NeuroICU

Director & Core Faculty

Katharina Busl MD, MS

James E. Rooks, Jr., Professor Of Neurology & Neurosurgery; Associate Chair, Clinical Operations, Neurology; Chief Division Of Neurocritical Care; Associate Editor, Critical Care Medicine; Editorial Board Member, Neurocritical Care

Department: MD-NEURO-NEUROCRITICAL CARE

Email: katharina.busl@neurology.ufl.edu

Chris Robinson DO, MS

Associate Professor Of Neurology And Neurosurgery, Division Of Neurocritical Care; Director, Shands Neuromedicine Intensive Care Unit; Program Director, NCC Fellowship; Neurology Clerkship Director, UF COM

Department: MD-NEURO-NEUROCRITICAL CARE

Email: christopher.robinson@neurology.ufl.edu

Carolina B Maciel MD, MSCR

Associate Professor Of Neurology And Neurosurgery, Divisions Of Neurocritical Care And Epilepsy; Director Of Research For NCC; Critical Care Encephalographer

Department: MD-NEURO-NEUROCRITICAL CARE

Email: carolina.maciel@ufl.edu

Overview

Description of the Rotation

Welcome to the Neuro Intensive Care Unit at the University of Florida. We are excited to have you in the NeuroICU. The core goal of the rotation is to learn and acquire the skills necessary for the evaluation and management of critically ill neurological and neurosurgical patients. Residents and rotators will learn the application of general and neurological-oriented critical care concepts in the management of these patients. In addition, residents and rotators are expected to gain familiarity with commonly performed procedures in the ICU. The resident/rotator is expected to be an essential member of the multidisciplinary care team. We hope that you enjoy this rotation.

Objectives

 Educational goals

• Learn the essential concepts pertinent to the management of specific neurological and neurosurgical diseases in the ICU.
• As a physician-learner, you are an essential part of the teaching rounds, and are expected to contribute to the daily rounds, both formally and informally.
• You are expected to present at least 1 topic per week to the staff (15-30 minutes) on a relevant topic, and at least one formal lecture (powerpoint format) at the end of the rotation. The topic should be identified early on (during the first week) and discussed with the attending or fellow.
• You are expected to apply an open-minded and analytical approach to the acquisition of new knowledge. A systematic approach to critical thinking is essential in the NeuroICU.
• Read mandatory topics (see list of core topics below) and additional topics.
• Adhere to the GME guidelines (i.e., no more than 80hrs/week). This is a very strict policy and no exceptions are allowed. The resident must keep track of their work hours and inform the NeuroICU attending if he/she is anticipating a violation.

Patient’s care responsibility

• You will be expected to carry a bed assignment as determined by the attending (or fellow, if applicable) of no less than 2 patients and no more than 8 patients, per day, depending on the schedule and work-load.
• This is a service rotation. If for some reason you are unable to make it to the unit, please notify the attending immediately. You are responsible for finding your own replacement.
• Perform and document a general and neurologic comprehensive exam on all new patients and daily as a follow up. Repeated focused examinations driven by patient-specific needs are also to be expected throughout your assignment.
• You are expected to demonstrate the ability to integrate decision-making, and choose appropriate management steps based on medical facts, guidelines, and patient’s specific condition.
• Document progress note on your assigned patient’s using the standardized Neuromedicine ICU progress note (“Neuromedicine ICU progress note), shortcut: .NMICU
• Gather accurate and essential information from all sources, including medical records, outside records (if applicable), consultant services, ancillary service, and integrate all acquired information when presenting during attending rounds to guide complex decision-making.
• You are expected to demonstrate the ability to prioritize competing care needs, procedures, or tests in the ICU.
• Identify patients no longer requiring ICU level of care, prepare for transferring to appropriate floor, and provide comprehensive sign-out
• Sign out patients to and from overnight care provided in an assertive yet comprehensive manner to facilitate continuity of care.

