Neurocritical care
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Raised intracranial pressure (ICP) has been consistently associated with poor neurological outcome. Our purpose was to systematically review the literature to estimate the association between ICP values and patterns and short- and long-term vital and neurological outcome. ⋯ Refractory ICP and response to treatment of raised ICP could be better predictors of neurological outcome than absolute ICP values. Limitations in the design of the studies analyzed precluded identification of the role of ICP monitoring in predicting short- and long-term outcomes.
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Hypotension is common following carotid artery stenting (CAS), and may be mediated by vagal stimulation and/or suppression of spinal sympathetic outflow. Both mixed alpha/beta agonists (dopamine (DA)), and more selective alpha- agonists (norepinephrine (NE) and phenylephrine (PE)), have been used, but the most effective treatment of post-CAS hypotension is unknown. ⋯ Compared with DA, treatment of post-CAS hypotension with a selective alpha-agonist (NE or PE) is associated with shorter drug infusion time, shorter CCU LOS, and fewer major adverse events.
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Case Reports
Aminophylline for the treatment of symptomatic bradycardia and asystole secondary to cervical spine injury.
Bradycardia is a common complication of cervical spine damage in the weeks following injury, occurring in up to 100% of patients in some studies. Cardiac arrest and asystole have been reported in as many as 15% of these patients and cardiac events are the main cause of death within the first year. We describe the case of a 25-year-old African-American male involved in a motor vehicle collision who suffered C6-C7 subluxation. ⋯ There is limited evidence for the use of methylxanthines in the treatment of bradycardia associated with spinal cord injury. In patients with recurrent asystolic events or symptomatic bradycardia the use of these agents should be considered.
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A 38-year-old man with severe head trauma complicated by paroxysmal severe intracranial pressure elevation associated with tachypnea, tachycardia, diaphoresis, and extensor posturing was diagnosed as suffering from paroxysmal autonomic instability with dystonia (PAID). These events were unresponsive to standard medical therapy, which included morphine, fentanyl, labetalol, lorazepam, metoprolol, and clonidine. ⋯ Dexmedetomidine may be a novel pharmacologic agent to aid in abrogating PAID.