Objective: To reduce time to imaging and intervention for brain herniation codes through provider education. Background: Brain herniation is a life-threatening event that occurs when compensatory mechanisms are overcome by increasing intracranial pressure. At Thomas Jefferson University Hospital, we implemented a brain herniation code (BHC) alert in 2019 to help quickly mobilize resources and provide care for these patients. However, healthcare providers (HCP) were not aware of this system and thus underutilized. We aim to study the "time to intervention" and outcomes of BHC patients before and after teaching sessions with HCP. We hypothesize that the implementation of BHC with HCP education at TJUH will improve efficiency of clinical care as well as clinical outcomes. Design/Methods: We retrospectively evaluated "time to intervention" for BHC patient charts at TJUH between 2019 to 2021. We then provided educational sessions to HCP with a pre and post lecture evaluation. Statistical analysis was performed using Graphpad Prism v9. Pre and post survey results were compared using paired analysis corrected for multiple comparisons. Results: Preliminary data found six BHC patients before education sessions. The average time to CTH was 39.8 + 6.02 minutes and the average time to administering hyperosmolar therapy was 56.6 + 26.23 minutes. We found a statistically significant difference in pre and post test scores in non-neurology residents (p<0.001, n=20) and Neurology residents (p=0.046, n=12) following our teaching session. Non-neurology providers scored significantly better on 3 questions directed at recognizing impending herniation and 1 question about brain herniation protocol (p<0.05, n=20). Neurology residents scored significantly better on 1 question about protocol (p < 0.05, n = 12) post teaching session. Conclusions: We found focused teaching had improved general knowledge and comfort regarding BHC. We continue to collect post education data to see if there is an improvement in "time to intervention" and patient outcomes. Disclosure: Dr. Lee has nothing to disclose. Dr. Gee has nothing to disclose. Dr. Pynes has nothing to disclose. Dr. Curran has nothing to disclose. Dr. Hsu has nothing to disclose. Dr. Gal has nothing to disclose. Dr. Newman has nothing to disclose. Dr. Fletman has nothing to disclose. Dr. Gupta has nothing to disclose. Dr. Yellin has nothing to disclose. Dr. Buslov has nothing to disclose. Dr. Lee has nothing to disclose. Dr. Navarathna has nothing to disclose. Dr. Vibbert has nothing to disclose. Dr. Shah has nothing to disclose.

Hypoxic brain injury is the leading cause of death in comatose patients following resuscitation from cardiac arrest. Neurological outcome can be difficult to prognosticate following resuscitation, and goals of care discussions are often informed by multiple prognostic tools. One tool that has shown promise is the SLANT score, which encompasses five metrics including initial nonshockable rhythm, leukocyte count after targeted temperature management, total adrenaline dose during resuscitation, lack of bystander cardiopulmonary resuscitation, and time to return of spontaneous circulation. This cohort study aimed to provide an external validation of this score by using a database of comatose cardiac arrest survivors from our institution. We retrospectively queried our database of cardiac arrest survivors, selecting for patients with coma, sustained return of spontaneous circulation, and use of targeted temperature management to have a comparable sample to the index study. We calculated SLANT scores for each patient and separated them into risk levels, both according to the original study and according to a Youden index analysis. The primary outcome was poor neurologic outcome (defined by a cerebral performance category score of 3 or greater at discharge), and the secondary outcome was in-hospital mortality. Univariable and multivariable analyses, as well as a receiver operator characteristic curve, were used to assess the SLANT score for independent predictability and diagnostic accuracy for poor outcomes. We demonstrate significant association between a SLANT group with increased risk and poor neurologic outcome on univariable (p = 0.005) and multivariable analysis (odds ratio 1.162, 95