Interpersonal and Professionalism

• As a key part of the team, you are expected to demonstrate behavior that reflect commitment to continuous professional development and ethical practice methods.
• You are expected to understand the sensitivity and responsiveness to gender, sexual orientation, socio-economic status, race, beliefs and religion, culture, age, and disabilities, of patients and professional colleagues.
• Ability to recognize self-deficiency and accept constructive criticism, with the goal to overcome any identifiable gaps.
• Professional attire appropriate to the critical care setting is expected, scrubs are highly suggested. At all times, the following are mandatory rules in the ICU: wear a clear and visible nametag; wear no tie during clinical practice; shoes must have close toe, nonskid, and show no visible skin.

System-Based Practice

• Ability to understand the limitations and opportunities inherent in various practice types, and delivery systems.
• Collaborate with other members of the health care systems to assist in the multidisciplinary delivery of care and improve systemic process of care.
• Apply evidence-based and cost-conscious strategy to prevention, diagnosis, and management of specific disease.
• Understand the limitation of care and expected/unexpected course of illnesses.

Method of assessment/grading

• Daily competency-based staff assessment of medical knowledge, professionalism, patient care and interpersonal skill.
• Ancillary staff evaluation.
• Evaluation of procedures.
• Presentation of relevant topics and formal lecture as well as case presentations.

General

• Over communicate rather than under communicate! All orders should be personally communicated to the nurse and relevant care plan changes to the team.
• Labs and diagnostic tests in the ICU should be ordered as stat when appropriate.
• Daily labs for most patients: CBC, BMP, and ABG/CXR if there is a clinical indication. SAH patients should receive daily orders for TCDs.
• Post-TPA patients, or acute cerebrovascular disease patients who have a change in exam (or NIHHS change >4 points) otherwise unexplained should undergo STAT repeat head imaging.
• Admission H&P’s for ALL stroke patients (ICH, SAH, ischemic stroke) should have an NIHSS documentation. Additionally, ICH score for ICH patients, and Hunt/Hess, WFNS, and Fisher grades for SAH patients.
• All orders, especially urgent medications or labs, should be directly communicated with ICU RNs. Simply ordering in MAR may not ensure accurate and/or timely delivery!
• Be present at bedside for sign-out from anesthesiologists, neurosurgeons, or other teams for new admissions/transfers into the unit.
• Pain control: No patient leaves the ICU unless pain is well controlled. Avoid drip pain medication (or drip sedative medication) on non-intubated patients unless first discussed with the attending.
• No procedures should be done on any patient unless first discussed with the attending (or fellow). Attending (or designee) must be present for all procedures.
• The medical chart is not the place to document disagreement with other teams (i.e., if a consult service makes a recommendation that seems it may deviate from an expected plan or is controversial). Please discuss first with the attending. In addition, if a consultant team suggest a controversial plan, this must be discussed with the attending before implementing that plan.
• Communicate with neurology/neurosurgery (or other applicable primary team) often and thoroughly on our joint patients. Call them ASAP with any urgent or critical developments in patient care, including but not limited to: exam or ICP changes, EVD/bolt malfunction, changes in cardiopulmonary status, intubation/extubation, need for repeated imaging, outcome of family discussions, et cetera.
• Maintain a visible presence on the unit by being available to the nursing staff at each team station. The back workrooms and call rooms should only be used for report, discussion, and rest. Being visible tells the nurses and consultants that you are engaged and available. Not only does this facilitate nurse-physician interaction, it also facilitates your learning.

Core Topics

A. Cerebrovascular Diseases

1. Infarction and ischemia

• Massive hemispheric infarction
• Posterior circulation infarctions
• Spinal cord infarction
• Arterial dissections

1. Intracerebral hemorrhage

• Supratentorial
• Cerebellar
• Brainstem
• Intraventricular

1. Subarachnoid hemorrhage – traumatic, aneurysmal and other vascular malformations
2. Dural sinus thrombosis and venous infarctions
3. Carotid-cavernous fistulae
4. Cerebral angiopathies and other dysautoregulation syndromes (PRES, RCVS, vasculitis, drug-related)

B. Neurotrauma

1. Traumatic brain injury

• “Diffuse axonal injury” / Traumatic axonal injury
• Epidural and subdural hematomas
• Skull fracture
• Contusions and lacerations
• Penetrating craniocerebral injuries

