The Neuro Exam

Much attention has been paid to targeted temperature management (TTM) in post-cardiac arrest patients. The evidence for this practice continues to evolve, and previous episodes of Critical Matters have covered this topic. In this episode, Dr. Zanotti focuses on other aspects of Neurological Support in the ICU for post-cardiac arrest patients. He is joined by Dr. Edilberto Amorin, a neurologist with subspecialty training in critical care and epilepsy. He has expertise in neurological intensive care, telemedicine, and multimodal brain monitoring with EEG. Dr Amorin is an Assistant Professor of Neurology at UCSF Weill Institute for Neurosciences and directs the Epilepsy and Clinical Neurophysiology Service at the Zuckerberg San Francisco General Hospital. Additional resources: Critical Care Management of Patients After Cardiac Arrest: A Scientific Statement From the American Heart Association and Neurocritical Care Society. Circulation 2024: https://pubmed.ncbi.nlm.nih.gov/38040992/ Treating Rhythmic and Periodic EEG Patterns in Comatose Survivors of Cardiac Arrest.TELSTAR Investigators. N Engl J Med 2022: https://www.nejm.org/doi/full/10.1056/NEJMoa2115998 Improving Outcomes After Post-Cardiac Arrest Brain Injury: A Scientific Statement from the International Liaison Committee on Resuscitation. ILCOR 2024: https://www.ilcor.org/news/improving-outcomes-after-post-cardiac-arrest-brain-injury Books mentioned in this episode: As Real as it Gets: The Life of a Hospital at the Center of the AIDS Epidemic. By Carol Pogash: https://bit.ly/4d4xHZC C. Miller Fisher: Stroke in the 2oth Century. By LR Caplan: https://bit.ly/3XFw3Jw

Hypotension and shock are both recognized as complications post-cardiac surgery. Some patients may develop more severe shock refractory to fluids and catecholamines. This response is also known as today's podcast episode, topic: vasoplegia after cardiac surgery. For this discussion, Dr. Zanotti is joined by Dr. Iqbal Ratnani, an intensivist who practices at the DeBakey Heart & Vascular Center and the Center for Critical Care at Houston Methodist Hospital. Dr. Ratnani is an Associate Professor of Clinical Anesthesiology & Critical Care for the Department of Anesthesiology and Critical Care at Weill Cornell Medical College. In addition, Dr. Ratnani is the Director of Critical Care Education at the Center for Critical Care. Additional resources: Vasoplegia: A Review. Igbal Ratnani, et al. Methodist DeBakey Cardiovascular Journal 2023: https://pubmed.ncbi.nlm.nih.gov/37547893/ Vasoplegic Syndrome after Cardiopulmonary Bypass in Cardiovascular Surgery: Pathophysiology and Management in Critical Care. Zied Ltaief, et al. Journal of Clinical Medicine 2022: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC9658078/ Books mentioned in this episode: Marino’s The ICU Book. By Paul Marino: https://bit.ly/3XmWPGA Every Deep-Drawn Breath. By Wes Ely: https://bit.ly/4cODkeq In Shock: My Journey from Death to Recovery to Redemption. By Rana Awdish: https://bit.ly/3Z4mC7z

We pulled out another favorite out this week - Dr. Zanotti's deep-dive on tracheostomy emergencies. Tracheostomies are common in ICU patients. Every intensivist should be capable of recognizing and providing initial management to potentially serious complications associated with tracheostomies. Dr. Zanotti is joined by Drs. Laura Bontempo and Sara Manning, emergency physicians and educators with a special interest in the topic. Dr. Laura Bontempo is an associate professor of emergency medicine and serves as Assistant Director for Faculty Development & Resident Education in the Department of Emergency Medicine at the University of Maryland Medical School. Dr. Sara Manning is an Assistant Professor of Clinical Emergency Medicine, in the Department of Emergency Medicine at the Indiana University School of Medicine. Additional Resources: Tracheostomy Emergencies. LJ Bontempo and SL Manning. Emerg Med Clin N Am 2019: pubmed.ncbi.nlm.nih.gov/30454773/ Link to Onepager on Tracheostomy Emergencies: onepagericu.com/trach-emergencies Bleeding Tracheostomy. Kenji Inaba MD. Presented at Essentials of EM: www.facebook.com/EssentialsofEM/v…163679590380038/ Book Recommendations: Who Moved my Cheese?: An A-Mazing Way to Deal with Change in Your Work and in Your Life. By Spencer Johnson, et al: amzn.to/3pq0CkR Where the Red Fern Grows. By Wilson Rawls: amzn.to/3AawH6a

