Emergency medicine clinics of North America
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Emerg. Med. Clin. North Am. · Feb 2009
ReviewCritical care transport of patients who have acute neurological emergencies.
This article reviews the special questions and issues in critical care transport related specifically to the care of patients who have neurologic emergencies. It first considers potential indications for transport and reviews attempts to create a hierarchical stroke center system akin to that developed for trauma care. It then discusses therapeutic concerns relating to the transport environment and the use of specific interventions, including the effects of end-tidal CO(2) monitoring on intracranial pressure, patient outcomes after traumatic brain injury, and opportunities to initiate therapeutic hypothermia in comatose survivors of cardiac arrest during transport. Finally, the cost of critical care transport of patients who have neurologic emergencies is considered.
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Mortality and morbidity remain high from neurologic emergencies, such as acute stroke, traumatic brain injury, and hypoxic-ischemic encephalopathy after cardiac arrest. Decisions regarding initial aggressiveness of care must be made at the time of presentation, and perceived prognosis is often used as part of this decision-making process. ⋯ Decisions to limit treatment early after neuroemergencies must be balanced with avoidance of self-fulfilling prophecies of poor outcome attributable to clinical nihilism. This article examines the role of prognostication early after neuroemergencies, the potential impact of early treatment limitations, and how these may relate to communication with patients and surrogate decision makers in the context of these acute neurologic events.
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Emerg. Med. Clin. North Am. · Feb 2009
ReviewManagement of transient ischemia attacks in the twenty-first century.
Patients who have a transient ischemic attack (TIA) represent a group that may appear well but are at high risk for stroke within 90 days. Management of patients who have a TIA requires an understanding of the short-term risk for stroke to guide acute management and the long-term benefits to medical and surgical therapies. ⋯ Extended testing may not be feasible in the ED, and to address this limitation, new outpatient strategies for patients who have a TIA have been developed, such as the use of an ED observation unit or an outpatient TIA clinic. Although controversy remains in some areas of acute TIA management because of the lack of evidence from controlled trials, evidence from large randomized trials have led to a better understanding of effective measures for the long-term prevention of stroke.
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The interaction between glycemic control and critical neurologic illness and injury is complex. Hyperglycemia can be either the cause or the result of severe brain injury. ⋯ Demographic patterns, including an aging population and shifts in racial and ethnic representation, contribute to the increasing prevalence of hyperglycemia and diabetes among victims of the most common neurologic emergencies. This article reviews the epidemiology of the problem, relevant pathophysiology, the use of tight glycemic control therapy in other populations, and the potential for tight glycemic control as a way to improve outcomes after acute neurologic illness and injury.
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Central nervous system infections have long been recognized as among the most devastating of diseases. This article describes the changing pattern and epidemiology of a variety of common central nervous system infections, including meningitis, encephalitis, and brain abscesses, and reviews pathophysiology and the most current approach to clinical diagnosis, treatment, and disposition from the emergency physician perspective.