The drug induced ICH

[VentMonkey]

Pretty clear cut scenario, but would still like to hear everyone's thoughts, treatments, and/ or differentials; then I'll share mine.

You respond to the residence of a 40 y/o male found lying supine on the living room floor of a single story house. There's plenty of room to work where the patient is found, however, he's noted to be incontinent to urine, and smells as if he's been laying in his urine for a good amount of time by the time you arrive.

You're greeted by your local BLS fire department, who's captain briefs you. He informs you that the patient was found by family with an AMS, snoring respirations, but an intact gag; the patient would not tolerate a BLS airway with simple BVM ventilations, and an OPA.

Once you enter the house you find your male patient with extremely erractic respirations, on O2 @ 15 lpm NRB. A brief primary assessment reveals unequal pupils with the right pupil 2 mm's and fixed, the left pupil 4 mm's and fixed. The patient appears to be intermittently posturing, but no active/ prolonged seizure activity...yet. The patient's other V/S are as follows: BP- 240/120; HR-60-70 (NSR); RR-20-24 erratic (Biot's pattern), and again SPO2 remains well above 94% with good waveform pleth.

You note no obvious trauma, nor is any reported. Breath sounds appear CBL, SPO2 is @ 100% with supplemental O2 being given, and the patient's BGL is 160 mg/ dl.

While having your partner, and fire personnel package the patient for transport, and load him onto the gurney, you ask family and friends, who are all hovering over their loved one understandably concerned, for some further H/A/M.

They don't provide much more than he's fairly healthy, has no allergies that they are aware of, doesn't take any home medications, but they do admit that the patient has a history of substance abuse; specifically methamphetamine, and heroin. You see no fresh track marks, and the patient has workable vascular access, but somewhat valvular, that leads you to believe that the patient is, perhaps a recovering (attempting to) addict.

You are 2-3 minutes away from a level 2 trauma center with no clear cut, or established neurological capabilities 24/7, and about an additional 7 minutes away from another ED who sees (atraumatic) neurological cases much more frequently.

You don't have RSI in your bag today (I didn't this day), but if you did, would you delay transport to secure said patient's airway?

Will you transport to the closer (trauma center) in hopes that there is neuro on-call today, or divert to the confirmed neuro center?

Are you going to given Narcan a try as a "rule out"?

What else can you guys think of, or would you like to know?

 

[Handsome Robb]

I'd tube him. He has a high likelihood of vomiting and he's not protecting his airway.

I'm going to the hospital with 24/7 neurosurgery capabilities 10 minutes away.

No narcan, he's not respiratory depressed, he's got a bleed, he's not ODing. Well not heroin anyways.


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[Handsome Robb]

One thing I'm going to add is he's not seizing, yet, but his ICP is through the roof so a seizure is the last thing this guy needs. If he's paralyzed we won't know if he's seizing but at least he won't be actively trying to pop his brain out of his ears if he does.


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[VentMonkey]

I'd tube him. He has a high likelihood of vomiting and he's not protecting his airway.

I'm going to the hospital with 24/7 neurosurgery capabilities 10 minutes away.

No narcan, he's not respiratory depressed, he's got a bleed, he's not ODing. Well not heroin anyways.


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So, my mistake, but his found GCS is about a 7-8, he clenches when you try to, you have no RSI, or NTI, but for the sake of a healthy discussion, you do tube him, even RSI if you like.

Are you placing him on the vent, and if so what are your settings? What's your target ETCO2 goal for this fella? Which mode, etc.

And yes I agree with, and with held the Narcan decision 100% as well. I'll elaborate further once others chime in, but strong work.

 

[Handsome Robb]

So, my mistake, but his found GCS is about a 7-8, he clenches when you try to, you have no RSI, or NTI, but for the sake of a healthy discussion, you do tube him, even RSI if you like.

Are you placing him on the vent, and if so what are your settings? What's your target ETCO2 goal for this fella? Which mode, etc.

And yes I agree with, and with held the Narcan decision 100% as well. I'll elaborate further once others chime in, but strong work.