Errors in communication are a major source of preventable medical errors. Neurosurgical patients fre-quently present to the neuro-intensive care unit (NICU) postoperatively, where handoffs occur to coordi-nate care within a large multidisciplinary team. A multidisciplinary working group at our institution started an initiative to improve postoperative neurosurgical handoffs using validated quality improve-ment methodology. Baseline handoff practices were evaluated through staff surveys and serial observa-tions. A formalized handoff protocol was implemented using the evidence based IPASS format (Illness severity, Patient summary, Action list, Situational awareness and contingency planning, Synthesis by receiver). Cycles of objective observations and surveys were employed to track practice improvements and guide iterative process changes over one year. Surveys demonstrated improved perceptions of handoffs as organized (17.1% vs 69.7%, p < 0.001), effi-cient (27.0% vs. 72.7%, p < 0.001), comprehensive (17.1% vs. 66.7%, p < 0.001), and safe (18.0% vs. 66.7%, p < 0.001), noting improved teamwork (31.5% vs. 69.7%, p < 0.001). Direct observations demonstrated improved communication of airway concerns (47.1% observed vs. 92.3% observed, p < 0.001), hemody-namic concerns (70.6% vs. 97.1%, p = 0.001), intraoperative events (52.9% vs. 100%, p < 0.001), neurolog-ical examination (76.5% vs. 100%, p < 0.001), vital sign goals (70.6% vs. 100%, p < 0.001), and required postoperative studies (76.5% vs. 100%, p < 0.001). Receiving teams demonstrating improved rates of sum-marization (47.1% vs. 94.2%, p = 0.005) and asking questions (76.5% vs 98.1%, p = 0.004). The mean hand -off time during long-term follow-up was 4.4 min (95% confidence interval = 3.9-5.0 min). Standardization of handoff practices yields improvements in communication practices for postopera-tive neurosurgical patients. (c) 2021 Elsevier Ltd. All rights reserved.

Background Coronavirus disease 2019 (COVID-19) mortality has waned significantly over time; however, factors contributing towards this reduction largely remain unidentified. The purpose of this study was to evaluate the trend in mortality at our large tertiary academic health system and factors contributing to this trend. Methods This is a retrospective cohort study of intensive care unit (ICU) patients diagnosed with COVID-19 between March and August 2020 admitted across 14 hospitals in the Philadelphia area. Collected data included demographics, comorbidities, admission risk of mortality score, laboratory values, medical interventions, survival outcomes, hospital and ICU length of stay (LOS) and discharge disposition. Chi-square (χ2) test, Fisher exact test, Cochran-Mantel-Haenszel method, multinomial logistic regression models, independent sample t-test, Mann-Whitney U test and one-way analysis of variance (ANOVA) were used. Results A total of 1,204 patients were included. Overall mortality was 39%. Mortality declined significantly from 46% in March to 14% in August 2020 (P < 0.05). The most common underlying comorbidities were hypertension (60.2%), diabetes mellitus (44.7%), dyslipidemia (31.6%) and congestive heart failure (14.7%). Hydroxychloroquine (HCQ) use was more commonly associated with the patients who died, while the use of remdesivir, tocilizumab, steroids and duration of these medications were not significantly different. Peak values of ferritin, lactate dehydrogenase (LDH), C-reactive protein (CRP) and D-dimer levels were significantly higher in patients who died (P < 0.05). The mean hospital LOS was significantly longer in the patients who survived compared to the patients who died (18 vs. 12, P < 0.05). Conclusions The mortality of patients admitted to our ICU system significantly decreased over time. Factors that may have contributed to this may be the result of a better understanding of COVID-19 pathophysiology and treatments. Further research is needed to elucidate the factors contributing to a reduction in the mortality rate for this patient population.

