Cluster breathing associated with bihemispheric infarction and sparing of the brainstem

Chameleons, red herrings, and false localizing signs in neurocritical care

False localizing signs (FLS) and other misleading neurological signs have long been an intractable aspect of neurocritical care. Because they suggest an incorrect location or etiology of the pathological lesion, they have often led to misdiagnosis and mismanagement of the patient. Here, we reviewed the existing literature to provide an updated, comprehensive descriptive review of these difficult to diagnose signs in neurocritical care. For each sign presented, we discuss the non-false localizing presentation of symptoms, the common FLS or misleading presentation, etiology/pathogenesis of the sign, and diagnosis, as well as any other clinically relevant considerations. Within cranial neuropathies, we cover cranial nerves III, IV, V, VI, VII, VIII, as well as multiple cranial nerve involvement of IX, X, and XII. FLS ophthalmologic symptoms indicate diagnostically challenging neurological deficits, and here we discuss downbeat nystagmus, ping-pong-gaze, one-and-a-half syndrome, and wall-eyed bilateral nuclear ophthalmoplegia (WEBINO). Cranial herniation syndromes are integral to any discussion of FLS and here we cover Kernohan's notch phenomenon, pseudo-Dandy Walker malformation, and uncal herniation. FLS in the spinal cord have also been relatively well documented, but in addition to compressive lesions, we also discuss newer findings in radiculopathy and disc herniation. Finally, pulmonary syndromes may sometimes be overlooked in discussions of neurological signs but are critically important to recognize and manage in neurocritical care, and here we discuss Cheyne-Stokes respiration, cluster breathing, central neurogenic hyperventilation, ataxic breathing, Ondine's curse, and hypercapnia. Though some of these signs may be rare, the framework for diagnosing and treating them must continue to evolve with our growing understanding of their etiology and varied presentations.

Comparison Between M-Mode Ultrasonography and Fluoroscopy for Diaphragm Excursion Measurement in Patients With Acquired Brain Injury

OBJECTIVES

Patients with acquired brain injury show decreased pulmonary function and diaphragm excursion (DE), which can affect functional outcomes. This study aimed to compare ultrasonography (US) and fluoroscopy for DE assessment and to determine how the relationship between pulmonary function test results and DE differs according to the paralytic condition.

METHODS

From September 2017 to April 2018, we prospectively enrolled patients with acquired brain injury. The patients underwent a pulmonary function test, including the functional vital capacity, forced expiratory volume at 1 second, forced expiratory volume at 1 second-to-functional vital capacity ratio, peak cough flow, and respiratory muscle strength such as the maximal inspiratory pressure and maximal expiratory pressure. Diaphragm excursion was measured with M-mode US and fluoroscopy on admission. A partial correlation analysis was used to assess the correlation between US and fluoroscopy for DE assessment.

RESULTS

During the study period, 50 patients with acquired brain injury were enrolled. After adjusting for age, sex, height, and weight, the correlation coefficients between US and fluoroscopy were 0.744 for the right side (P < .001) and 0.631 for the left side (P < .001). In a subgroup analysis for patients with hemiplegia, the correlation coefficients were 0.507 for the paretic side (P = .007) and 0.677 for the nonparetic side (P < .001). Diaphragm excursion in the nonparetic side was significantly correlated with the maximal inspiratory pressure, maximal expiratory pressure, and peak cough flow (P < .05).

CONCLUSIONS

M-mode US can be an alternative method for DE measurement in patients with impaired locomotion function after acquired brain injury. Preserved function of the nonparetic side might affect pulmonary function after brain injury, which suggests the importance of prestroke respiratory function.

Exam 1 Questions

Which of the following is the most common form of incomplete spinal cord injury?A.

Central cord syndrome

B.

Cauda equina syndrome

C.

Anterior spinal cord syndrome

D.

Posterior spinal cord syndrome

E.