If I don't have RSI/DSI capabilities I'm not going to tube him. Not going to risk inducing a gag and all that comes with it (emesis, ICP, ect). With RSI/DSI I'm going to be stuck using ketamine because it's all we carry but etomidate and fentanyl would be a great option for this guy. Propofol wouldn't be a bad choice either. I'm going to use roc because, well, succs sucks.

I'd put him on a vent, we use roc so in this situation the mode isn't going to matter since he's paralyzed but preferably SIMV. I'm going to use 4-6cc/kg IBW and a slightly elevated RR to target an EtCO2 of 35mmHg. This is the one patient that you could argue targeting closer to 30 with the impending herniation. PEEP of 5 since it's basically intrinsic and is lost when you introduce plastic.




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[VentMonkey]

I'm going to use roc because, well, succs sucks.

I'd put him on a vent, we use roc so in this situation the mode isn't going to matter since he's paralyzed but preferably SIMV. I'm going to use 4-6cc/kg IBW and a slightly elevated RR to target an EtCO2 of 35mmHg. This is the one patient that you could argue targeting closer to 30 with the impending herniation. PEEP of 5 since it's basically intrinsic and is lost when you introduce plastic.Sent from my iPhone using Tapatalk

What's your grips with Succs (just curious) vs. Roc? I realize there's currently quite the debate with this subject matter.

Also, why SIMV? Are you adding PS with your SIMV? Why or why not?

TMK, A/C may be a better mode for the brain injured patient, traumatic or otherwise.

Keep up the good work, and hopefully we'll hear others thoughts on this case scenario as well.

 

[Handsome Robb]

What's your grips with Succs (just curious) vs. Roc? I realize there's currently quite the debate with this subject matter.

Also, why SIMV? Are you adding PS with your SIMV? Why or why not?

TMK, A/C may be a better mode for the brain injured patient, traumatic or otherwise.

Keep up the good work, and hopefully we'll hear others thoughts on this case scenario as well.

There's just too many side effects with sux, personally. Roc for me has had consistent effects and been super reliable. N=1 though.


I think PS would definitely be appropriate. My reasoning for SIMV is most seem to tolerate it better than A/C which is going to reduce any sort of sympathetic response to stimulus that the body is perceiving as uncomfortable. Ultimately in this patient and transport time and using ROC the mode isn't going to matter because he'll remain paralyzed for the duration of my care.

I honestly don't know which setting would be best, that's just my opinion.


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[VentMonkey]

There's just too many side effects with sux, personally. Roc for me has had consistent effects and been super reliable. N=1 though.


I think PS would definitely be appropriate. My reasoning for SIMV is most seem to tolerate it better than A/C which is going to reduce any sort of sympathetic response to stimulus that the body is perceiving as uncomfortable. Ultimately in this patient and transport time and using ROC the mode isn't going to matter because he'll remain paralyzed for the duration of my care.

I honestly don't know which setting would be best, that's just my opinion.


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I'll go ahead and add this to the mix as well:

https://www.acep.org/Physician-Reso...curonium-vs--Succinylcholine--Which-Is-Best-/

As far as modes of ventilation, TBH, if you ask 100 different clinicians, chances are you'll get 100 different answers.

My CCP instructor was big on A/C in brain injured patients. If I can dig up an abstract (or anyone else wants to), I will.

For me, SIMV w/ PS, and an (intrinsic) standardized PEEP of 5 is a given, however, for this patient I am going with an A/C mode and paralysis long enough to keep them this way until we arrive at the ED. This is a great mode for, say, a respiratory failure patient needing ETI in hopes of beginning weaning trials sooner rather than later.

I personally have nothing against Succs in your average patient, though I do understand it isn't without its inherent risks.

I would soon as rather keep them paralyzed to further increase/ worsen any ICP. I would also shoot for a target ETCO2 of 30-35, as well as an FiO2 of 100% (1.0 for the respiratory sticklers out there).

The way I learned it, was hypoxia, and hypotension are thee number 1 killers of the brain injured patient.

