Neurocritical care
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Acute traumatic spinal cord injury (SCI) affects more than 250,000 people in the USA, with approximately 17,000 new cases each year. It continues to be one of the most significant causes of trauma-related morbidity and mortality. Despite the introduction of primary injury prevention education and vehicle safety devices, such as airbags and passive restraint systems, traumatic SCI continues to have a substantial impact on the healthcare system. ⋯ We review the pre-hospital management of a patient with an acute SCI, including triage, immobilization, and transportation. Upon arrival to the definitive treatment facility, we review initial evaluation and management steps, including initial neurological assessment, radiographic assessment, cervical collar clearance protocols, and closed reduction of cervical fracture/dislocation injuries. Finally, we review ICU issues including airway, hemodynamic, and pharmacological management, as well as future directions of care.
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Neurocritical care is usually practiced in the comfort of an intensive care unit within a tertiary care medical center. Physicians deployed to the frontline with the US military or allied military are required to use their critical care skills and their neurocritical skills in austere environments with limited resources. ⋯ Although limited interventions can be performed in austere conditions, they can significantly impact patient outcome. This review focuses on the US Army approach to the patient requiring tactical neurocritical care specifically point of injury care and care during transportation to a higher level of care.
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Observational Study
Inpatient Complications Predict Tracheostomy Better than Admission Variables After Traumatic Brain Injury.
Data regarding who will require tracheostomy are lacking which may limit investigations into therapeutic effects of early tracheostomy. ⋯ Potentially modifiable inpatient factors have a stronger association with tracheostomy than do admission characteristics. Multicenter studies are needed to validate the results.
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Automated devices collecting quantitative measurements of pupil size and reactivity are increasingly used for critically ill patients with neurological disease. However, there are limited data on the effect of ambient light conditions on pupil metrics in these patients. To address this issue, we tested the range of pupil reactivity in healthy volunteers and critically ill patients in both bright and dark conditions. ⋯ Ambient light levels impact pupil parameters in both healthy and critically ill subjects. Changes in NPi under different light conditions are small and more consistent in healthy subjects, but significantly differ in the critically ill. Practitioners should standardize lighting conditions to maximize measurement reliability.