Continuum : lifelong learning in neurology
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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.
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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.
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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.
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Continuum (Minneap Minn) · Oct 2015
ReviewDiagnosis and Management of Spontaneous Intracerebral Hemorrhage.
This article updates neurologists on recent insights and management strategies of intracerebral hemorrhage (ICH). ⋯ Measurable progress continues toward establishing effective therapies to improve outcomes in patients with ICH. Blood pressure reduction and reversal of medications that exacerbate bleeding are likely to improve outcomes. Recommendations for neuromonitoring will help clinicians at the bedside attend to the most important abnormalities and optimize later quality of life. This article reviews standards for diagnosis and severity of ICH, monitoring and treatment of complications in the hospital, available interventions, and the measurement of outcomes.
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Continuum (Minneap Minn) · Oct 2015
Case ReportsEthical Aspects of Organ Donation After Circulatory Death.
Neurologists should be familiar with the process and ethical aspects of organ donation. While most neurologists understand the steps involved in organ procurement following brain death, the controversial practice of organ donation after circulatory death (also referred to as non-heart-beating organ donation) is less familiar but increasingly frequent. This article presents a hypothetical case of a patient with a devastating neurologic injury and a poor prognosis for meaningful recovery and discusses the ethical considerations underlying donation after circulatory death, the general procedure of donation after circulatory death, and ethical controversies associated with this practice.