Brain bleeds: prophylactic care

[zzyzx]

I'm wondering what protocols/decisions strategies the neurologists in your ICU/ER use for deciding to use Keppra prophylacticaly for seizures, and mannitol/hypertonic saline? I ask the question because I don't seem to see uniformity in how certain patients are treated. FYI I'm not a neuro ICU nurse, so perhaps I'm ignorant about something basic.

1) Patient has extensive subarachnoid bleed showing on CT. There is no signs of herniation yet. Is it standard of care to give an anti-epileptic prohylactically? Is there evidence that it really will prevent seizures? Would you give mannitol/hypertonic saline, again prophylacticly for expected clinical course?

2) A patient with an extensive intraparenchymal bleed, again with no signs of herniation yet. Do you give Keppra and mannitol/hypertonic saline?

3) A patient who is ALOC, combative with an obvious traumatic head injury, but no CT has been done. Would you give these treatments? If they were posturing, you would give the mannitol/hypertonic saline, correct?

[NeuroNerd]

1. In an unsecured/unidentified aneurysm, it is standard to see AED given because those patients are at an increased risk for seizures due to the irritation from the blood in the subarachnoid space.  Also, vasospasms are common in the acute period for that pt population, with the risk being the highest on days 7 through 14.  Seizure activity has been associated with an increased risk of further disability and even pt mortality.  Seizures are a known complication of this type of neurologic injury, and that is why you see patients on an AED.  Once the aneurysm has been secured, the risk of mortality/further neurologic damage is rare, and they will discontinue prophylactic therapy.   

2. In patients with cerebral edema, you will almost always see them on an AED.  Hypertonic saline/mannitol is used at the neurosurgeon's discretion, and it is based on the patient's serum sodium level.  The goal of hypertonic saline is to prevent herniation. If herniation appears to be imminent, the physician or AAP can push 23% saline that usually will take effect faster than the hypertonic or mannitol.  If the patient's scan shows increased cerebral edema and the brain has no room to continue swelling, Neurosurgery will most likely have you bolus the patient with Mannitol, intubate them and take them to the OR for a crani.  They may even do this first, depending on how imaging looks.  

3.  Hypertonic isn't a medication that would be started as a first-line treatment.  The pt should have had imaging completed to assess for neurologic injury. Labs should be assessed, and if the imaging shows that hypertonic is appropriate, it would be started then based on the sodium result from labs collected before his scan.  If the patient is posturing, they are most likely herniating or experiencing cerebral edema.  The patient would need an emergent consult to neurosurgery and most likely end up with a crani.  

[amoLucia]

OP has not been back for a year.