Objective: To determine if ultra-early (<24 h) venous thromboembolism (VTE) prophylaxis was associated with hematoma growth in spontaneous intracerebral hemorrhage (ICH). Background: Patients with ICH have a high risk of VTE. Pharmacological prophylaxis such as unfractionated heparin (UFH) have been demonstrated to reduce VTE. However, published datasets exclude patients with recent ICH out of concern for hematoma enlargement. American Heart/Stroke Association guidelines recommend UFH 1-4 days after hematoma stabilization while the European Stroke Organization has no recommendations on when to begin UFH. Our institutional practice is to obtain stability CT scans at 6 to 24 h and to begin UFH following documented clinical and radiologic stability. We examined the impact of this practice on hematoma expansion. Methods: We performed a retrospective cohort analysis of consecutive ICH patients treated at a single tertiary academic referral center in the US. Demographic and clinical characteristics were abstracted. ICH volume was measured via 3D volumetrics for a CT head done on admission, follow-up stability, and prior to discharge. The primary outcome was analyzed as >= 3 mL hematoma enlargement. Secondary outcomes include hematoma expansion of >= 6mL and >= 33%, length of stay (LOS), discharge disposition and mortality. Results: A total of 163 ICH patients were analyzed. There were 58 (35.6%) patients in the ultra-early UFH group and UFH was initiated on average at 13.8 h from initial scan. There were 105 (64.6%) patients in the standard group who initiated UFH at an average of 46.6 h. The primary outcome of hematoma enlargement >= 3 mL was observed in 2/58(3.4%) patients with ultra-early initiation of UFH and in 7/105(6.7%) in the standard group (p=0.49). Secondary outcomes were not significant including hematoma expansion in the ultra-early group >= 6 mL 3/58 (5.2%) and >= 33% 7/58 (12.1%) (p=0.91, 0.61, respectively) as well as mortality or LOS. Conclusion: Venous thromboembolism prophylaxis started ultra-early (<= 24 h) after ICH was not associated with hematoma expansion.

Background: Data suggest that elderly patients have less favorable outcomes after ischemic stroke. Objective: To study the outcomes after intravenous tissue plasminogen activator (tPA) administration in elderly patients with acute ischemic stroke. Methods: Cross-sectional study using prospective collected patient data maintained via our "tele-stroke" network, which provides acute care in 29 community hospitals within our region from 2013-2015. Exposure of interest was age divided into >80 years (octogenarian) or younger. Outcomes of interest were rate of intravenous tPA administration, hemorrhagic transformation (ICH), in-hospital neurological deterioration, and poor outcome defined as a composite of hospital discharge to long-term care facility or death. Results: Mean age 67 +/- 16 years, 57 % (743/1317) were women, and median (Md) NIHSS was 4 (Interquartile Range [IQR] 8). The rate of tPA was 20 % (267/1317). Compared to reported rates of tPA administration in the nation, our tPA rate exceeded the one from the literature (20 % v 3%, z = 2.83, SE = 0.04, p = .005). There were no differences in ICH or neurological deterioration. The octogenarian group had a higher proportion of poor-outcome (61 % vs. 23 %, p < 0.001) than the younger group but similar in-hospital case-fatality (25 % v 14 %, p = 0.09). Predictors of poor-outcome were age >80 (OR 4.9; CI, 2.0-12, p < .001) and alpha-NIHSS>9. (OR 8.7; CI, 3.5-20, p < .001). Conclusion: Our data suggest that in our "tele-stroke" network, rates of tPA administration are higher than those reported in the literature and that this rate was not different in octogenarians compared to younger patients. Octogenarians were not at risk for ICH or neurological deterioration after tPA administration. However, octogenarians had a higher risk of poor outcome.

INTRODUCTION:Acute ischemic stroke (AIS) is the fourth leading cause of death in the US. Numerous studies have demonstrated the use of comprehensive stroke units and neurological intensive care units (NICU) in improving outcomes after stroke. We hypothesized that an expanded neurocritical care (NCC) service would decrease resource utilization in patients with LHI.METHODS:Retrospective data from consecutive admissions of large hemispheric infarction (LHI) patients requiring mechanical ventilation were acquired from the hospital medical records. Between 2011-2013, there were 187 consecutive patients admitted to the Jefferson Hospital for Neuroscience (Philadelphia, USA) with AIS and acute respiratory failure. Our intention was to determine the number of tracheostomies done over time. The primary outcome measure was the number of tracheostomies over time. Secondary outcomes were, ventilator-free days (Vfd), total hospital charges, intensive care unit length of stay (ICU-LOS), and total hospital length of stay (hospital-LOS), including ICU LOS. Hospital charges were log-transformed to meet assumptions of normality and homoscedasticity of residual variance terms. Generalized Linear Models were used and ORs and 95% CIs calculated. The significance level was set at α = 0.05.RESULTS:Of the 73 patients included in this analysis, 33% required a tracheostomy. There was a decrease in the number of tracheostomies undertaken since 2011. (OR 0.8; 95% CI 0.6-0.9: p=0.02).Lower Vfd were seen in tracheostomized patients (OR 0.11; 95%CI 0.1-0.26: p<0.0001). The log-hospital charges decreased over time but not significantly (OR 0.9; 95%CI 0.78-1.07: p=0.2) and (OR 0.99; 95%CI 0.85-1.16: p=0.8) from 2012 to 2013 respectively.The ICU-LOS at 23 days vs 10 days (p=0.01) and hospital-LOS at 33 days vs 11 days (p=0.008) were higher in tracheostomized patients.CONCLUSION:The data suggest that in LHI-patients requiring mechanical ventilation, a dedicated NCC service reduces the overall need for tracheostomy, increases Vfd, and decreases ICU and hospital-LOS.

