Seminars in pediatric neurology
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Ethical issues in the critical care unit frequently arise in children with neurological problems. These ethical issues frequently challenge our medical management of such cases and can be quite problematic. This article reviews key ethical issues that may arise including informed consent, futility, justice/rationing, clinical research conduct and the severely compromised patient who is in either a permanent vegetative or minimally conscious state.
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The pediatric neurologist's role in the neonatal intensive care unit is described in four clinical settings: (1) assessment of outcome in neonatal encephalopathy, (2) treatment of seizures in full-term infants, (3) assessment and treatment of intraventricular hemorrhage with posthemorrhagic hydrocephalus, and (4) assessment of outcome in preterm infants. Emphasis is placed on the evidenced-based information available in these settings and on new therapies on the horizon. Using evidence-based information, the pediatric neurologist can accurately assess prognosis in the neonatal period, and this can provide the basis for a rational assessment of newer therapies in neonatal intensive care.
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Semin Pediatr Neurol · Jun 2004
ReviewCerebral pathophysiology and critical care neurology: basic hemodynamic principles, cerebral perfusion, and intracranial pressure.
Pediatric neurologic intensive care differs from standard pediatric intensive care in two important respects. First, the diagnosis, monitoring, and management of problems related to disorders of cerebral perfusion and intracranial pressure (ICP) are central to nearly all of pediatric neurologic and neurosurgical intensive care. ⋯ Regardless of the cause, treatment should be undertaken as expeditiously as possible and should be based on the principles of resuscitation, reducing the volume of the intracranial contents, and reassessment. This chapter aims to outline some basic principles underlying the diagnosis and management of elevated ICP in children.
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Coma is a nonspecific sign of widespread central nervous system impairment resulting from various metabolic and structural etiologies. The rapid recognition of this neurologic emergency and results from the history, physical examination, and early investigative studies are key to the identification and treatment of its underlying cause. The prognosis for recovery depends greatly on the underlying etiology as well as on its optimal treatment, which seeks to preserve neurologic function and maximize the potential for recovery by reversing the primary cause of brain injury, if known, and preventing secondary brain injury from anoxia, ischemia, hypoglycemia, cerebral edema, seizures, infections, and electrolyte and temperature disturbances. Brain death must be diagnosed with similar care and precision, and families approached compassionately about the diagnosis and their decisions regarding organ donation.
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Semin Pediatr Neurol · Jun 2004
ReviewNeuromuscular problems of the critically ill neonate and child.
This review presents insights gained over 24 years of clinical and laboratory evaluations of children, newborn to 18 years of age, who present with acute weakness in the intensive care setting. The differential diagnosis of neuromuscular disorders in these cases begins with recognition of three categories-the infant and toddler, the older child and adolescent, and the child with critical illness-within which predisposition to specific disorders may be identified. ⋯ Nerve conduction studies, electromyography, electroencephalography, cerebrospinal fluid analysis, and magnetic resonance imaging each play important diagnostic roles in the differentiation of neuromuscular disorders in the critically ill child. Case studies suggest the wide range of presentations these disorders may make to the pediatrician or pediatric neurologist.