Brown-Sequard lesion

A 64-year-old male with a history of chronic alcohol abuse and congestive heart failure is currently recovering from excision of a large right shoulder lesion suspicious for melanoma. Postoperatively, he is experiencing bleeding and oozing from his surgical site that has persisted despite suture repair and direct pressure for an extended period of time. His labs are drawn, and are as follows: platelets 141 × 10³/mL, INR 1.2, fibrinogen 90 mg/dL. Which of the following blood products should be administered next?A.

Fresh frozen plasma

B.

Cryoprecipitate

C.

Prothrombin complex concentrate

D.

Recombinant activated factor VII

E.

Aminocaproic acid

A 75-year-old, 90 kg male with a history of peripheral vascular disease, coronary artery disease, and epilepsy following a recent cerebral infarction presents to the emergency department after having three witnessed seizures at home. He was intubated at the scene by the paramedics, and received 8 mg of intravenous lorazepam and 1 g of phenytoin. While you are evaluating him, he has another generalized tonic-clonic seizure, and the nurse asks if you would like to initiate a continuous propofol infusion. His blood pressure is 94/42 mmHg, and he is having numerous premature ventricular contractions (PVCs) on the electrocardiographic monitor. He has no history of platelet or liver dysfunction. Which of the following should be performed next?A.

Complete the phenytoin load to attain 20 mg/kg, then start propofol infusion

B.

Complete the phenytoin load to attain 20 mg/kg only

C.

Administer valproate, 30 mg/kg over 10 min, as well as midazolam 0.2 mg/kg

D.

Start immediate midazolam infusion at 2 mg/kg/h

E.

Give a 1 L normal saline bolus, and start a norepinephrine infusion to normalize blood pressure

A 38-year-old male is brought to the emergency department after a motor vehicle accident. He is found to have significant ecchymoses on his chest and face, with multiple apparent rib fractures. He is in mild respiratory distress, with an oxygen saturation of 89% on room air, and hypotensive, with a systolic blood pressure of 88 mmHg. He has absent breath sounds on the right side. There is currently a delay in obtain a bedside portable chest x-ray. Which of the following should be performed next?A.

28-French chest tube placement

B.

16-French chest tube placement

C.

Obtain computed tomography (CT) of the chest

D.

Administer 30 cc/kg crystalloid

E.

Obtain urgent cardiothoracic surgery consult

Stress ulcer prophylaxis is often undertaken to prevent clinically important upper gastrointestinal (GI) bleeding. Which of the following factors puts patients at highest risk for such bleeding episodes?A.

Respiratory failure

B.

History of alcohol abuse

C.

NPO status

D.

Diverticulitis

E.

All of the above

In an intact heart, the Frank-Starling mechanism describes contractility increases in responses to:A.

Decreased preload

B.

Increased afterload

C.

Decreased left ventricular end-diastolic pressure

D.

Increased left ventricular end-diastolic volume

E.

Increased pulmonary vascular resistance

A 68-year-old female with a history of hyperlipidemia, hypothyroidism, and gastric cancer on total parenteral nutrition is currently in the ICU following a small traumatic subdural hemorrhage. On hospital day 5, the patient begins to spike fevers that persist despite broad spectrum antibiotic coverage with vancomycin and piperacillin-tazobactam. She is otherwise hemodynamically stable. The lab calls you to notify you that multiple sets of blood cultures display budding yeast forms and pseudohyphae. Which of the following should be administered next?A.

Fluconazole

B.

Posaconazole

C.

Anidulafungin

D.

Caspofungin

E.

Amphotericin B

A 56-year-old male with a past medical history of hypertension, hyperlipidemia, and morbid obesity is currently intubated in the ICU following a left middle cerebral artery infarct. The respiratory therapist alerts you the fact that the patient has become markedly dysynchronous with the ventilator, including breath holding episodes, breath stacking, and resisting ventilator-delivered breaths. A variety of pressure- and volume-regulated ventilator modes have been attempted without improvement, as well as boluses of both fentanyl and midazolam. The most recent arterial blood gas is as follows: pH 7.19, PaCO₂ 78 mmHg, PaO₂ 61 mmHg. The patient is now hypotensive to 91/66 mmHg with sinus tachycardia at 117 beats/min. A recent bedside chest x-ray shows no consolidation or pneumothorax. Which of the following should be performed next?A.

