File:Neuroscience Intensive Care Unit- Educational Curricula 6.2022 (1).docx

VCU NSICU Educational Objectives

Neuroscience Intensive Care Unit

Educational Objectives, Curricula

Revised June, 2022

The Neuroscience Intensive Care Unit (NSICU)

The Neuroscience Intensive Care Unit (NSICU) at VCU is a multi-disciplinary ICU where we manage patients with critical neurological and neurosurgical disease. As Virginia’s oldest and largest neurocritical care intensive care unit, providing tertiary and quarternary care, patients present with substantial medical comorbidities which depend on balancing treatment goals. The curriculum, designed for fourth year medical students in their acting internship and rotating residents, thus encompasses critical care and neurocritical care topics in a flexible manner. This allows for completion of our educational mission for learners, while balancing it with clinical demands.

Resources

• ⦁ Emergency Neurological Life Support, course from Neurocritical Care Society
  • ⦁ We encourage and can facilitate your enrollment in this course certification, which covers a broad range of neurocritical care topics in moderate depth with a practice focus
  • ⦁ Open to students, residents, nurses, and all health care providers care for neurocritical care patients
• ⦁ Neurocritical Care Pocket Guide by Neurocritical Care Society
• ⦁ The Ventilator Book by William Owens
• ⦁ The NeuroICU Book by Kiwon Lee
• ⦁ Neurocritical Care, Pittsburgh Critical Care Medicine, by Shutter and Molyneaux

Journal Club

An essential part of medical education is the knowledge and discovery of new information. Engaging with recent published material is a dynamic way to engage and discuss information in a collaborative manner. Dedicated time will be Thursday afternoons 3 PM-4 PM. At this time the Neuroscience APPs will take the unit phone and cover all patients.

First week on service for any resident or student will have no assignment for time to adjust to the unit. The stagger schedule and attending lectures will allow continued didactics.

Senior residents will be expected to choose a recent piece of literature in neurocritical care to discuss for a 30 min session. This will be for Neurology senior residents on their second week, and for anesthesiology senior residents on one of their 3 weeks after the first week. There can be flexibility in the topic chosen, which is confirmed with faculty on service prior to presentation.

The second half of the educational hour will be dedicated to an intern or medical student talk on a high-yield and foundational neurocritical care topic. Basic topics and foundational publications are listed below.

Grand Rounds Topics

Weekly Grand Rounds are held by Neurology, Neurosurgery, and Anesthesiology. There will also be lectures by the Department of Pulmonary and Critical Care Medicine. Anesthesiology Grand Rounds are Thursdays at 6:45 a.m., Neurosurgery at 7:00 a.m., and for Neurology, Fridays at 12:00 p.m., with all available by remote video teleconference. Especially if the topic of discussion pertains to neurocritical care, the team should make an effort to join.

Foundations Talks/Topics

In addition to case-based learning at the bedside, during the course of your rotation you will receive certain foundational talks for critical care and neurocritical care. This is a list of topics you should be familiar with by the time your rotation ends. The faculty will make a point to speak on these topics, but the trainees will need to advocate for topics they may not have heard yet during their block or other rotations. This constitutes core so that when you leave the ICU you have this fundamental knowledge.

General ICU Topics

• ⦁ Ventilator Management In Respiratory Failure (Basic, Advanced)
• ⦁ Airway Management (NC, NRB, HFNC, CPAP/BiPAP, escalation)
• ⦁ Shock States
• ⦁ Vasoactive Medication Use
• ⦁ Sepsis and Infection
• ⦁ Antibiotic Stewardship
• ⦁ Coagulopathy, Testing, Prophylaxis, Treatment (General)
• ⦁ Nutrition in the ICU
• ⦁ Electrolyte disorders and management
• ⦁ Acute Abdomen – identify, workup
• ⦁ ACLS/BLS

Advanced ICU Topics

• ⦁ ARDS
• ⦁ Pulmonary Embolism
• ⦁ Pulmonary Hypertension
• ⦁ COPD/Asthma/Bronchospasm
• ⦁ Arrhythmias and Management
• ⦁ Aortic Dissections
• ⦁ Point of Care Ultrasound
• ⦁ Acute Kidney Injury and management of renal failure
• ⦁ Cirrhosis and Implications
• ⦁ Ileus
• ⦁ Coagulopathy – Testing and Treatment
• ⦁ Stewardship of Healthcare Resources (Cost Savings, Planning)

Neurocritical Care Core

• ⦁ Neuro-Imaging (Approaches to CT, MRI)
• ⦁ Disorders of Consciousness – Coma, Unresponsive Wakefulness, Minimally Conscious
• ⦁ Delirium in the ICU
• ⦁ Cerebral Edema – Types and Management Approaches
• ⦁ Invasive Intracranial Pressure Monitoring
• ⦁ Herniation Syndromes
• ⦁ Subarachnoid Hemorrhage
• ⦁ Traumatic Brain Injury – Diagnostics and Management Considerations
• ⦁ ICH Scores and Treatment Approaches
• ⦁ EEG Foundations
• ⦁ Adjunctive Neuromonitoring Technology
• ⦁ Metabolic and Toxic Encephalopathies
• ⦁ CNS Infections
• ⦁ Autonomic Hyperactivity/PSH/Neurological Storming
• ⦁ Primary Brain Tumors/Metastases
• ⦁ Myasthenic Crisis
• ⦁ Brain Death
• ⦁ Organ Donation, Ethics
• ⦁ Spinal Cord Injury, Protocols
• ⦁ Targeted Temperature Management