Thank you very much for downloading neurotrauma and critical care of the spine. Maybe you have knowledge that, people have look hundreds times for their chosen novels like this neurotrauma and critical care of the spine, but end up in malicious downloads. Rather than reading a good book with a cup of tea in the afternoon, instead they juggled with some malicious virus inside their desktop computer. neurotrauma and critical care of the spine is available in our digital library an online access to it is set as public so you can get it instantly. Our digital library hosts in multiple locations, allowing you to get the most less latency time to download any of our books like this one. Kindly say, the neurotrauma and critical care of the spine is universally compatible with any devices to read.

Deep venous thrombosis (DVT) of the lower extremities is a common cause of morbidity and mortality among neurologically injured patients. The data on incidence and prevalence rates of DVT among high risk neurologic populations is scarce. The available literature focuses largely on patients admitted to a medical or surgical intensive care unit with very limited information on patients in neuro-intensive care units (NICU). The aim of the present study is to assess the incidence and prevalence of deep vein thrombosis among patients admitted with acute neurologic injury.

Background and Purpose: Many authors have reported the effectiveness of telemedicine in healthcare and medical education. There has been limited research addressing its use with nursing education. We sought to examine the impact and effectiveness of education in the Neuro-ICUs of two Comprehensive Stroke Centers. Methods: Guided by a knowledge needs assessment completed by critical care nurses at an academic medical facility in Louisiana, a topic of Intracranial Pressure Crisis in Hemorrhagic Stroke was chosen for an educational course conducted via telepresence. The Neuro-ICU nurses from an academic medical facility in Pennsylvania developed the course content. The course consisted of a 10 questions pre-test, a 30 minute didactic session, an interactive case scenario, and a 10 question post-test. The didactic session reviewed basic neuro pathophysiology and interventions to treat increased intracranial pressure. The interactive case scenario used 3G simulation to allow real time implementation of interventions to treat increased intracranial pressure in the setting of hemorrhagic stroke. The session concluded with a debriefing and post- test. The entire session was completed using telepresence. 15 ICU nurses participated in the course. Participants subsequently completed an anonymous survey. Results of the pre- and post-test were compared via a paired-samples t-test. Results: The mean pre-test score was 7.5/10 (sd 2.378). The mean post-test score was 9.57/10 (sd 1.089). This represents a significant improvement (t=3.64, p= 0.003). All course participants completed the anonymous survey. 89% of participants felt that tele-education was a valuable learning tool. 100% agree that they will change their current bedside practice based on the information provided during the tele-education session. Conclusion: These results demonstrate improved knowledge in the management of elevated intracranial pressure. A tele-presence platform may be an effective means of delivering of educational content to neuro ICU nurses separated by geographic barriers.

