Neurocritical care
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Prognostic determination of patients in coma after resuscitation from cardiac arrest is both common and difficult. We explored clinical and electrophysiological testing to determine their associations with favorable and poor outcomes. ⋯ It seems unlikely that any single test will prove to have 100% predictive value for outcome; further studies combining clinical, EEG, and SSEP testing are warranted.
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Paradoxical embolus should be suspected in young patients with cerebrovascular events who do not have any vascular risk factors. There is significant controversy as to how best to treat his phenomenon. ⋯ This case emphasizes the potential complications of the use of central lines in ICUs, particularly in patients with diabetic ketoacidosis in whom sluggish blood flow may predispose to a procoagulant state.
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Weaning patients with myasthenic crisis (MC) from mechanical ventilation is often difficult, and the ideal time for extubation is often uncertain. However, little is known about the risk of extubation failure and the factors that may affect its occurrence. The goals of this study were to assess the risk of extubation failure in patients with MC and to determine which clinical variables may predict unsuccessful extubation. ⋯ Extubation failure may often complicate MC. Older age and development of pulmonary complications during mechanical ventilation increase the risk of extubation failure.
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Inadvertent hyperventilation has been documented during aeromedical transports but has not been studied following paramedic rapid sequence intubation (RSI). The San Diego Paramedic RSI Trial was designed to study the impact of paramedic RSI on outcome in patients with severe head injury. This analysis explores ventilation patterns in a cohort of trial patients undergoing end-tidal CO2 (ETCO2) monitoring. ⋯ Inadvertent hyperventilation is common following paramedic RSI, despite ETCO2 monitoring and target parameters.
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The acceptance of brain death by society has allowed for the discontinuation of "life support" and the transplantation of organs. The standard clinical criteria for brain death, when rigorously applied, ensure that the brainstem is destroyed. Because more rostral structures are more vulnerable than the brainstem, these are almost invariably devastated when brainstem function is irreversibly lost as a result of whole brain insults. ⋯ Ancillary tests are also required in very young children. In addition, some societies require their use as a matter of principle. Only tests of whole-brain perfusion adequately serve these purposes.