Neurocritical care
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In many neurological diseases, intracranial pressure (ICP) is elevated and needs to be actively managed. ICP is typically measured with an invasive transducer, which carries risks. Non-invasive techniques for monitoring ICP (nICP) have been developed. The aim of this study was to compare three different methods of transcranial Doppler (TCD) assessment of nICP in an animal model of acute intracranial hypertension. ⋯ TCD-based methods of nICP monitoring are better at detecting changes of ICP occurring in time, rather than absolute prediction of ICP as a number. Of the studied methods of nICP, the method based on FVd is best to discriminate between raised and 'normal' ICP and to monitor relative changes of ICP.
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Traumatic spine injuries (TSIs) carry significantly high risks of morbidity, mortality, and exorbitant health care costs from associated medical needs following injury. For these reasons, TSI was chosen as an ENLS protocol. ⋯ Alhough the review focuses primarily on cervical spinal column injuries, thoracolumbar injuries are briefly discussed as well. The initial emergency department clinical evaluation of possible spinal fractures and cord injuries, along with the definitive early management of confirmed injuries, is also covered.
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Coma is an acute failure of neuronal systems governing arousal and awareness and represents a medical emergency. When encountering a comatose patient, the clinician must have an organized approach to detect easily remediable causes, prevent ongoing neurologic injury, and determine a hierarchical plan for diagnostic tests, treatments, and neuromonitoring. Coma was chosen as an Emergency Neurological Life Support protocol because timely medical and surgical interventions can be life-saving, and the initial work-up of such patients is critical to establishing a correct diagnosis.
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Patients with prolonged or rapidly recurring convulsions lasting more than 5 min are in status epilepticus (SE) and require immediate resuscitation. Although there are relatively few randomized clinical trials, available evidence and experience suggest that early and aggressive treatment of SE improves patient outcomes, for which reason this was chosen as an Emergency Neurological Life Support protocol. The current approach to the emergency treatment of SE emphasizes rapid initiation of adequate doses of first-line therapy, as well as accelerated second-line anticonvulsant drugs and induced coma when these fail, coupled with admission to a unit capable of neurological critical care and electroencephalography monitoring. This protocol will focus on the initial treatment of SE but also review subsequent steps in the protocol once the patient is hospitalized.
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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.