Clearly, this patients focus for now at least, is hypoxia.

 

[Summit]

I don't need to mess with narcan on a guy whose breathing problems are directly related to the transtentorial herniation that is impending at the very least if it has not already occurred. Mannitol STAT STAT, like it literally might be worth going to the closer ER for mannitol, like call ahead and tell them to have it mixed, walk in the door get in the mannitol and start administering it while you drive to where there is NS and NSICU! Tube him in the truck. His SpO2 is 100%. If you don't drop the ICP right now, he is done... although he may already be done. Prognosis is extremely poor for this patient.

 

[Summit]

Oh yea and put him in fowlers at about 30-45deg

 

[VentMonkey]

Mannitol STAT STAT, like it literally might be worth going to the closer ER for mannitol, like call ahead and tell them to have it mixed, walk in the door get in the mannitol and start administering it while you drive to where there is NS and NSICU!

I think we're all in agreement with no Narcan, that being said, if anyone were to choose it in this scenario, I am curious as to why/ what their thought process would be behind it.

Also, interesting take on the Mannitol. What's your spin on this vs. 3% NS, and why?

Transtentorial herniation is a new term to me. This patient, IMO, was already entering tonsillar herniation with the clear signs of uncal herniation reflected in the intermittent posturing, and unequal pupils.

Thanks for your input.

 

[VentMonkey]

Oh yea and put him in fowlers at about 30-45deg

Yes, indeed he was, but again, thanks for pointing it out.

 

[Summit]

I think we're all in agreement with no Narcan, that being said, if anyone were to choose it in this scenario, I am curious as to why/ what their thought process would be behind it.

Also, interesting take on the Mannitol. What's your spin on this vs. 3% NS, and why?

Transtentorial herniation is a new term to me. This patient, IMO, was already entering tonsillar herniation with the clear signs of uncal herniation reflected in the intermittent posturing, and unequal pupils.

Thanks for your input.

Uncal herniation is a subset of transtentorial herniation. I agree uncal likely based on respiratory patterns.

Mannitol was the gold standard for osmotic gradient mediated control of ICP. It is what I've given so it is what my mind reaches for. HTS is now maybe more slightly more favored, but it depends on the doc. However 3% NS is not hypertonic enough when we need to bolus dose. It makes a fine maintenance fluid, but 7.9% or 15% are more favored for this situation as I understand it.

But if you have 3%, give it, just not in huge volume (perhaps this pt is volume depleted depending on how long they have been down).

I'll admit, Neuro is my weak point in CC.

 

[VentMonkey]

Uncal herniation is a subset of transtentorial herniation. I agree uncal likely based on respiratory patterns.

Mannitol was the gold standard for gold standard for osmotic gradient mediated control of ICP. HTS is now maybe more favored, but 3% is not hypertonic enough when we need to bolus. It makes a fine maintenance fluid, but 7.9% or 15% are more favored for this situation.

But if you have 3%, give it, just not in huge volume (perhaps this pt is volume depleted depending on how long they have been down).

I'll admit, Neuro is my weak point in CC.

A good case review. I am digging the responses thus far. I hope to hear others input on this case.

Here was my treatment modalities:

Have tech, and fire place him on the gurney, instantly placed the patient in the semi-fowler position, placed the patient on the cardiac monitor/ SPO2 (sadly, I was working as a regular ground paramedic, so I didn't have my nurse or their expanded protocols at my disposal; yaaay, California).

We then loaded the patient into the unit, I checked a BGL (TBH, I kinda knew it wasn't his BGL after seeing dealing with enough as I am sure many can attest), went for my IV's, unfortunately I was only able to get one lock in him, which was all that was needed to push the Versed once he did begin to actually seize.

I kept him on the NRB, and took a firefighter with me as an extra set of hands to the neuro capable ED, bypassing the closest ED; this only added and additional 3-4 minutes.

When I did call the hospital, I pitched a "hey it's not quite a stroke alert but you all will need to RSI this fella" approach.

Lo and behold there were plenty of "cooks" in this poor patients "kitchen" on my arrival.

