Neurologic clinics
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Traumatic brain injury is a common and complex clinical entity that deserves better and continued research on interventions and initial treatment postinjury. Current medical management of traumatic brain injury is articulated on minimizing secondary injury by optimizing cerebral perfusion and oxygenation and preventing or treating nonneurologic morbidity. There are major medical research efforts examining the underlying mechanisms of secondary brain injury, which provides hope for effective therapies in the future. Presently, a number of promising therapeutic modalities are undergoing clinical trials, and as new pharmacologic and medical approaches are introduced, there will be increasing opportunity to treat these patients and improve their neurologic outcomes.
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Effective management of intracranial hypertension involves meticulous avoidance of factors that precipitate or aggravate increased intracranial pressure. When intracranial pressure becomes elevated, it is important to rule out new mass lesions that should be surgically evacuated. ⋯ For intracranial hypertension refractory to initial medical management, barbiturate coma, hypothermia, or decompressive craniectomy should be considered. Steroids are not indicated and may be harmful in the treatment of intracranial hypertension resulting from traumatic brain injury.
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The devastating neurologic injury in survivors of cardiac arrest has been recognized since the development of modern resuscitation techniques. After numerous failed clinical trials, two trials showed that induced mild hypothermia can ameliorate brain injury and improve survival and functional neurologic outcome in comatose survivors of out-of-hospital cardiac arrest. This article provides a comprehensive review of the advances in the care of brain injury after cardiac arrest, with updates on the process of prognostication, the use of therapeutic hypothermia and adjunctive intensive care unit care for cardiac arrest survivors.
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Mechanical ventilation (MV) is fundamental to the resuscitation of brain injured patients, facilitating tissue oxygen delivery, helping to modulate cerebral vascular reactivity, and ensuring protection of the airway. These benefits come at a cost, which includes a significantly increased risk of pneumonia, delirium, and the complications of sedation and of endotracheal intubation. ⋯ MV can also induce alveolar damage in susceptible individuals, yet changes in ventilation designed to limit this damage may not be tolerated in the setting of brain injury. Recent research has begun to clarify key questions regarding the pathophysiology and management of MV in critically ill neurological patients.
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Temperature management in acute neurologic disorders has received considerable attention in the last 2 decades. Numerous trials of hypothermia have been performed in patients with head injury, stroke, and cardiac arrest. ⋯ Detrimental effects of fever and benefits of normalizing elevated temperature in experimental models are discussed. This article presents a detailed analysis of trials of induced hypothermia in patients with acute neurologic insults and describes methods of fever control.