Prone the patient

B.

Administer nitric oxide at 10 parts per million

C.

Administer 10 mg of cisatracurium

D.

Administer a mixture of 60% helium/40% oxygen

E.

Administer a continuous infusion of phenobarbital

Compared to lactulose for the treatment of hepatic encephalopathy, polyethylene glycol (PEG) has been shown to:A.

Decrease in-hospital mortality

B.

More rapidly improve symptoms

C.

Increase the rate of gastrointestinal complications

D.

Increase the incidence of major electrolyte abnormalities

E.

None of the above

Which of the following neurologic insults is the least likely to cause central (non-infectious) fever in the ICU?A.

Intracranial neoplasm

B.

Intraventricular hemorrhage

C.

Normal pressure hydrocephalus

D.

Subarachnoid hemorrhage

E.

Traumatic brain injury

A 57-year-old male with a history of epilepsy and medication noncompliance is admitted to a small community hospital after a brief tonic-clonic seizure. A non-contrast head CT on admission is normal. On the second hospital day, the patient begins to complain of severe substernal chest pressure, and an urgent bedside EKG shows evidence of an acute inferior myocardial infarction (MI). The nearest percutaneous coronary intervention (PCI) capable center is approximately 150 min away by the fastest transport method available. Which of the following is the most appropriate next step in this patient’s care?A.

Arrange for transport to the closest PCI center with anticipated balloon time within 30 min of arrival

B.

Prepare to administer fibrinolytic therapy

C.

Consult cardiothoracic surgery for possible coronary artery bypass grafting (CABG)

D.

Place the patient on a continuous nitroglycerine infusion and administer aspirin, clopidogrel, and heparin

E.

Await serum cardiac biomarkers and repeat EKG in 1 h

A 62-year-old male with unknown past medical history who recently immigrated from El Salvador is currently in the stroke unit after suffering from an acute left middle cerebral artery infarction. The patient is aphasic; his wife states that he been in his usual state of health lately, and denies any recent weakness, dizziness, chest pain, cough, shortness of breath, or fevers. On reviewing this patient’s belongings, the nurse discovers a bottle of isoniazid, as well as paperwork demonstrating a positive quantiferon gold test performed at a local clinic approximately 3 weeks ago. He does not appear to be on any other medications. A bedside portable chest x-ray is performed, which preliminarily appears normal. Which of the following should be performed next?A.

Move the patient to a negative pressure isolation room, continue isoniazid

B.

Isolate the patient, continue isoniazid, add rifampin

C.

Isolate the patient, continue isoniazid, add rifampin and pyrazinamide

D.

Isolate the patient, continue isoniazid, add rifampin, pyrazinamide and ethambutol

E.

None of the above

A 56-year-old, 70 kg female patient in oliguric renal failure would be expected to have a daily urine output of:A.

No more than 50 mL

B.

No more than 400 mL

C.

No more than 800 mL

D.

Less than 70 mL/h

E.

Less than 35 mL/h

A 37-year-old female with a history of epilepsy is admitted to the ICU with status epilepticus. She required several doses of lorazepam in the emergency department in addition to fosphenytoin, intubation, and a continuous propofol infusion. There was concern for aspiration in the prehospital setting. Approximately 3 days after being admitted to the hospital, her respiratory status has worsened; she is increasingly hypoxic, and her chest x-ray demonstrates diffuse bilateral interstitial infiltrates. The patient is afebrile with minimal secretions. Her most recent arterial blood gas is as follows: pH 7.21, PaO₂ 107 mmHg, PCO₂ 55 mmHg, 100% FiO₂, and a positive end-expiratory pressure (PEEP) of 8 cm H₂O. According to the Berlin criteria, how would you categorize this patient’s acute respiratory distress syndrome (ARDS)?A.