1. Traumatic Spinal Cord injury

• Central cord syndrome
• Conus medullaris / Cauda Equina Syndromes

C. Seizures, and Epilepsy and Other common Miscellaneous Diseases/Disorders

1. Seizures and epilepsy

• Status epilepticus (SE)
  − Convulsive
  − Non-convulsive (focal, generalized, and secondarily generalized SE)

1. Neuromuscular diseases

• Myasthenia gravis
• Guillain-Barre syndrome and other acute inflammatory demyelinating neuropathies
• Amyotrophic Lateral Sclerosis and other motor neuron diseases requiring ICU level of care
• Rhabdomyolysis and toxic myopathies
• Critical illness myopathy and neuropathy

1. Infections

• Encephalitis (viral, bacterial, mycobacterial, fungal, parasitic)
• Meningitis (viral, bacterial, mycobacterial, fungal, parasitic)
• Transverse myelitis
• Brain and spinal epidural abscess

1. Toxic-metabolic disorders

• Neuroleptic malignant syndrome/malignant hyperthermia
• Serotonin syndrome
• Drug overdoses and withdrawal (e.g., barbiturates, narcotics, alcohol, cocaine, acetaminophen)
• Temperature related injuries (hyperthermia, hypothermia)

1. Inflammatory and demyelinating diseases

• Multiple sclerosis (Marburg variant, transverse myelitis)
• Neurosarcoidosis
• Acute disseminated encephalomyelitis (ADEM)
• CNS vasculitis
• Limbic and other autoimmune encephalomyelitis
• Chemical or sterile meningitis (i.e. posterior fossa syndrome, NSAID induced)
• Central pontine myelinolysis
• Others

1. Neuroendocrine disorders

• Pituitary apoplexy
• Diabetes insipidus (including triple phase response)
• Panhypopituitarism
• Thyroid storm and coma
• Myxedema coma
• Addisonian crisis

D. Neuro-oncology

1. Brain tumors and metastases
2. Spinal cord tumors and metastases
3. Carcinomatous meningitis
4. Paraneoplastic syndromes

E. Encephalopathies

1. Eclampsia, including HELLP Syndrome
2. Hypertensive encephalopathy
3. Hepatic encephalopathy
4. Uremic encephalopathy
5. Hypoxic-ischemic and anoxic encephalopathy
6. Mitochondrial encephalomyopathy, lactic acidosis, and stroke-like episodes (MELAS)

F. Clinical syndromes

1. Coma
2. Herniation syndromes with/without ICP monitoring
3. Elevated intracranial pressure and Intracranial hypotension/hypovolemia
4. Hydrocephalus detection & management
5. Cord compression
6. Death by neurologic criteria / “Brain Death”, end of life issues, and organ donation
7. Vegetative state
8. Dysautonomia (cardiovascular instability, central fever, hyperventilation)

G. Perioperative Neurosurgical Care

1. Familiarity with expected neurological examination findings after individual procedures
2. Management of post-operative seizures
3. Understanding need for neurological follow up in individual neurosurgical diseases
4. Medical management and optimization of care post-operatively

H. General Critical Care

1. Cardiovascular physiology and hemodynamic monitoring
2. Respiratory physiology, airway management and mechanical ventilation
3. Renal physiology, fluid and electrolyte, renal failure and renal replacement therapy
4. Metabolic and endocrine effects of critical illness
5. Infectious disease pathophysiology and therapy
6. Acute hematologic disorder pathophysiology, hemostasis and coagulopathy
7. GI/GU pathophysiology
8. Immunology and transplantation
9. General trauma and burns
10. Death and dying, end-of-life care management

I. Principles of Neurocritical Care Monitoring

1. Interpretation of ICP/CPP
2. Interpretation of brain tissue oxygen
3. Interpretation of continuous EEG
4. Interpretation of transcranial Doppler ultrasound and angiography
5. Interpretation of cardiac output

J. Procedural Skllls

1. Central venous catheter and arterial line placement
2. Management of mechanical ventilation
3. Airway maintenance
4. Management of external ventricular drain
5. Induction of coma

