Neurocritical care
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Given the rarity of brain death in clinical practice, trainees may complete their training without ever performing a brain death exam. Little is known about the performance of trainees in the evaluation of brain death. The accuracy of brain death determination can be audited and improved through simulation models. ⋯ We successfully tested a new simulation model which emphasized training in crucial pitfalls. More than one in four trainees performed poorly in the evaluation of prerequisites and the clinical examination. Few trainees considered the possibility of drug or alcohol ingestion. Simulation training improved clinical performance and trainee confidence in the evaluation of brain death.
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We recently described a technique for monitoring intraspinal pressure (ISP) after traumatic spinal cord injury (TSCI). This is analogous to intracranial pressure monitoring after brain injury. We showed that, after severe TSCI, ISP at the injury site is elevated as the swollen cord is compressed against the dura. ⋯ After severe TSCI, three intradural compartments form (space above injury, injury site, space below injury) with different ISPs. At the level of maximum spinal cord swelling (injury site), subdural ISP is comparable to intraparenchymal ISP.
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Emergency neurological life support (ENLS) is an educational program designed to provide users advisory instruction regarding management for the first few hours of a neurological emergency. The content of the course is divided into 14 modules, each addressing a distinct category of neurological injury. ⋯ Certification and training in ENLS is hosted by the Neurocritical Care Society. This document introduces the concept of ENLS and describes the revisions that constitute this second version.
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Cardiac arrest is the most common cause of death in North America. Neurocritical care interventions, including targeted temperature management (TTM), have significantly improved neurological outcomes in patients successfully resuscitated from cardiac arrest. Therefore, resuscitation following cardiac arrest was chosen as an emergency neurological life support protocol. ⋯ This protocol will review induction, maintenance, and re-warming phases of TTM, along with management of TTM side effects. Aggressive shivering suppression is necessary with this treatment to ensure the maintenance of a target temperature. Ancillary testing, including electrocardiography, computed tomography and/or magnetic resonance imaging of the brain, continuous electroencephalography monitoring, and correction of electrolyte, blood gas, and hematocrit changes, are also necessary to optimize outcomes.
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Acute ischemic stroke is a neurological emergency that can be treated with time-sensitive interventions, including intravenous thrombolysis and endovascular approaches. Extensive study has demonstrated that rapid assessment and treatment are essential for improving neurological outcome. For this reason, acute ischemic stroke was chosen as an Emergency Neurological Life Support protocol. The protocol focuses on the first hour following the onset of neurological deficit.