Neurocritical care
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Current applications of lytic therapy for intraventricular hemorrhage (IVH) rely on exclusion of vascular abnormalities as etiology. Its use in patients with recently coiled aneurysms remains far from considered safe. We report a patient with subarachnoid hemorrhage (SAH) and massive IVH from aneurysmal rupture, which was safely treated with intraventricular recombinant tissue plasminogen activator (rt-PA) after endovascular coiling. We also review two other similar cases reported in the literature. ⋯ We report the safe administration of intraventricular rt-PA after endovascular coiling of a ruptured cerebral aneurysm. Two other similar cases were found in the literature and are reviewed. Hindrance of aneurysmal cavity thrombosis by early administration of rt-PA (increasing the risk of rerupture) remains a widespread concern. The lack of such instances should therefore be acknowledged. We propose that inclusion of such patients in trials assessing safety/efficacy of thrombolytic therapy in the treatment of patients with intracranial hemorrhage should be carefully considered.
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Inadvertent hyperventilation has been documented during aeromedical transports but has not been studied following paramedic rapid sequence intubation (RSI). The San Diego Paramedic RSI Trial was designed to study the impact of paramedic RSI on outcome in patients with severe head injury. This analysis explores ventilation patterns in a cohort of trial patients undergoing end-tidal CO2 (ETCO2) monitoring. ⋯ Inadvertent hyperventilation is common following paramedic RSI, despite ETCO2 monitoring and target parameters.
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Cerebral perfusion pressure (CPP) is one aspect of an all-encompassing approach in the management of traumatic brain injury (TBI). The clinical use of CPP is based on theoretical considerations that optimal cerebral blood flow is necessary to meet the metabolic needs of the injured brain. The goal is to preserve the ischemic penumbra and avoid secondary insults. ⋯ Recently, the Brain Trauma Foundation updated their Web-based recommendation of a lower CPP goal of 60 mmHg. However, the lack of definitive data, such as from a randomized prospective intention-to-treat clinical trials, leaves this goal open to controversy. Therefore, for a variety of reasons, the physician may be most prudent to use the published CPP guideline of 70 mmHg until a consensus statement is published advocating a different value.
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Numerous systems are reported for grading the clinical condition of patients following subarachnoid hemorrhage (SAH). The literature was reviewed for articles pertaining to the grading of such patients, including publications on the Hunt and Hess Scale, Fisher Scale, Glasgow Coma Score (GCS), and World Federation of Neurological Surgeons Scale. This article reviews the advantages and limitations of these scales as well as more recent proposals for other grading systems based on these scales with or without addition of other factors known to be prognostic for outcome after SAH. ⋯ Most grading scales were derived retrospectively, and the intra- and interobserver variability has seldom been assessed. Inclusion of additional factors increases the complexity of the scale, possibly making it less likely to be adopted for routine usage and increasing (only marginally in some cases) the ability to predict prognosis. Until further data are available, it is recommended that publications on patients with SAH report at least the admission GCS as well as factors commonly known to influence prognosis, such as age, pre-existing hypertension, the amount of blood present on admission computed tomography, time of admission after SAH, aneurysm location and size, presence of intracerebral or intraventricular hemorrhage, and blood pressure at admission.
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Neuromuscular disorders increasingly are recognized as a complication in patients in the intensive care unit (ICU) and represent a common cause of prolonged ventilator dependency. The distinct syndromes of critical illness myopathy, prolonged neuromuscular blockade, and critical illness polyneuropathy (CIP) may arise as a consequence of sepsis, multi-organ failure, and exposure to various medications--notably, intravenous corticosteroids and neuromuscular blocking agents--but the pathophysiology of these disorders remains poorly understood. More than one syndrome may occur simultaneously, and the distinctions may be difficult in a particular patient, but a specific diagnosis usually can be established after careful clinical, electrodiagnostic, and, when necessary, histological evaluation. ⋯ Repetitive nerve stimulation shows a decrement of the compound muscle action potential and, in most cases, establishes a disorder of neuromuscular transmission. With the recent epidemic of West Nile virus infection, a clinical syndrome of acute flaccid paralysis with several features indistinguishable from poliomyelitis has emerged. This article critically examines the clinical, electrophysiological, and pathological features of these and other acute neuromuscular syndromes that arise in the context of ICU care and summarizes the current understanding of the pathophysiology and treatment of these disorders.