The doc (not particularly one I respect) cut me off two sentences in, so I stopped, helped off load, and walked out, but not before I heard him ask for Narcan (I admittedly snarled when he asked if I gave it).

As I stood outside within earshot I hears him say repeatedly "I think it's a bleed; it looks like a bleed", which is what was coming out of my mouth when he ever so politely cut me off.

 

[Carlos Danger]

As usual, I'll be the voice of dissent when it comes to the need to intubate this guy. This is probably the hardest type of patient to intubate without causing further harm. Increase or decrease the ICP by very much or cause any hypoxemia at all, and you've significantly worsened his already poor prognosis. Considering his Sp02 is fine and that he appears to have been in this condition for quite some time already, a few more minutes without a tube is probably not going to cause any harm, whereas any complications from intubation very possibly could. It would be better to do that procedure in a more controlled setting with more resources. That isn't always possible in the field of course, but in this case, with 2 capable ED's within 10 minutes, it is an option, and the one to take, IMO. Some fentanyl during transport to assuage the stimulus of transport might not be a bad idea.

If you do intubate him, you need to use enough sedation to blunt the stimulus of laryngoscopy, but not affect his BP much at all. That can be tricky. I am not personally sold on ketamine for a fragile patient like this. I would probably use little sedation if any, and give a little fentanyl along with some lidocaine and a healthy dose of esmolol prior to the sux.

Per ACOS requirements, a level 2 hospital should have neurosurgery coverage 24/7 as well as all the related ICU capabilities, so it really shouldn't matter which hospital you go to, from that perspective.

Ventilation mode doesn't matter as long he remains chemically relaxed or at least compliant with the vent. The only important thing there is to keep in mind how your ventilation strategy will affect venous return and therefore ICP. So no 10 mg/kg tidal volumes or PEEP of 10 on this guy. Normal tidal volume per ARDSnet guidelines (4-6 ml/kg), small amount of PEEP (3-5), rate that keeps his PaCo2 at the low end of normal (ETCo2 ~28-30).

 

[VentMonkey]

As usual, I'll be the voice of dissent when it comes to the need to intubate this guy. This is probably the hardest type of patient to intubate without causing further harm. Increase or decrease the ICP by very much or cause any hypoxemia at all, and you've significantly worsened his already poor prognosis. Considering his Sp02 is fine and that he appears to have been in this condition for quite some time already, a few more minutes without a tube is probably not going to cause any harm, whereas any complications from intubation very possibly could. It would be better to do that procedure in a more controlled setting with more resources. That isn't always possible in the field of course, but in this case, with 2 capable ED's within 10 minutes, it is an option, and the one to take, IMO. Some fentanyl during transport to assuage the stimulus of transport might not be a bad idea.

If you do intubate him, you need to to blunt to the stimulus of laryngoscopy, but not affect his BP much at all. That can be tricky. I am not personally sold on ketamine for a fragile patient like this. I would probably use little sedation if any, and give a little fentanyl along with some lidocaine and a healthy dose of esmolol prior to the sux.

Per ACOS requirements, a level 2 hospital should have neurosurgery coverage 24/7 as well as all the related ICU capabilities, so it really shouldn't matter which hospital you go to, from that perspective.

Ventilation mode doesn't matter as long he remains chemically relaxed or at least compliant with the vent. The only important thing there is to keep in mind how your ventilation strategy will affect venous return and therefore ICP. So no 10 mg/kg tidal volumes or PEEP of 10 on this guy. Normal tidal volume per ARDSnet guidelines (4-6 ml/kg), small amount of PEEP (3-5), rate that keeps his PaCo2 at the low end of normal (ETCo2 ~28-30).

Interesting perspective, and hardly the voice of dissent. Again, I like hearing, and learning any, and every perspective that I can.

As far as the Lidocaine to blunt the response. This, TMK, is yet another hot button and debatable topic. I had a very similar case when working a ground CCT shift in which a patient suffered a catastrophic (most likely non-drug related) ICH, and required emergent intubation en route. Long story short, I gave the Lido, and was chastised by the receiving physician.