Today, we are revisiting one of our favorite episodes from last year - The Forgotten Patient. Dr. Zanotti focuses on the loved ones and families of critically ill patients and explores the topic through the lens of a cardiac arrest co-survivor. His guest is Kristin Flanary, a cognitive neuroscientist and social psychologist. Kristin is a co-survivor of cancer(twice) and a co-survivor of sudden cardiac arrest. She is also known for her social media alter ego – Lady Glaucomflecken. In 2022 Kristin co-founded Glaucomflecken LLC, where she works to advocate for caregivers and co-survivors of medical trauma and critical illness, community CPR and AED use, and sudden cardiac arrest survivorship. She has written about her experience as a co-survivor in medical journals and has received an EMS Cardiac Arrest Save Challenge Coin, the Citizen CPR Foundation’s '40 Under 40' award, and the American Heart Association’s Resuscitation Champion award. Additional Resources: The Quiet Place. K. Flanary. Journal of Cardiac Failure, 2021: www.onlinejcf.com/article/S1071-91…00403-6/fulltext Roger. K Flanary. CHEST. 2022: journal.chestnet.org/article/S0012-…029-6/fulltext Life after Cardiac Arrest: The importance of engaging with the “forgotten patient.” K Haywood & K Dainty. Resuscitation, 2018: www.resuscitationjournal.com/article/S0…0195-3/pdf Link to the Glaucomflecken’s website: glaucomflecken.com/ Books Mentioned in this Episode: In Shock. By Rana Awdish: bit.ly/441b0Cx

In this episode, Dr. Zanotti covers temporary pacing in the ICU. He is joined by Dr. Christopher Noel, a Critical Care Attending at Cooper University Healthcare, and an Assistant Professor of Medicine at Cooper Medical School of Rowan University. In addition, Dr. Noel is the Associate Program Director for the Critical Care Medicine Fellowship and the Director of the Medical Student Critical Care Clerkship. Additional resources: Temporary Epicardial Pacing After Cardiac Surgery. Cronin b, et al. Journal of Cardiothoracic and Vascular Anesthesia 2022: https://pubmed.ncbi.nlm.nih.gov/36180288/ Temporary epicardial pacing after cardiac surgery: a practical review. Part 1: General considerations in the management of epicardial pacing. M.C. Reade. Anesthesia 2007: https://pubmed.ncbi.nlm.nih.gov/17300304/ Temporary epicardial pacing after cardiac surgery: a practical review. Part 2: Selection of epicardial pacing modes and troubleshooting. M.C. Reade. Anesthesia 2007: https://pubmed.ncbi.nlm.nih.gov/17381573/ Medtronic Educational Resources on Temporary Pacemakers: https://www.medtronic.com/us-en/healthcare-professionals/products/cardiac-rhythm/pacemakers/temporary-external-pacemakers.html Books mentioned in this episode: Crucial Conversations: Tools for Talking When Stakes are High. By Joseph Grenny, et al.: https://bit.ly/3XWFo0d The Mutiny on the Bounty. By Peter FitzSimons: https://bit.ly/4cwGkNb

Disturbances in neurological function due to primary neurological disorders or organ failure from critical illness are common in patients admitted to the ICU. In this episode, Dr. Zanotti discusses the neurological physical exam in the ICU. He is joined by Dr. Adam Rizvi, a neurologist with Neurocritical care and vascular neurology fellowship training who currently practices critical care, neurocritical care, and tele-neurology/tele-stroke in several hospitals in California. In addition to his clinical work, Dr. Rizvi is an accomplished educator and researcher. Additional Resources: Neurological examination of critically ill patients: a pragmatic approach: Report of an ESICM expert panel. Intensive Care Med 2014. https://pubmed.ncbi.nlm.nih.gov/24522878/ Critical Matters Podcast episode: Brain Death / Death by Neurological Criteria. Host: S. Zanotti. Guest: D. Greer: https://soundphysicians.com/podcast-episode/?podcast_id=342&track_id=1677810255 Clinical Neuroanatomy Made Ridiculously Simple. Edition 6. Stephan Goldberg, MD: https://amzn.to/4cC34uZ Books mention in the episode: Meditations. By Marcus Aurelius. Translation by Gregory Hayes: https://amzn.to/4eBxK1d

This is the second part in our series discussing temporary mechanical circulatory support (tMCS). Part one, covered different types of devices for tMCS, pathophysiology of shock, clinical indications, and general considerations for critical care clinicians. In Part 2, Dr. Zanotti covers a more detailed discussion of medical management and troubleshooting of patients on tMCS. He is again joined by Bindu Akkanti, MD, an associate professor in the Division of Pulmonary, Critical Care, and Sleep Medicine at UTHealth Houston. Dr. Akkanti is the Medical Director of the Heart Failure ICU and the Director of Critical Care for the Heart & Vascular Institute at Memorial Hermann Texas Medical Center. Additional Resources: More about Dr. Akkanti: https://med.uth.edu/internalmedicine/2022/11/17/bindu-akkanti-md/ Mechanical Circulatory Support Part 1 - Critical Matters Podcast. https://soundphysicians.com/podcast-episode/?podcast_id=342&track_id=1828006629 A Comprehensive Review of Mechanical Circulatory Support Devices. V Atti, et al. Heart Intl. 2022. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC9524665/ American Society of Artificial Internal Organs website. https://asaio.org/ IABP: Hemodynamics, troubleshooting, technical tips. https://www.youtube.com/watch?v=ULgjuhBgP9U Composer and Musician A.R. Rahman. https://www.arrahman.com/

