Critical care clinics
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Primary, spontaneous intracerebral hemorrhage (ICH) confers significant early mortality and long-term morbidity worldwide. Advances in acute care including investigative, diagnostic, and management strategies are important to improving outcomes for patients with ICH. Physicians caring for patients with ICH should anticipate the need for emergent blood pressure reduction, coagulopathy reversal, cerebral edema management, and surgical interventions including ventriculostomy and hematoma evacuation. This article reviews the pathogenesis and diagnosis of ICH, and details the acute management of spontaneous ICH in the critical care setting according to existing evidence and published guidelines.
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Although neurocritical care as a subspecialty is a relatively young field of medicine, its origins can be traced back to ancient times. This article focuses on the progression of neurocritical care from prehistoric trepanation procedures, through the development of mechanical ventilation, management of increased intracranial pressure, and traumatic brain injury, to the establishment of the first "real" intensive care units, and finally to modern monitoring in neurocritical care, management of post-cardiac arrest patients, and the diagnosis of brain death. This article also focuses on the future direction of neurocritical care.
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Nontraumatic subarachnoid hemorrhage from intracranial aneurysm rupture presents with sudden severe headache. Initial treatment focuses on airway management, blood pressure control, and extraventricular drain for hydrocephalus. After identifying the aneurysm, they may be clipped surgically or endovascularly coiled. ⋯ Monitoring includes serial neurologic assessments, transcranial Doppler ultrasonography, computed tomography perfusion, and angiographic studies. Treatment includes augmentation of blood pressure and cardiac output, cerebral angioplasty, and intra-arterial infusions of vasodilators. Although early mortality is high, about one half of survivors recover with little disability.
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Status epilepticus (SE) is a life-threatening medical and neurologic emergency requiring prompt recognition and treatment. SE may be classified into convulsive and nonconvulsive, based on the presence of rhythmic jerking of the extremities. ⋯ Benzodiazepines are first-line therapy, usually followed by phenytoin/fosphenytoin. A low threshold should exist for obtaining an urgent electroencephalogram.