Time-critical neurological emergencies in the ICU: the status epilepticus ladder, acute ischaemic stroke and thrombolysis, intracerebral and subarachnoid haemorrhage, a structured approach to coma, CNS infections, and neuromuscular respiratory failure (GBS and myasthenic crisis).
6 topics
- 01
Status epilepticus ladder
Seizure > 5 min or recurrent without recovery: adequate-dose benzodiazepine by 5-10 min, a second-line agent (levetiracetam, valproate or phenytoin, all equivalent in ESETT) by 20-30 min, then anaesthetic infusion with EEG for refractory status.
6 stepsAlgorithm4 dosesNew - 02
Acute ischaemic stroke and thrombolysis
Time is brain: non-contrast CT (± CT angiography), glucose check, then IV thrombolysis (tenecteplase 0.25 mg/kg or alteplase 0.9 mg/kg) within 4.5 h if eligible, and thrombectomy for large vessel occlusion up to 24 h. Keep BP < 185/110 before and < 180/105 for 24 h after lysis.
6 stepsAlgorithm2 dosesNew - 03
Intracerebral and subarachnoid haemorrhage
ICH: lower SBP to ~140 mmHg (avoid < 130) within 2 h, reverse anticoagulants immediately, treat hydrocephalus, and avoid prophylactic antiseizure drugs. Aneurysmal SAH: nimodipine, early aneurysm securing, euvolaemia, and vigilance for rebleeding, hydrocephalus and delayed cerebral ischaemia.
7 stepsAlgorithm1 dosesNew - 04
Approach to coma (GCS and FOUR score)
Stabilise ABC and glucose first, then look for the pattern: structural (focal signs, asymmetric pupils) vs metabolic/toxic (symmetric, reactive pupils). Record GCS components and the FOUR score in intubated patients; image early and treat reversible causes.
5 stepsAlgorithmNew - 05
Meningitis and encephalitis
Suspected bacterial meningitis: blood cultures, dexamethasone and antibiotics within 1 hour; do not delay for CT or LP. Add aciclovir for encephalitis. In India think also of TB meningitis, Japanese encephalitis, scrub typhus, cerebral malaria and cryptococcus.
6 stepsAlgorithm3 dosesNew - 06
Guillain-Barré syndrome and myasthenic crisis
Neuromuscular respiratory failure creeps up silently: monitor vital capacity and NIF, intubate electively when VC < 20 mL/kg or NIF weaker than −30 cmH2O, or with bulbar failure. Treat GBS with IVIg or plasma exchange; myasthenic crisis with IVIg or PLEX plus steroids.
6 stepsAlgorithm1 dosesNew
Drugs in this module
Doses written for this module's context. The same drug may read differently in another module.
Lorazepam
Benzodiazepine
Lorazepam
Benzodiazepine
- Indications
- First-line for status epilepticus.
- Adult dose
- 0.1 mg/kg IV (max 4 mg per dose) at 2 mg/min, repeat once after 5-10 min.
- Preparation (India)
- 2 mg/mL ampoules; needs refrigeration.
- Cautions
- Respiratory depression, hypotension; under-dosing is the commonest error.
Midazolam
Benzodiazepine
Midazolam
Benzodiazepine
- Indications
- First-line SE without IV access (IM/buccal); refractory SE infusion.
- Adult dose
- IM 10 mg (> 40 kg) or 5 mg (13-40 kg) once. Refractory SE: 0.2 mg/kg IV bolus, then 0.05-2 mg/kg/h titrated to seizure/EEG suppression.
- Preparation (India)
- 1 mg/mL and 5 mg/mL ampoules.
- Cautions
- Accumulates in renal failure and obesity; hypotension.
Levetiracetam
Antiseizure medication
Levetiracetam
Antiseizure medication
- Indications
- Second-line for established SE; seizure prophylaxis.
- Adult dose
- 60 mg/kg IV (max 4500 mg) over 10-15 min; maintenance 1-1.5 g every 12 h (reduce in renal impairment).
