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Maintain day-night cycles.
Add or adjust benzodiazepines and opiates when needed.
Analgesia should give adequate pain control while avoiding respiratory depression.
Continuous analgesia while on ventilator.
Patient Controlled Analgesia used if patient not obtunded. Adjust daily.
Use sedation always with paralysis.
Physical therapy.
Speech therapy.
Occupational therapy.
Delerium Tremens prophylaxis in alcoholics.
- Increased Pain
- Sedated/ Sleeping
- Confusion/Agitation:
- Increased Intracranial Pressure
- Seizures
- Hepatic Encephalopathy
- Possibility of an Intracranial Bleed
 Benzodiazepines used often.
Consult ICU protocol for Triazolam, Lorazepam.
Side effects: Respiratory depression/Amnesia/Confusion.
Antihistamines
Diphenylhdramine (Benadryl)
Side effects: Urinary retention/constipation/tachycardia.
- Hypoxia-Check pulse oximetry, ABG. Hematocrit.
- Sepsis-Consider sources of infection. Lumber Puncture.
- Intracranial Bleed - CT scan.
- Hypotension-EKG.
- Medication-Alcohol, Insulin, Benzodiazepines, Opiates, Nitroglycerine, Lidocaine
Steroids, Digitalis.
Tx: with naloxone for opiod over dose and D50 for hypoglycemic crisis empirically.
- Metabolic-Chemistry abnormalities.
- Lateralizing signs? Get a neuro consult immediately.
- Inadequate pain management? --Adjust hourly infusions and PCA.
- "Sundowning" and ICU psychosis are diagnoses of exclusion.
- An Emergency!!!!!
Dilated/blown+/- bradycardia, hypertension, change in respiration.
Tx: Call resident, anesthesia, respiratory.
Plan for intubation.
Elevate Head of bed to lower venous pressure.
Hyperventilate by ET tube. Lowers PCO2.
Mannitol 1 gm/kg, Consider dexamethasone to reduce brain inflammation.
Arrange for emergent head CT.
Metabolic disarray
Meningitis
Encephalitis
Drug/Alcohol withdrawal
Drug Intoxication
Hypertensive Encephalopathy
Intracerebral Mass
Post traumatic injury
If last greater than 2- 5 minutes, start diazepam/phenytoin.
Hyperventilation and dexamethasone if suspect mass.
Consider Head CT, EKG, LP, Chemistry, ABG.
- ASA levels
- Acetominiphen levels
- Digoxin toxicity
- Serum tox screen
- Urine tox screen
- Known liver disease with mental status changes.
Low Protein Diet
Lactulose 30 gm PO tid, titrate to produce 2-3 bm a day.
Neomycin 1-2 gm PO qid acutely
(reduces GI bacteria production of ammonium)
Avoid sedatives, tranquilizers, and acetominophen.
Dx: Head CT and/or LP.
Neurology and Neurosurgery are involved in care.
Tx: Codeine, Colace, Keep volume up, Neuro-check q 1 hour, Avoid ASA, NSAIDs
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