Seminars in neurology
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Seminars in neurology · Sep 2006
ReviewPrehospital interventions to improve neurological outcome following cardiac arrest.
As many cases of cardiac arrest occur outside of the health care setting, prehospital treatment may dramatically affect patient outcomes. The three major interventions that have been studied are chest compressions and ventilation, electrical defibrillation, and medications. Recent studies show that increasing the rate of cardiopulmonary resuscitation (CPR), decreasing the rate of ventilation, and initiation of CPR prior to defibrillation may result in improved survival. ⋯ Public access to automatic defibrillators has been shown to increase the survival of cardiac arrest patients. Medications such as amiodarone, vasopressin, and thrombolytics also may have a role in the prehospital treatment of cardiac arrest. Recent advances in these areas will be reviewed with a discussion of the effect of each intervention on the restoration of circulation and neurological outcomes.
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Seminars in neurology · Sep 2006
ReviewLong-term neurological complications after hypoxic-ischemic encephalopathy.
Hypoxic-ischemic encephalopathy accompanying cardiac arrest is a common cause of long-term neurological dysfunction. With the improvement in prehospital emergency systems, larger numbers of people are resuscitated from cardiac arrests, although with the increased prospect of neurological sequelae. Neurological impairment after cardiac arrest is dependent on the degree of brain damage suffered during the arrest. ⋯ Neurological impairments range from mild cognitive deficits to severe motor and cognitive deficits that preclude independence in many activities of daily living. Several neurological syndromes have been described in patients who awaken from hypoxic-ischemic coma with lasting motor and cognitive deficits. This review will address many of the common syndromes after hypoxic-ischemic encephalopathy, including persistent vegetative states, seizures, myoclonus, movement disorders, cognitive dysfunction, and other neurological abnormalities.
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Seminars in neurology · Sep 2006
ReviewBiomarkers and neuroimaging of brain injury after cardiac arrest.
Unfortunately, it remains a difficult task to predict with certainty which patients will have a poor neurological outcome following cardiac arrest. Finding a quantitative prognostic model of outcome has become the objective of many intensivists to assist grieving families in making early difficult decisions regarding withdrawal of life support. An ideal prognostic test should be readily available, easily reproducible, and associated with a high degree of specificity for poor outcome. ⋯ Each serum or radiological marker has its pros and cons. To accurately prognosticate following cardiac arrest, a multimodal scale or algorithm that incorporates serum markers, radiological markers, and the neurological exam is clearly needed. As these techniques are being evaluated more closely and as imaging modalities increase in sensitivity and portability, physicians will continue to assist families by providing some guidance as to which patients have no chance of meaningful recovery.
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Seminars in neurology · Sep 2006
ReviewTherapeutic hypothermia for brain injury after cardiac arrest.
Morbidity and mortality in patients successfully resuscitated from cardiac arrest primarily depends on neurological outcome. Clinical trials of therapies directed toward reducing the extent of neuronal damage by means of pharmacological agents have been disappointing. To date, the only clinically effective tool for amelioration of brain damage by ischemia and reperfusion is mild to moderate induced hypothermia. The pathophysiology of global hypoxic-ischemic brain injury, the mechanisms by which hypothermia confers neuroprotection, and the encouraging beneficial effects of mild to moderate hypothermia in experimental studies and clinical trials are discussed.
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Seminars in neurology · Sep 2006
ReviewPostresuscitative intensive care: neuroprotective strategies after cardiac arrest.
Cardiac arrest is a common disease in the United States, and many patients will die as a result of the neurological damage suffered during the anoxic period, or will live in a neurologically debilitated state. When cardiopulmonary-cerebral resuscitation results in the return of spontaneous circulation, intensive care is required to optimize neurological recovery. Such "brain-oriented" therapies include routine care, such as positioning and maintenance of volume status; optimization of cerebral perfusion, with the use of vasopressors if needed; management of increased intracranial pressure with agents such as hypertonic saline; assuring adequate oxygenation and avoiding hypercapnia; aggressive fever control; intensive glucose control, with the use of an insulin drip if needed; and management of seizures if they occur. ⋯ Induced moderate therapeutic hypothermia is utilized as a neuroprotective maneuver. Future treatment options and advanced monitoring techniques are also discussed. Further study to optimize neuroprotective strategies when treating patients who survive cardiac arrest is needed.