Neurocritical care
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Intracerebral hemorrhage (ICH) is a subset of stroke due to spontaneous bleeding within the parenchyma of the brain. It is potentially lethal, and survival depends on ensuring an adequate airway, proper diagnosis, and early management of several specific issues such as blood pressure, coagulopathy reversal, and surgical hematoma evacuation for appropriate patients. ICH was chosen as an Emergency Neurological Life Support (ENLS) protocol because intervention within the first hours may improve outcome, and it is critical to have site-specific protocols to drive care quickly and efficiently.
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Severe traumatic brain injury (TBI) causes substantial morbidity and mortality, and is a leading cause of death in both the developed and developing world. The need for a systematic evidence-based approach to the care of severe TBI patients within the emergency setting has led to its inclusion as an Emergency Neurological Life Support topic. This protocol was designed to enumerate the practice steps that should be considered within the first critical hours of neurological injury from severe TBI.
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The appropriate use of medications during Emergency Neurological Life Support (ENLS) is essential to optimize patient care. Important considerations when choosing the appropriate agent include the patient's organ function and medication allergies, potential adverse drug effects, drug interactions and critical illness and aging pathophysiologic changes. Critical medications used during ENLS include hyperosmolar therapy, anticonvulsants, antithrombotics, anticoagulant reversal and hemostatic agents, anti-shivering agents, neuromuscular blockers, antihypertensive agents, sedatives, vasopressors and inotropes, and antimicrobials. This article focuses on the important pharmacokinetic and pharmacodynamics characteristics, advantages and disadvantages and clinical pearls of these therapies, providing practitioners with essential drug information to optimize pharmacotherapy in acutely ill neurocritical care patients.
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There are many causes of acute myelopathy including multiple sclerosis, systemic disease, and acute spinal cord compression (SCC). SCC should be among the first potential causes considered given the significant permanent loss of neurologic function commonly associated with SCC. ⋯ Bowel and bladder dysfunction and neck or back pain may also be part of the clinical presentation, but are not uniformly present. Because interventions are critically time-sensitive, the recognition and treatment of SCC was chosen as an ENLS protocol.
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Acute non-traumatic weakness may be life-threatening if it involves the respiratory muscles and/or is associated with autonomic dysfunction. Most patients presenting with acute muscle weakness have a worsening neurological disorder that requires a rapid, systematic evaluation and detailed neurological exam to localize the disorder. ⋯ Causes of acute non-traumatic weakness are discussed here by both presenting clinical signs and anatomical location. For each diagnosis, key features of the history, examination, investigations, and treatment are outlined in the included tables or in the "Appendix".