In the first part of this two-part series, Dr. Zanotti is joined by Bindu Akkanti, MD, an associate professor in the Division of Pulmonary, Critical Care, and Sleep Medicine at UTHealth Houston. Together, they discuss temporary mechanical circulatory support, an increasingly vital modality in treating cardiogenic shock and other subsets of critically ill patients in shock. Dr. Akkanti is the Medical Director of the Heart Failure ICU and the Director of Critical Care for the Heart & Vascular Institute at Memorial Hermann Texas Medical Center. Additional Resources: More about Dr. Bindu Akkanti: https://med.uth.edu/internalmedicine/2022/11/17/bindu-akkanti-md/ Review of Pathophysiology of Cardiogenic Shock and Escalation of Mechanical Circulatory Support Devices. Pahuja M, et al. Curr Cardiol Rep 2023: https://pubmed.ncbi.nlm.nih.gov/36847990/ Temporary mechanical circulatory support devices: practical considerations for all stakeholders. Salter BS, et al. Nature Reviews Cardiology 2023: https://www.nature.com/articles/s41569-022-00796-5 Microaxial Flow Pump or Standard Care in Infarct-Related Cardiogenic Shock. Moller JE, et al. N Engl J Med 2024: https://www.nejm.org/doi/full/10.1056/NEJMoa2312572 Books Mentioned in this Episode: The Alchemist. By Paulo Coelho: https://bit.ly/3yv4Zmt

With over 700 modes of mechanical ventilation available today, it can be overwhelming to find the best application of technology at the bedside. Focused on goal-directed mechanical ventilation, this discussion covers the taxonomy of mechanical ventilation modes and provides a framework for a rational approach at the bedside. Dr. Zanotti is joined by Dr. Eduardo Mireles-Cabodevila, Director of the Medical Intensive Care Unit and the Simulation and Advanced Skills Center at the Cleveland Clinic. In addition, Dr. Mireles-Cabodevila is the Vice-Chair of the Division of Critical Care Medicine, Department of Pulmonary and Critical Care, within the Integrated Hospital-Care Institute at the Cleveland Clinic. Additional Resources: How do I ventilate patients with ARDS: Goal-directed mode selection. E. Mireles-Cabodevila. Med Intensiva 2022: https://pubmed.ncbi.nlm.nih.gov/36220727/ A Rational Framework for Selecting Modes of Ventilation. E. Mireles-Cabodevila, et al. Respir Care 2013: https://pubmed.ncbi.nlm.nih.gov/22710796/ Closing the Gap in Patient-Ventilator Discordance Recognition. A. Liendo and E. Mireles-Cabodevila. Respir Care 2024: https://pubmed.ncbi.nlm.nih.gov/38267228/ Standardized Education for Ventilatory Assistance (SEVA) resources page; https://my.clevelandclinic.org/departments/respiratory/medical-professionals/seva#seva-resources-tab Mechanical Ventilation Mode Taxonomy App: iPhone: https://apps.apple.com/us/app/ventilator-mode-map/id1508307955 Android: https://play.google.com/store/apps/details?id=org.ccf.vmm&hl=en_US Books mentioned in this episode: Solito: A Memoir. By Javier Zamora: https://bit.ly/4b6hPG8

In this episode, Dr. Zanotti discusses the management of acute life-threatening asthma exacerbations in the ICU with this guest, Dr. Haney Mallemat, a physician trained in EM/IM and Critical Care. Dr. Mallemat is currently an Associate Professor of Emergency Medicine and Internal Medicine at the Cooper Medical School at Rowan University. Additional Resources: How Not to Kill an Asthmatic – Presented at CODA Change by Haney Mallemat: https://codachange.org/severe-asthma Management of Acute Life-Threatening Asthma Exacerbations in the Intensive Care Unit. Talbot T, et al. Appl. Sci 2024: https://www.mdpi.com/2076-3417/14/2/693 ResusX,- a medical resuscitation conference created by Dr. Mallemat: https://www.resusx.com Last Week Now! - A curated newsletter by ResusX: https://www.resusx.com/newsletter Keynotable – a course for beginners and seasoned speakers: https://www.keynotable.net Books mentioned in this episode: How to Win Friends and Influence People. By Dale Carnegie: https://bit.ly/49WlcOd