- Preparation (India)
- 500 mg/5 mL vials.
- Cautions
- Agitation; renally cleared (dose adjust in AKI/CRRT).
Sodium valproate
Antiseizure medication
Sodium valproate
Antiseizure medication
- Indications
- Second-line for established SE.
- Adult dose
- 40 mg/kg IV (max 3000 mg) over 10 min; maintenance 1-2 g/day in divided doses.
- Preparation (India)
- 100 mg/mL 5 mL vials.
- Cautions
- Avoid in liver disease, mitochondrial disorders, pregnancy if alternatives exist; hyperammonaemia; interacts with carbapenems (levels fall sharply).
Phenytoin
Antiseizure medication
Phenytoin
Antiseizure medication
- Indications
- Second-line for established SE.
- Adult dose
- 20 mg/kg IV at ≤ 50 mg/min (≤ 25 mg/min in elderly/cardiac) in 0.9% saline; maintenance 100 mg every 8 h guided by levels. Fosphenytoin 20 mg PE/kg at up to 150 mg PE/min where available.
- Preparation (India)
- 50 mg/mL ampoules; precipitates in dextrose.
- Cautions
- Hypotension, bradyarrhythmia (ECG monitoring), purple glove syndrome; many interactions.
Tenecteplase
Thrombolytic
Tenecteplase
Thrombolytic
- Indications
- Acute ischaemic stroke within 4.5 h (or selected later windows).
- Adult dose
- 0.25 mg/kg IV single bolus (max 25 mg).
- Preparation (India)
- Indian biosimilar tenecteplase 20 mg and 30 mg vials are available.
- Cautions
- Different dose from STEMI (do not use the cardiac weight-band dose). BP must be < 185/110.
Alteplase
Thrombolytic
Alteplase
Thrombolytic
- Indications
- Acute ischaemic stroke within 4.5 h.
- Adult dose
- 0.9 mg/kg (max 90 mg): 10% IV bolus over 1 min, remainder over 60 min.
- Cautions
- Angio-oedema (especially with ACE inhibitors), bleeding.
Nimodipine
Calcium channel blocker
Nimodipine
Calcium channel blocker
- Indications
- Aneurysmal SAH (improves outcome).
- Adult dose
- 60 mg orally/NG every 4 h for 21 days (30 mg every 2 h if hypotension).
- Cautions
- Hypotension: reduce dose and split rather than stop.
Ceftriaxone
Third-generation cephalosporin
Ceftriaxone
Third-generation cephalosporin
- Indications
- Empirical bacterial meningitis.
- Adult dose
- 2 g IV every 12 h (meningitic dose).
- Cautions
- Biliary sludge; calcium co-infusion in neonates.
Dexamethasone
Corticosteroid
Dexamethasone
Corticosteroid
- Indications
- Suspected bacterial meningitis (start with or before first antibiotic dose).
- Adult dose
- 10 mg IV every 6 h for 4 days; stop if not pneumococcal/Haemophilus or if non-bacterial.
- Cautions
- Hyperglycaemia; reduces vancomycin CSF penetration.
Aciclovir
Antiviral
Aciclovir
Antiviral
- Indications
- Suspected HSV/VZV encephalitis.
- Adult dose
- 10 mg/kg IV every 8 h for 14-21 days (adjust for renal function; use ideal body weight in obesity).
- Cautions
- Crystal nephropathy: hydrate, monitor creatinine.
Intravenous immunoglobulin (IVIg)
Immunomodulator
Intravenous immunoglobulin (IVIg)
Immunomodulator
- Indications
- GBS (unable to walk unaided); myasthenic crisis.
- Adult dose
- 0.4 g/kg/day for 5 days (total 2 g/kg).
- Preparation (India)
- 5 g and 10 g vials; very costly; check IgA deficiency if possible.
- Cautions
- Thrombosis, AKI (sucrose-containing products), aseptic meningitis, volume load.
Module references (13)
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