Learning Objectives: Global hypoxic-ischemic (GHI) events are a common cause of morbidity and mortality. There is a paucity of literature on the cerebrovascular response following GHI; thus, no evidence-based, goal directed therapies exist. Understanding the basic response is necessary to inform trials aimed at therapeutic options. Methods: This is a single-center, prospective, observational study of children (0–18 years) admitted to our PICU following a GHI. Those with prior pathology that would alter cerebral blood flow velocity (CBFV) were excluded. Patients underwent daily transcranial Doppler ultrasonography for 8 days, during which the bilateral middle cerebral arteries (MCA) were insonated and cerebral autoregulation was tested using the transient hyperemic response ratio. 3 month follow-up was performed using the Glasgow Outcome Score– Pediatric Extended Version (PE-GOS). Results: 18 patients met inclusion criteria, 3 declined for a sample size of 15. Median age was 3 years (0.33, 9.5), 67% male. GHI etiology included: drowning+cardiac arrest–2, asphyxia without arrest–1, asphyxia+cardiac arrest–4, and cardiopulmonary arrest–8. Median GCS 3T (3,3), initial pH 6.88 (6.66,6.99), and initial lactate 5.9 (3.9,11.3). Mean MCA CBFV was near normal for critically ill children on post-injury day (PID) 1. Hyperemia occurred on PID 2–3 with return to normal by day 8 in survivors (n=7). Non-survivors (n=8, 53%) did not follow this pattern as their CBFV was abnormal until the end of the study period. 91% of those with a bad outcome (n = 11, PE-GOS 5–8) compared to 50% in the good outcome group (n=4, PEGOS 1–4) had at least one episode of extreme CBFV (+/2 standard deviations), p=0.1538 (Fisher’s exact). Autoregulation was not reliably intact in any child. Median PE-GOS score was 8 (6,8). Conclusions: Following a GHI, survivors had a hyperemic response on PID 2–3 with normalization thereafter. Non-survivors and those with poor neurologic outcome had persistently abnormal CBFV. Abnormal cerebral autoregulation was noted in all cases. These findings may aid prognostication and encourage the use of neuroprotective measures.

Objective: To study outcomes after intravenous tissue plasminogen activator (IV-tPA) administration in octogenarians with acute ischemic stroke. Background: Data suggest octogenarians have less favorable post-IV-tPA-administration outcomes than younger patients. Methods: Cross-sectional study analyzed 2013-2015 patient data from the Thomas Jefferson University Hospital Telemedicine Stroke Network. Primary outcome was poor outcome (long-term care or death) at hospital discharge. Secondary outcome was hemorrhagic transformation. We compared the results in octogenarians (patients 80-89 years of age) versus younger patients. We used National Institutes of Health Stroke Scale (NIHSS) admission (α) and discharge (δ)NIHSS scores as surrogates for neurological deterioration and calculated the median difference (Δ-NIHSS) using the Wilcoxon-Signed-Rank matched test for pairs. Higher NIHSS scores represented more severe symptoms. We used logistic regression to determine predictors of poor outcome. Results: The study involved 197 patients (mean age, 69±16 years), including 52 octogenarians and 104 women. Median αNIHSS was 9 (Interquartile Range [IQR] 14) and median δNIHSS 6 (IQR 15). The IV-tPA-administration rate was similar among groups at 50[percnt]. The octogenarian group had a higher median αNIHSS (16, IQR 16 vs. 8, IQR 11, p≤0.01), more women (69[percnt] vs. 45[percnt], p.003), and a higher poor-outcome rate (61[percnt] vs. 23[percnt], p≤0.0001) than the younger group, but no in-hospital mortality (25[percnt] vs. 14[percnt], p=0.09). Younger patients had a higher median Δ-NIHSS than octogenarians (5 vs. 0, p.0.001). Adjusting for age, sex, IV-tPA, year, and physician, poor outcome predictors were octogenarian (OR 4.1; CI, 1.6-10.9, p.0.003) and αNIHSS>9 (OR 8.7; CI, 3.7-22.7, p<0.0001). We observed an interaction with poor outcome and IV-tPA for octogenarians (OR 1.9; CI, 1.2-3.1, p=0.007) only. All groups had similar cumulative hemorrhagic-conversion rates (3[percnt]). Conclusions: Older patients had a higher risk of poor outcome at hospital discharge and this effect was independent of hemorrhagic transformation or in-hospital neurological deterioration.

Muhktar, Umer; Athar, Muhammad; Boorman, David; Rincon, Fred; Vibbert, Matthew; Shah, Syed; Urtecho, Jacqueline; Jallo, Jack

Copyright © 2016 by the Society of Critical Care Medicine and Wolters Kluwer Health, Inc. All Rights Reserved.