Mandatory Reading

Emergency Neurological Life Support (ENLS) is a set of protocols that have been designed to help healthcare professionals improve patient care and outcomes during the critical first hours of a patient’s neurological emergency.  ENLS is a collaborative and multi-disciplinary approach, provides a consistent set of protocols, practical checklists, decision points, and suggested communication to use during patient management. Topics include:

• Acute Non-Traumatic Weakness
• Acute Stroke
• Airway and Ventilation and Sedation
• Coma
• Intracerebral Hemorrhage
• Intracranial Hypertension and Herniation
• Ischemic Stroke
• Meningitis/Encephalitis
• Resuscitation following Cardiac Arrest
• Pharmacotherapy
• Spinal Cord Compression
• Status Epilepticus
• Subarachnoid Hemorrhage
• Traumatic Brain Injury
• Traumatic Spine Injury

These can be freely accessed from the neurocritical care society website.

The NeuroICU (by Kiwon Lee): Section 1, Section 2 and Section 3

Recommended books

• Neurocritical care (What do I do) (2016), by Eelco Widjicks and Alejandro Rabinstein
• The NeuroICU Book (2017) by Kiwon Lee
• Textbook of Critical Care (7e) by Jean-Louis Vincent and Edward Abraham
• Critical Care Medicine by Joseph Parrilo and Philip Delinger

Suggested articles

Acute Stroke

• Jauch, E.C., Saver, J.L., Adams, H.P., Bruno, A., Conors, J.J., Demaerschalk, B.M.., et al. (2013). Guidelines for the early management of patients with ischemic stroke: a guideline for healthcare professionals from the American Heart Association/American Stroke Association. Stroke, available online.
• The National Institute of Neurological Disorders and Stroke rt-PA Stroke Study Group. (1995). Tissue plasminogen activator for acute ischemic stroke. The New England Journal of Medicine, 333(24), 1581–1587.
• Hacke, W., Kaste, M., Bluhmki, E., Brozman, M., Dávalos, A., Guidetti, D., et al. (2008). Thrombolysis with alteplase 3 to 4.5 hours after acute ischemic stroke. The New England Journal of Medicine, 359(13), 1317–1329.
• Furlan, A., Higashida, R., Wechsler, L., Gent, M., Rowley, H., Kase, C., et al. (1999). Intra-arterial prourokinase for acute ischemic stroke. The PROACT II study: a randomized controlled trial. Prolyse in Acute Cerebral Thromboembolism. Journal of the American Medical Association, 282(21), 2003–2011.
• Balucani, C., & Grotta, J. C. (2012). Selecting stroke patients for intra-arterial therapy. Neurology, 78(10), 755–761.
• Vahedi, K., Hofmeijer, J., Juettler, E., Vicaut, E., George, B., Algra, A., et al. (2007). Early decompressive surgery in malignant infarction of the middle cerebral artery: a pooled analysis of three randomised controlled trials. Lancet Neurology, 6(3), 215–222.

Brain Death

• Wijdicks, E. F. M., Varelas, P. N., Gronseth, G. S., Greer, D. M., & American Academy of Neurology. (2010). Evidence-based guideline update: determining brain death in adults: report of the Quality Standards Subcommittee of the American Academy of Neurology. Neurology, 74(23), 1911–1918.

Cardiac Arrest

• Hypothermia after Cardiac Arrest Study Group. (2002). Mild therapeutic hypothermia to improve the neurologic outcome after cardiac arrest. The New England Journal of Medicine, 346(8), 549–556.
• Bernard, S. A., Gray, T. W., Buist, M. D., Jones, B. M., Silvester, W., Gutteridge, G., & Smith, K. (2002). Treatment of comatose survivors of out-of-hospital cardiac arrest with induced hypothermia. The New England Journal of Medicine, 346(8), 557–563.
• Sandroni, C., Cariou, A., Cavallaro, F., Cronberg, T., Friberg, H., Hoedemaekers, C., Horn, J., Nolan, J.P., Rossetti, A.O., Soar, J. (Dec., 2014). Prognostication in comatose survivors of cardiac arrest: An advisory statement from the European Resuscitation Council and the European Society of Intensive Care Medicine.  Intensive Care Medicine, 40(12), 1816-1831.
• Wijdicks, E. F. M., Hijdra, A., Young, G. B., Bassetti, C. L., Wiebe, S., & Quality Standards Subcommittee of the American Academy of Neurology. (2006). Practice parameter: prediction of outcome in comatose survivors after cardiopulmonary resuscitation (an evidence-based review): report of the Quality Standards Subcommittee of the American Academy of Neurology. Neurology, 67(2), 203–210.

