management following first event On-site Neurological Grade evaluation evacuation Grade 1 Yes Not required, but may be pursued depending on clinical evaluation

Grade 2 Grade 3

Yes Yes

Yes Yes

Same day return to play Yes, if normal sideline assessment while at rest and with exertion, including detailed mental status examination No No

Table 5 When to return to play after removal from contest Grade of concussion Time until return to play * Multiple Grade 1 concussion 1 week Grade 2 concussion 1 week Multiple Grade 2 concussions 2 weeks Grade 3 – brief loss of consciousness 1 week (seconds) 2 weeks Grade 3 – prolonged loss of 1 month or longer, based on clinical decision of consciousness (minutes) evaluating physician Multiple Grade 3 concussions * Only after being asymptomatic with normal neurological assessment at rest and with exercise.

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2007

PREDICTION OF OUTCOME IN COMATOSE SURVIVORS AFTER CARDIOPULMONARY RESUSCITATION

RECOMMENDATIONS FOR THE PROGNOSTIC VALUE OF THE CLINICAL EXAMINATION Strong (Level Features of the neurological The prognosis is invariably poor in A) evidence examination; Glasgow Coma comatose patients with absent Scale (GCS) score; Motor part of papillary or corneal reflexes, or the GCS; Brainstem reflexes absent or extensor motor responses (papillary light reflexes, corneal three days after cardiac arrest reflexes and eye movements) (Level A). Good (Level Present of seizures or myoclonus Patients with myoclonus status B) evidence status epilepticus (defined as epilepticus within the first day spontaneous, repetitive, after a primary circulatory arrest unrelenting, generalized have a poor prognosis (Level B). Multifocal myoclonus involving the face, limbs, and axial musculature in comatose patients) Good (Level Circumstances surrounding Prognosis cannot be based on the B) evidence CPR: Anoxia time; Duration of circumstances of CPR (Level B). CPR; Cause of the cardiac arrest (cardiac vs. non-cardiac); Type of cardiac arrhythmia Weak (Level Elevated body temperature Prognosis cannot be based on C) evidence elevated body temperature alone (Level C). RECOMMENDATIONS FOR THE PROGNOSTIC VALUE OF ELECTROPHYSIOLOGIC STUDIES Good (Level Somatosensory evoked The assessment of poor prognosis can be B) evidence potential (SSEPs) guided by the presence of bilaterally absent cortical SSEPs (N20 response) within one to three days (Level B). Weak (Level EEG and evoked/eventBurst suppression or generalized C) evidence related potential (EP) epileptiform discharges on EEG predicted studies poor outcomes but with insufficient prognostic accuracy (Level C).

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2007 RECOMMENDATIONS FOR THE PROGNOSTIC VALUE OF BIOCHEMICAL MARKERS Good (Level B) Serum neuronSerum NSE levels >33 µg/L at evidence specific enolase days one to three post-CPR (NSE) accurately predict poor outcome (Level B). Insufficient (Level Serum S100; There are inadequate data to U) evidence Creatine kinase support or refute the prognostic brain isoenzyme value of other serum and CSF (CKBB) biochemical markers (Level U). Insufficient (Level Intracranial There are inadequate data to U) evidence pressure; Brain support or refute the prognostic oxygenation value of ICP monitoring (Level U).

RECOMMENDATIONS FOR THE PROGNOSTIC VALUE OF RADIOLOGIC STUDIES Insufficient Neuroimaging studies: There are inadequate data to (Level U) CT; MRI; PET support or refute whether evidence neuroimaging is indicative of poor outcome (Level U).

Confounding factors Some factors may confound the reliability of the clinical exam and ancillary tests. Major confounders could include the use or prior use of sedatives or neuromuscular blocking agents, induced hypothermia therapy, present of organ failure (e.g., acute renal or liver failure) or shock (e.g., cardiogenic shock requiring inotropes). However, studies in comatose patients have not systematically addressed the role of these confounders in neurological assessment.

- 83 -

2007 COMA DECISION ALGORITHM Exclude major confounders No brain stem reflexes at any time (pupil, cornea, oculocephalic, cough) - or -

►

Yes

Day 1: Myoclonus status epilepticus ►

Brain death testing

►

No

Indeterminate outcome

Yes

Poor outcome

FPR* 0% (08.8)

►

No

Indeterminate outcome

Yes

Poor outcome

FPR 0% (03)

►

No

Indeterminate outcome

Yes

Poor outcome

FPR 0% (03)

►

No

Indeterminate outcome

Yes

Poor outcome

FPR 0.7% (0-3.7)

►

No

Indeterminate outcome

- or Day 1-3: Serum NSE*>33 ug/L** ► - or Day 3: Absent pupil or corneal reflexes; extensor or absent motor response - or Day 1-3: SSEP* absent N20 responses**

►

►

Decision algorithm for use in prognostication of comatose survivors after CPR. The numbers in parentheses are exact 95% confidence intervals. The confounding factors potentially could diminish prognostic accuracy of this algorithm. *NSE = neuro-specific enolase; SSEP = somatosensory evoked potential; FPR = false positive rate. ** These tests may not be available on a timely basis. Serum NSE testing may not be sufficiently standardized.

- 84 -

2007

Communication with family and further decision making The complexity of evaluation and various options of decision making require neurological professional expertise. More than one scheduled meeting with the family is generally required to facilitate a trusting relationship. The neurologist can explain that the prognosis is largely based on clinical examination with some help from laboratory tests. In a conversation with the family, the neurologist may further articulate that the chance of error is very small. When a poor outcome is anticipated, the need for life supportive care (mechanical ventilation, use of vasopressors or inotropics agents to hemodynamically stabilize the patient) must be discussed. Fully informed and more certain, the family or proxy is allowed to rethink resuscitation orders or even to adjust the level of care to comfort measures only. However, these decisions should be made after best interpretation of advance directives or the previously voiced wishes of the patient.

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