ABEM Neurocritical Care common mistakes
ABEM Neurocritical Care · Understand the traps and how to avoid them.
In acute ischemic stroke with a blood pressure of 188/112 mm Hg, orders rapid normalization to less than 140/90 or cancels reperfusion because the pressure is above a normal target.
This conflates chronic hypertension goals and intracerebral hemorrhage targets with the permissive thresholds used around reperfusion therapy.
What to do instead
Use the stroke protocol: lower below 185/110 before thrombolysis, maintain below 180/105 afterward, and use titratable agents such as labetalol or nicardipine with frequent rechecking rather than aiming for a normal reading.
In anticoagulation-associated intracerebral hemorrhage, orders vitamin K and fresh frozen plasma alone and delays specific reversal while waiting for repeat imaging.
The candidate relies on generic reversal and does not match the agent to the anticoagulant, so coagulopathy persists during the highest-risk period.
What to do instead
Reverse immediately by agent: four-factor prothrombin complex concentrate plus intravenous vitamin K for warfarin, idarucizumab for dabigatran, and andexanet alfa or prothrombin complex concentrate for factor Xa inhibitors according to local protocol.
In severe traumatic brain injury, starts prophylactic hyperventilation to a PaCO2 of 30 to 35 mm Hg for a high intracranial pressure number without signs of herniation and continues it for hours.
Routine hyperventilation reduces cerebral blood flow and can cause ischemia; the candidate treats the monitor value rather than the clinical syndrome.
What to do instead
Keep PaCO2 in the normal range unless there is acute herniation; if hyperventilation is used as a bridge, limit it to minutes, monitor for ischemia, and pair it with definitive intracranial pressure control.
In acute cervical spinal cord injury with hypotension and bradycardia, gives repeated large crystalloid boluses alone and labels the problem spinal shock without starting a vasopressor or treating bradycardia.
The candidate misses neurogenic shock from loss of sympathetic tone and risks pulmonary edema from fluid loading while mean arterial pressure remains inadequate.
What to do instead
Target mean arterial pressure of 85 to 90 mm Hg for about 5 to 7 days using cautious fluids plus norepinephrine, and treat symptomatic bradycardia with atropine or pacing as needed.
In convulsive status epilepticus, gives a single subtherapeutic benzodiazepine dose such as lorazepam 1 to 2 mg and waits for electroencephalography before repeating the benzodiazepine or loading a second-line antiseizure medication.
Underdosing and diagnostic delay allow ongoing seizure activity and increase the risk of refractory status epilepticus.
What to do instead
Give weight-based lorazepam 0.1 mg/kg up to 4 mg per dose, repeat once if seizures persist, and proceed promptly to a second-line load such as levetiracetam or fosphenytoin without waiting for electroencephalography.
In myasthenic crisis or Guillain-Barre syndrome, extubates because arterial blood gas values and oxygen saturation are normal, without serial vital capacity, maximal inspiratory pressure, or bulbar weakness assessment.
Neuromuscular respiratory failure can occur with preserved oxygenation and normal carbon dioxide until late; the candidate relies on insensitive markers.
What to do instead
Use serial respiratory measurements and clinical bulbar assessment; consider intubation when vital capacity falls below about 20 mL/kg, maximal inspiratory pressure is weaker than about -30 cm H2O, or secretion clearance is impaired.
Accepts an isolated intracranial pressure reading as accurate and titrates osmotic therapy without checking transducer zeroing and leveling, waveform quality, or correlation with the examination and cerebral perfusion pressure.
Artifact, transducer error, and positioning can produce a plausible but false number, and the candidate treats the display rather than the patient.
What to do instead
Verify zeroing at the appropriate reference point, inspect the waveform, confirm with repeat readings and imaging or examination, and interpret intracranial pressure alongside cerebral perfusion pressure and clinical trends before escalating therapy.
Rules out aneurysmal subarachnoid hemorrhage with a noncontrast head CT alone when the thunderclap headache started more than 6 hours earlier, and does not proceed to lumbar puncture or vascular imaging.
CT sensitivity for small subarachnoid hemorrhage declines with time, and the candidate applies the early-presentation rule to a delayed presentation.
What to do instead
Use pretest probability and timing: proceed to lumbar puncture for xanthochromia or to CT angiography according to local protocol when CT is negative after about 6 hours, especially in high-risk presentations.
In subarachnoid hemorrhage with hyponatremia, orders free-water restriction or rapid hypertonic saline without distinguishing SIADH from cerebral salt wasting, and corrects sodium faster than 8 to 10 mmol/L per day.
The candidate treats the sodium number without assessing volume status, risking hypovolemia and delayed cerebral ischemia or osmotic demyelination.
What to do instead
Assess volume status, urine output, and urine sodium; treat cerebral salt wasting with volume and sodium replacement and use restriction cautiously for SIADH; limit correction to about 8 to 10 mmol/L per day with frequent monitoring.
After cardiac arrest, withdraws life-sustaining treatment within 24 to 72 hours based on one poor finding such as absent pupillary reflexes or a malignant electroencephalogram while sedation or neuromuscular blockade may still be active, without a multimodal assessment.
Premature prognostication ignores confounders, temperature effects, and the low reliability of any single predictor, risking a self-fulfilling prophecy.
What to do instead
Wait at least 72 hours after rewarming, confirm that confounders are cleared, and combine serial examinations, pupillary and corneal reflexes, somatosensory evoked potentials, electroencephalography, biomarkers, and imaging before discussing withdrawal.