Extubation

• Coplin, W. M., Pierson, D. J., Cooley, K. D., Newell, D. W., & Rubenfeld, G. D. (2000). Implications of extubation delay in brain-injured patients meeting standard weaning criteria. American Journal of Respiratory and Critical Care Medicine, 161(5), 1530–1536.
• McConville, J.F., & Kress, J.P. (2012).  Weaning patients from the ventilator.  The New England Journal of Medicine, 367, 2233-2239.

Fever

• Greer, D. M., Funk, S. E., Reaven, N. L., Ouzounelli, M., & Uman, G. C. (2008). Impact of fever on outcome in patients with stroke and neurologic injury: a comprehensive meta-analysis. Stroke, 39(11), 3029–3035.

General Critical Care

• The Acute Respiratory Distress Syndrome Network. (2000). Ventilation with lower tidal volumes as compared with traditional tidal volumes for acute lung injury and the acute respiratory distress syndrome. The New England Journal of Medicine, 342(18), 1301–1308.
• The NICE-SUGAR Study Investigators. (2009).  Intensive versus conventional glucose control in critically ill patients. The New England Journal of Medicine, 360(13), 1283–1297.
• Adrogue, H.J., & Madias, N.E. (1998).  Management of life-threatening acid-base disorders.  The New England Journal of Medicine, 338, 26-34; 107-111.  (Parts 1 and 2)
• Axler, O. (2006). Evaluation and management of shock.  Seminars in Respiratory and Critical Care Medicine, 27, 230-240.
• Dellinger, R.P., Levy, M.M., Rhodes, A., Annane, D., Gerlach, H., Opal, S.M., et al. (2013).  Surviving sepsis campaign: international guidelines for management of severe sepsis and septic shock: 2012.  Critical Care Medicine, 41, 580-637.
• Ellison, D.H., & Berl, T. (2007).  The syndrome of inappropriate antidiuresis.  The New England Journal of Medicine, 356, 2064-2072.
• Hébert, P. C., Wells, G., Blajchman, M. A., Marshall, J., Martin, C., Pagliarello, G., et al. (1999). A multicenter, randomized, controlled clinical trial of transfusion requirements in critical care. The New England Journal of Medicine, 340(6), 409–417.
• Rivers, E., Nguyen, B., Havstad, S., Ressler, J., Muzzin, A., Knoblich, B., et al. (2001). Early goal-directed therapy in the treatment of severe sepsis and septic shock. The New England Journal of Medicine, 345(19), 1368–1377.

Intracerebral Hemorrhage

• Morgenstern, L. B., Hemphill, J. C., Anderson, C., Becker, K., Broderick, J. P., Connolly, E. S., et al. (2010). Guidelines for the management of spontaneous intracerebral hemorrhage: a guideline for healthcare professionals from the American Heart Association/American Stroke Association. Stroke, 41(9), 2108–2129.
• Hemphill, J. C., Farrant, M., & Neill, T. A. (2009). Prospective validation of the ICH Score for 12-month functional outcome. Neurology, 73(14), 1088–1094.
• Becker, K. J., Baxter, A. B., Cohen, W. A., Bybee, H. M., Tirschwell, D. L., Newell, D. W., et al. (2001). Withdrawal of support in intracerebral hemorrhage may lead to self-fulfilling prophecies. Neurology, 56(6), 766–772.