Acute lung injury (ALI)

B.

Mild ARDS

C.

Moderate ARDS

D.

Severe ARDS

E.

None of the above

An 80-year-old male presents to the emergency department with multiple episodes of bright red blood per rectum. He is on aspirin and clopidogrel for a history of coronary artery disease and a previous transient ischemic attack. He underwent aortic graft surgery for repair of an abdominal aortic aneurysm 2 years ago. A complete blood count and coagulation profile are all within normal limits. His vital signs are as follows: blood pressure 102/58 mmHg, heart rate 98 beats/min, respiratory rate 18 breaths/min, oxygen saturation 98% on room air, and temperature 98.3 °F. Which of the following is the next best step in the care of this patient?A.

Transfuse platelets, fresh frozen plasma, and recombinant factor VIIa

B.

Consult gastroenterology for emergent upper endoscopy

C.

Consult gastroenterology for emergent colonoscopy

D.

CT angiogram of the abdomen and pelvis

E.

Expectant management with fluids and blood transfusions

A thrombus in which of the following veins would not be considered a deep vein thrombosis (DVT)?A.

Popliteal vein

B.

Soleal vein

C.

Femoral vein

D.

Gastrocnemius vein

E.

Greater saphenous vein

After partial resection of the pituitary stalk, secretion of which of the following hormones will be most affected?A.

Oxytocin

B.

Adrenocorticotrophic hormone

C.

Melanocyte-stimulating hormone

D.

Thyroid-stimulating hormone

E.

All will be equally affected

A 58-year-old female with a history of hypertension, rheumatoid arthritis, metastatic ovarian cancer, and bilateral deep venous thrombosis status post recent inferior vena cava filter placement presents to the emergency department with right flank pain. She states the pain began approximately 1 h ago when bending down to pick something off the floor, and that it is constant and severe in nature. She denies dysuria or hematuria. Her vital signs are as follows: blood pressure 108/62 mmHg, heart rate 121 beats/min, respiratory rate 20 breaths/min, oxygen saturation 99% on room air, and temperature 99.6 °F. A CT scan of the abdomen is obtained (see Image 1). Which of the following is the next best step in this patient’s management?A.

Administer vancomycin and cefepime, and draw two sets of blood cultures

B.

Urgent vascular surgery consult

C.

Immediately place the patient on her left side

D.

Rapid sequence intubation with mechanical ventilation

E.

Perform bedside diagnostic peritoneal lavage

Sleep among opioid users

Use of opioids in the treatment of both acute and chronic pain has increased significantly in the past 2 decades. Recent literature suggests that chronic opioid use is related to sleep-related breathing disorders, particularly central sleep apnea of both the periodic and nonperiodic breathing pattern. The clinical significance, pathogenesis, and treatment options of these sleep-related breathing disorders are not well understood. This article summarizes the current literature on the effects of both acute and chronic opioid use on sleep, sleep-disordered breathing, and the current evidence on various treatment options for breathing disorders related to chronic opioid use.

Reversal of sleep-disordered breathing with opioid withdrawal

Obstructive sleep apnea, central sleep apnea, sleep related hypoventilation, Biot's or ataxic breathing, and cluster breathing are some of the commonly described sleep disorders in patients who are on long-term opioids. Continuous positive airway pressure that is commonly used to treat obstructive sleep apnea may not be effective in treating sleep-disordered breathing in long-term opioid users, and an adaptive servoventilator (ASV) may be needed. We present a 30-year-old woman with excessive daytime sleepiness and sleep-disordered breathing for the past 4 years. Medical history was complicated by chronic osteomyelitis, periorbital abscess, and chronic facial pain requiring methadone for pain control for the last 4 years. In this case, ASV, though effective, was not tolerable due to chronic facial pain, and successful withdrawal of methadone at our pain rehabilitation center resolved the sleep-disordered breathing and improved daytime sleepiness. This is to our knowledge the first case report of resolution of sleep-disordered breathing and improvement in daytime sleepiness after withdrawal of long-term opioid use.