Foundational Publications

DVT in Stroke

Dennis, Martin et al. “The Clots in Legs Or sTockings after Stroke (CLOTS) 3 trial: a randomised controlled trial to determine whether or not intermittent pneumatic compression reduces the risk of post-stroke deep vein thrombosis and to estimate its cost-effectiveness.” Health technology assessment (Winchester, England) vol. 19,76 (2015): 1-90. doi:10.3310/hta19760

BP Management in ICH

Qureshi, Adnan I et al. “Outcomes of Intensive Systolic Blood Pressure Reduction in Patients With Intracerebral Hemorrhage and Excessively High Initial Systolic Blood Pressure: Post Hoc Analysis of a Randomized Clinical Trial.” JAMA neurology vol. 77,11 (2020): 1355-1365. doi:10.1001/jamaneurol.2020.3075

Qureshi, Adnan I et al. “Intensive Blood-Pressure Lowering in Patients with Acute Cerebral Hemorrhage.” The New England journal of medicine vol. 375,11 (2016): 1033-43. doi:10.1056/NEJMoa1603460

Anderson, Craig S et al. “Rapid blood-pressure lowering in patients with acute intracerebral hemorrhage.” The New England journal of medicine vol. 368,25 (2013): 2355-65. doi:10.1056/NEJMoa1214609

Platelet Transfusion for ICH

Baharoglu, M Irem et al. “Platelet transfusion versus standard care after acute stroke due to spontaneous cerebral haemorrhage associated with antiplatelet therapy (PATCH): a randomised, open-label, phase 3 trial.” Lancet (London, England) vol. 387,10038 (2016): 2605-2613. doi:10.1016/S0140-6736(16)30392-0

Hemicraniectomy For Stroke Trials

Amiri H, Bösel J, Jüttler E, Sakowitz OW, Unterberg A, Woitzik J, et al. Hemicraniectomy in older patients with extensive middle-cerebral-artery stroke. N Engl J Med. 2014;370:1091–100.

Hennerici M, Jüttler E, Schmiedek P, Schwab S, Unterberg A, Woitzik J, et al. Decompressive surgery for the treatment of malignant infarction of the middle cerebral artery (DESTINY): A randomized, controlled trial. Stroke. 2007;38:2518–25.

Algra A, Amelink GJ, Hofmeijer J, Kappelle LJ, van der Worp HB, van Gijn J HAMLET investigators. Surgical decompression for space-occupying cerebral infarction (the Hemicraniectomy After Middle Cerebral Artery infarction with Life-threatening Edema Trial [HAMLET]): A multicentre, open, randomised trial. Lancet Neurol. 2009;8:326–33.

Guichard JP, Kurtz A, Mateo J, Orabi M, Vahedi K, Vicaut E, et al. Sequential-design, multicenter, randomized, controlled trial of early decompressive craniectomy in malignant middle cerebral artery infarction (DECIMAL Trial) Stroke. 2007;38:2506–17.

SAH Papers

Qureshi, Adnan I et al. “Outcomes of Intensive Systolic Blood Pressure Reduction in Patients With Intracerebral Hemorrhage and Excessively High Initial Systolic Blood Pressure: Post Hoc Analysis of a Randomized Clinical Trial.” JAMA neurology vol. 77,11 (2020): 1355-1365. doi:10.1001/jamaneurol.2020.3075

TBI Papers

Cooper, D. James, et al. "Decompressive craniectomy in diffuse traumatic brain injury." New England Journal of Medicine 364.16 (2011): 1493-1502.

Hutchinson, Peter J., et al. "Trial of decompressive craniectomy for traumatic intracranial hypertension." N Engl J Med 375 (2016): 1119-1130.

Chesnut, Randall M et al. “A trial of intracranial-pressure monitoring in traumatic brain injury.” The New England journal of medicine vol. 367,26 (2012): 2471-81. doi:10.1056/NEJMoa1207363

Cerebral Edema:

Cook, A.M., Morgan Jones, G., Hawryluk, G.W.J. et al. Guidelines for the Acute Treatment of Cerebral Edema in Neurocritical Care Patients. Neurocrit Care 32, 647–666 (2020). https://doi.org/10.1007/s12028-020-00959-7

Jo, KwangWook et al. “A simple prediction score system for malignant brain edema progression in large hemispheric infarction.” PloS one vol. 12,2 e0171425. 8 Feb. 2017, doi:10.1371/journal.pone.0171425

Kasner, S E et al. “Predictors of fatal brain edema in massive hemispheric ischemic stroke.” Stroke vol. 32,9 (2001): 2117-23. doi:10.1161/hs0901.095719

Stent vs Medical Therapy for Carotid Disease:

Derdeyn, Colin P et al. “Aggressive medical treatment with or without stenting in high-risk patients with intracranial artery stenosis (SAMMPRIS): the final results of a randomised trial.” Lancet (London, England) vol. 383,9914 (2014): 333-41. doi:10.1016/S0140-6736(13)62038-3