Ya gotta love medicine, and it's infinite spin on things from different practioners.

Thanks for adding in vent settings. I do follow (I should say we as a whole) the lower Vt guidelines that are being pushed by such folks like the ARDS network. This seems to be the norm.

Another great point you mentioned was decreasing stimulus. This was also harped on in my CCP course; particularly with neuro cases. I like the Fentanyl angle. I know at least on the helicopter, everyone gets ear plugs unless they're fully coherent and don't want them.

Our level 2 may, or may not have neurological capabilities available around the clock, so don't quote me on this, but I am going off of what I get told at times from some of the ED folks, so I had to go with the sure bet.

Again, thanks for the input @Remi, I always enjoy reading your posts.

 

[Carlos Danger]

As far as the Lidocaine to blunt the response. This, TMK, is yet another hot button and debatable topic. I had a very similar case when working a ground CCT shift in which a patient suffered a catastrophic (most likely non-drug related) ICH, and required emergent intubation en route. Long story short, I gave the Lido, and was chastised by the receiving physician.

I think the main reason that there's so much controversy over lidocaine for intubation is simply that people misunderstand it. Opponents of using lidocaine usually say "lidocaine doesn't blunt ICP increase due to laryngoscopy", and that is false. It is well known in neurosurgical circles that IV lido does blunt ICP increases due to noxious stimulus. Where the confusion comes from is that studies have never been able to show that lidocaine improves outcomes when used routinely in head-injured TBI patients.

So I would agree that routinely using it whenever you RSI a patient with a TBI is not necessary - at least not if you are going with a strictly evidence based approach. However, in a patient like this who likely has a large SAH and for whom you want to do everything you can to prevent further increases in their already high ICP, I think it makes good sense.

 

[TXpeds16]

With the report from the fire chief and without having put hands on the patient or vital signs I would be working through CVA/headbleed, glucose, drugs, seizure, sepsis or electrolytes. Once those vitals were obtained I would become highly suspicious of increased ICP, and the unequal pupils would help confirm that. Although no signs of trauma are apparent, I would still likely package this patient if for no other reason than ease of moving. He obviously needs a definitive airway, however, with the close proximity to either hospital I would be hard pressed to RSI on scene unless extrication would be prolonged. If i had access to RSI on that day, and extrication would be prolonged, my current protocol would be 1mg/kg lidocaine>5mg versed>1.5mg/kg Succ's(although for this particular patient i would prefer roc for induction)>intubate>0.1mg/kg Vec(or Roc 1mg/kg, sometimes what we are carrying varies)>5mg versed, further sedation as necessary.

Initial vent settings would be VC-Vt(6/kg) RR(12) Fio2(1.0) PEEP(5) I:E(1:2), adjusting minute ventilation to achieve an ETCO2 on the low side of normal.

If I had access to mannitol or 3% i would highly consider those as well.

I would forgo narcan, even if he has opiates on board, its not what is causing his symptoms.

Transport to facility with neurocapabilities.

 

[VentMonkey]

So let me throw another general question out there for y'all:

If you had access to an antihypertensive, just one, which one would you choose if choosing to use it at all, and why?

 

[Handsome Robb]

So let me throw another general question out there for y'all:

If you had access to an antihypertensive, just one, which one would you choose if choosing to use it at all, and why?

His MAP is 160 if I did the math correctly, that's far too high. I can't remember where I read it but it associated severe hypertension with worse M&M similarly to hypotension. I believe the "highest" you want to see is 130mmHg so I think it would be prudent with this guy but you also don't want a huge drastic drop in his pressure as well.

The two obvious choices are either esmolol or labetalol. Both have a quick onset but esmolol is going to be faster however labetalol is going to have a longer effect. I don't think you'd be wrong with either, the faster onset of esmolol might be beneficial for this guy although I believe labetalol was shown to be more effective during intubation for patients with increased ICP.

Ultimately this dude needs his head opened up, quickly. Even then he likely will not have any sort of quality of life if he does survive this.


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