Neurocritical care
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Bacterial meningitis and viral encephalitis, particularly herpes simplex encephalitis (HSE), are severe neurological infections that, if not treated promptly and effectively, lead to poor neurological outcome or death. Because treatment is more effective if given early, the topic of meningitis and encephalitis was chosen as an Emergency Neurological Life Support protocol. ⋯ Though uncommon in its full form, the typical clinical triad of headache, fever, and neck stiffness should alert the clinical practitioner to the syndromes. Early attention to the airway and maintaining normotension is crucial in treatment of these patients, as is rapid treatment with anti-infectives and, in some cases, corticosteroids.
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Airway management is central to the resuscitation of the neurologically ill. These patients often have evolving processes that threaten the airway and adequate ventilation. Therefore, airway, ventilation, and sedation were chosen as an Emergency Neurological Life Support (ENLS) protocol. Reviewed topics include airway management; the decision to intubate; when and how to intubate with attention to cardiovascular status; mechanical ventilation settings; and the use of sedation, including how to select sedative agents based on the patient's neurological status.
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Sustained intracranial hypertension and acute brain herniation are "brain codes," signifying catastrophic neurological events that require immediate recognition and treatment to prevent irreversible injury and death. As in cardiac arrest, evidence supports the organized implementation of a stepwise management algorithm. Because there are multiple etiologies and many treatments that can potentially reverse cerebral herniation, intracranial hypertension and herniation was chosen as an Emergency Neurological Life Support (ENLS) protocol.
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Emergency Neurological Life Support (ENLS) is a series of protocols, generated by experienced neurocritical care and emergency physicians that describe key steps when managing a patient within the first hours of a neurological emergency. The protocols are designed to help standardize these important early steps for several reasons: (1) patients will likely experience better outcomes, (2) they provide the essential elements to communicate to receiving physicians a patient's diagnosis and emergency treatment, (3) this approach forms the foundation for eventual consensus on neurological emergency decisions, and (4) this consensus can inform researchers about the important clinical questions that need resolution to enhance patient care. ⋯ Certification and training in ENLS is hosted by the Neurocritical Care Society. This document introduces the concept of ENLS, reviews the history of its creation, and enumerates future goals as ENLS becomes adopted more widely.