Continuum : lifelong learning in neurology
-
Status epilepticus, which is simultaneously a neurologic and systemic emergency, often results in significant disability and may be fatal. This article presents a pragmatic approach to the evaluation and management of status epilepticus in adults for the practicing clinician. ⋯ This article reviews the guidelines and up-to-date information on the use of both pharmacologic and nonpharmacologic therapies in status epilepticus and discusses the shifts in our understanding of the balance between the need for aggressive control of seizures and the risks of treatment. This article also presents a suggested approach to the evaluation and management of common types of status epilepticus and explores future directions.
-
Continuum (Minneap Minn) · Oct 2015
Evaluating the Potential for Recovery of Consciousness in the Intensive Care Unit.
Evaluating patients in the intensive care unit (ICU) with disorders of consciousness has prognostic implications. When brainstem functions are intact, the neurologist must use ancillary testing to help determine prognosis. This article addresses the challenges of arriving at prognoses in patients with hypoxic-ischemic encephalopathy and traumatic brain injury (TBI) and discusses strategies for dealing with these challenges. This has some relevance to other conditions that are capable of causing irreversible brain damage. ⋯ To arrive at a more accurate prognosis, it is best to employ multiple pieces of evidence and incorporate the most updated information from the literature. In some cases, newer technologies can provide further insights into cortical function in behaviorally unresponsive patients.
-
Neuroprognostication following cardiac arrest is a common and challenging dilemma for neurologists and intensivists, complicated by the use of therapeutic hypothermia and targeted temperature management. Great advances have been made in understanding the mechanisms of disorders of consciousness in hypoxic-ischemic brain injury, and new diagnostic and therapeutic avenues are arising. ⋯ Predicting neurologic prognosis following cardiac arrest is an evolving field, with new prognostic methods and reevaluation of older techniques holding great promise for advancing our ability to predict outcome and improve patient care.
-
Neurologists working in the hospital are often called to evaluate patients with severe muscle weakness. Some of these patients can develop ventilatory compromise and require admission to the intensive care unit (ICU). This article reviews the general evaluation of neuromuscular respiratory failure, discusses its differential diagnosis, and provides practical advice on the management of its most common causes. ⋯ Prompt recognition of neuromuscular respiratory failure can be lifesaving, and identification of its cause has substantial prognostic implications. Adequate management of these patients requires a multidisciplinary team with the neurologist at its center, not only to guide the diagnostic evaluation but often also to prescribe the optimal management.
-
Intracranial pressure (ICP) can be elevated in traumatic brain injury, large artery acute ischemic stroke, intracranial hemorrhage, intracranial neoplasms, and diffuse cerebral disorders such as meningitis, encephalitis, and acute hepatic failure. Raised ICP is also known as intracranial hypertension and is defined as a sustained ICP of greater than 20 mm Hg. ⋯ Management of elevated ICP is, in part, dependent on the underlying cause. Medical options for treating elevated ICP include head of bed elevation, IV mannitol, hypertonic saline, transient hyperventilation, barbiturates, and, if ICP remains refractory, sedation, endotracheal intubation, mechanical ventilation, and neuromuscular paralysis. Surgical options include CSF drainage if hydrocephalus is present and decompression of a surgical lesion, such as an intracranial hematoma/large infarct or tumor, if the patient's condition is deemed salvageable. Future research should continue investigating medical and surgical options for the treatment of raised ICP, such as hypothermia, drugs that reduce cerebral edema, and operations aimed at reducing intracranial mass effect.