ABEM Neurocritical Care cheat sheet

Acute ischemic stroke within 4.5 h: IV alteplase 0.9 mg/kg (max 90 mg), 10% as bolus and remainder over 60 min; tenecteplase 0.25 mg/kg (max 25 mg) is a single-bolus alternative in eligible patients.

Before IV thrombolysis, lower BP to <185/110 mmHg; after thrombolysis, keep BP <180/105 mmHg for 24 h.

Mechanical thrombectomy is indicated for anterior circulation large-vessel occlusion within 6 h of last known well; selected patients with salvageable tissue may benefit up to 24 h.

For ischemic stroke without reperfusion therapy, permissive hypertension is usual; treat BP only if >220/120 mmHg or if end-organ injury, aortic dissection, or pre-eclampsia is present.

Aspirin 160-325 mg should be started within 24-48 h of ischemic stroke unless thrombolysis was given, in which case delay antiplatelet therapy for 24 h.

Spontaneous ICH: for mild-to-moderate presentation, begin BP lowering when systolic BP >150 mmHg and target systolic 130-150 mmHg; avoid systolic <130 mmHg unless a specific indication exists.

Aneurysmal SAH: start nimodipine 60 mg orally every 4 h for 21 days; maintain euvolemia and secure the aneurysm early to reduce rebleeding.

Malignant MCA infarction: decompressive hemicraniectomy within 48 h reduces mortality in selected patients ≤60 years with large infarct and early deterioration; osmotic therapy is temporizing.

CPP = MAP - ICP; in TBI, target CPP 60-70 mmHg while treating ICP >22 mmHg.

BTF threshold: treat ICP >22 mmHg; use tiered therapy with sedation/analgesia, CSF drainage, osmotic agents, and short-term hyperventilation for herniation.

Hypertonic saline 3% 250 mL bolus or mannitol 0.25-1 g/kg can lower ICP; monitor sodium and osmolality.

Avoid hypotension after TBI: keep SBP ≥100 mmHg for ages 50-69 and ≥110 mmHg for ages 15-49 or >70.

Severe TBI: give seizure prophylaxis for 7 days; prophylaxis does not prevent late posttraumatic epilepsy.

Do not use glucocorticoids for TBI; high-dose methylprednisolone is not recommended for acute spinal cord injury.

Acute spinal cord injury: maintain spinal immobilization until cleared; MAP target 85-90 mmHg for 5-7 days may be used in selected patients.

Cervical spine clearance in obtunded patients often uses CT plus clinical assessment; MRI is used when ligamentous injury is suspected or examination is unreliable.

Status epilepticus is continuous seizure activity ≥5 min or ≥2 seizures without full recovery between them.

First-line: IV lorazepam 0.1 mg/kg (max 4 mg) or diazepam; if no IV access, IM midazolam 10 mg.

Second-line after benzodiazepines: fosphenytoin 20 phenytoin equivalents/kg, valproate 40 mg/kg, or levetiracetam 60 mg/kg.

Refractory SE: continuous IV midazolam, propofol, or pentobarbital with EEG monitoring; titrate to seizure suppression or burst suppression.

Nonconvulsive SE requires EEG; consider it in unexplained coma, subtle twitching, or after convulsive SE without recovery.

Myasthenic crisis: monitor vital capacity and negative inspiratory force; treat with IVIG or plasma exchange and avoid aminoglycosides and magnesium when possible.

Guillain-Barré syndrome: IVIG or plasma exchange shortens recovery; glucocorticoids alone do not improve outcomes.

Post-cardiac arrest: routine seizure prophylaxis is not recommended; treat electrographic or clinical seizures when identified.

ICP monitoring: GCS ≤8 with abnormal CT, or normal CT plus ≥2 of age >40, motor posturing, or SBP <90 mmHg.

Lundberg A waves are plateau waves of ICP lasting 5-20 min and indicate impaired intracranial compliance.

Brain tissue oxygen threshold: PbtO2 <15-20 mmHg indicates risk; normal is approximately 25-35 mmHg.

Transcranial Doppler vasospasm: MCA mean velocity >120 cm/s with Lindegaard ratio >3 suggests vasospasm.

EVD zero reference is at the tragus or midbrain; keep drainage height ordered and avoid rapid over-drainage.

Burst suppression on EEG is typically 10-20 seconds of suppression between bursts; used to titrate refractory SE therapy.

CT ASPECTS ≤6 predicts larger infarct core and worse outcome in MCA stroke; CTA identifies large-vessel occlusion.

For warfarin-associated ICH, give vitamin K plus prothrombin complex concentrate; for dabigatran, idarucizumab reverses anticoagulation.

Lung-protective ventilation: tidal volume 6 mL/kg predicted body weight; keep plateau pressure ≤30 cmH2O and PaCO2 35-45 mmHg unless hyperventilation is indicated.

Target glucose 140-180 mg/dL in neurocritical care; avoid intensive control to <110 mg/dL because of hypoglycemia risk.

Fever after brain injury increases metabolic demand; treat temperatures >38°C with antipyretics and surface cooling.

Hyponatremia correction should generally be ≤8-10 mmol/L per 24 h to reduce osmotic demyelination risk.

After cardiac arrest, neuroprognostication should be multimodal and delayed ≥72 h; examine pupillary and corneal reflexes, SSEP N20, EEG, and neuron-specific enolase.

Brain death requires irreversible coma, absent brainstem reflexes, and apnea in the absence of confounders; ancillary testing is used when apnea testing cannot be completed.

VTE prophylaxis with LMWH or unfractionated heparin is started after hemostasis is achieved; mechanical prophylaxis is used when pharmacologic prophylaxis is contraindicated.

Early enteral nutrition within 24-48 h is preferred in critically ill neuro patients who cannot eat; monitor for aspiration and ileus.