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Blood Pressure Management in Neurocritical Care

Anand Swaminathan, MD FAAEM and Evie Marcolini, MD
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15:11
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Nurses Edition Commentary

Kathy Garvin, RN and Lisa Chavez, RN
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02:40

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EMRAP_2018_10_October_Written Summary_v2 548 KB - PDF

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David B. -

Is it still recommended to do seizure prophylaxis with a traumatic bleed?

Evie M., M.D. -

Hi David,
Yes, the latest Trauma Foundation guidelines (Carney N et al Guidelines for the Management of Severe Traumatic Brain Injury, Fourth Edition. Neurosurgery 2017 Jan 1;80(1)6-15) recommend to treat for prophylaxis against early post-traumatic seizure (PTS), which by definition is clinical or subclinical seizure within the first 7 days. The guidelines encourage treatment if the risk of early PTS outweighs the side effects of the medication, and we lack great evidence for any particular agent. Having said that, they recommend phenytoin, but acknowledge that many centers are using levitiracetam.
The risk of PTS with severe TBI is roughly 12% clinically, but can be up to 25% by EEG, and it is acknowledged that early PTS can be a risk factor for post traumatic epilepsy later on. So the recommendation is to treat for any of the following risk factors: GCS <10, immediate seizures, post-traumatic amnesia > 30 minutes, linear or depressed skull fracture, penetrating head injury, subdural, epidural or intracerebral hematoma, cortical contusion, <65 years old or chronic alcoholism.
Bottom line: severe TBI - treat with the agent that your institution/neurosurgeons prefer.
Thanks for your question
Evie

David B. -

Dr. Marcolini,
Thank you so much for your in-depth response. I appreciate the time you took to answer and your knowledge very much! Hope you have a great day!
Sincerely,
David

Quang N. -

For subarachnoid haemorrhages, you advocated systolic BP <140mmHg, but for traumatic brain injury, including traumatic subarachnoid bleed, you advised to keep the blood pressure above 100-110. So for a traumatic subarachnoid haemorrhage, does that leave us with a target sysBP of 110-140? Or do we have separate blood pressure targets for non-traumatic vs. traumatic subarachnoid bleeds?

Evie M., M.D. -

Hi Quang,
Yes, traumatic subarachnoid hemorrhages are considered as and treated as a TBI, so blood pressure should be managed above 100 for ages 50-69, and above 110 or ages 50-49 or >70. The mechanism for aneurysmal SAH is a ruptured aneurysm that we want to prevent from re-rupturing (thus targeting SBP<140). With a traumatic mechanism, we want to maintain CPP = MAP-ICP, so keeping blood pressure up is important to maintain perfusion, and there is no need to protect a ruptured aneurysm.
Sometimes it can be tricky figuring out which came first, such as in a case where there is a SAH and a concomitant fall - if the story isn't clear, you may get a CTA (to see a possible aneurysm) and discuss with radiology to ascertain the most likely case before targeting blood pressure goals.

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EM:RAP 2018 October Full episode audio for MD edition 245:31 min - 230 MB - M4AEM:RAP 2018 October Canadian Edition Canadian 48:30 min - 67 MB - MP3EM:RAP 2018 October German Edition Deutsche 98:17 min - 135 MB - MP3EM:RAP 2018 October French Edition Français 31:44 min - 25 MB - MP3EM:RAP 2018 October Spanish Edition Español 89:24 min - 123 MB - MP3EMRAP_2018_10_Oct_Board Review Answers_Vol.18_10 128 KB - PDFEMRAP_2018_10_Oct_Board Review Questions_Vol.18_10 95 KB - PDFEM:RAP 2018 10 October Individual MP3 files 302 MB - ZIPEMRAP_2018_10_October_Individual PDF 855 KB - ZIPEM:RAP 2018 10 October Spanish Written Summary 812 KB - PDFEMRAP_2018_10_October_Written Summary_v2 548 KB - PDF

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