Intracranial Pressure and Osmotherapy

• Eccher, M., & Suarez, J.I. (2010). Cerebral edema and intracranial dynamics: monitoring and management of intracranial pressure. In J.I. Suarez (Ed.), Current Clinical Neurology: Critical Care Neurology and Neurosurgery (1^st edition, pp. 47-100).  Totowa, NJ: Humana Press, Inc.
• Ropper, A. H. (2012). Hyperosmolar therapy for raised intracranial pressure. The New England Journal of Medicine, 367(8), 746–752.

Neuroanatomy

• Tatu, L., Moulin, T., Bogousslavsky, J., & Duvernoy, H. (1998). Arterial territories of the human brain: cerebral hemispheres. Neurology, 50(6), 1699–1708.
• Tatu, L., Moulin, T., Bogousslavsky, J., & Duvernoy, H. (1996). Arterial territories of human brain: brainstem and cerebellum. Neurology, 47(5), 1125–1135.
• Schwamm, L.H., & Finklestein, S.P. (1997). Infratentorial ischemic syndromes. In H.H. Batjer (Ed.), Cerebrovascular Disease (pp. 347-375).  Philadelphia, PA: Lippincott-Raven Publishers.

Posterior Reversible Encephalopathy Syndrome

• Bartynski, W. S. (2008). Posterior reversible encephalopathy syndrome, part 1: fundamental imaging and clinical features. American Journal of Neuroradiology, 29(6), 1036–1042.

Subarachnoid Hemorrhage

• Molyneux, A. J., Kerr, R. S. C., Yu, L.-M., Clarke, M., Sneade, M., Yarnold, J. A., et al. (2005). International subarachnoid aneurysm trial (ISAT) of neurosurgical clipping versus endovascular coiling in 2143 patients with ruptured intracranial aneurysms: a randomised comparison of effects on survival, dependency, seizures, rebleeding, subgroups, and aneurysm occlusion. Lancet, 366(9488), 809–817.
• Diringer, M. N., Bleck, T. P., Claude Hemphill, J., Menon, D., Shutter, L., Vespa, P., et al. (2011). Critical care management of patients following aneurysmal subarachnoid hemorrhage: recommendations from the Neurocritical Care Society’s Multidisciplinary Consensus Conference. Neurocritical Care, 15(2), 211–240.
• Sandsmark, D. K., Kumar, M. A., Park, S., & Levine, J. M. (2012). Multimodal monitoring in subarachnoid hemorrhage. Stroke, 43(5), 1440–1445.

Status Epilepticus

• Brophy, G. M., Bell, R., Claassen, J., Alldredge, B., Bleck, T. P., et al. (2012). Guidelines for the evaluation and management of status epilepticus. Neurocritical Care, 17(1), 3–23.
• Wittman, J. J., & Hirsch, L.J. (2005). Continuous electroencephalogram monitoring in the critically ill.  Neurocritical Care, 2, 330-341.

Traumatic Brain Injury

• Andrews, P.J.D., Sinclair, H.L., Rodriguez, A., Harris, B.A., Battison, C.G., Rhodes, J.K.J., Murray, G.D., for the Eurotherm 3235 Trial Collaborators.  (2015).  Hypothermia for Intracranial Hypertension after Traumatic Brain Injury. N Engl J Med; 373:2403-2412.
• Brain Trauma Foundation. (2017). Guidelines for the Management of Severe Traumatic Brain Injury, 4^th ed. Neurosurgery, 80 (1):6-15.
• Cooper, D. J., Rosenfeld, J. V., Murray, L., Arabi, Y. M., Davies, A. R., D’Urso, P., et al. (2011). Decompressive craniectomy in diffuse traumatic brain injury. The New England Journal of Medicine, 364, 1493-1502.
• MRC CRASH Trial Collaborators. (2008). Predicting outcome after traumatic brain injury: practical prognostic models based on large cohort of international patients. British Medical Journal, 336(7641), 425–429.

Vascular Malformations

• Pérez-Carrillo, G. J. G., & Hogg, J. P. (2010). Intracranial vascular lesions and anatomical variants all residents should know. Current Problems in Diagnostic Radiology, 39(3), 91–109.