Seminars in neurology
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Seminars in neurology · Feb 2017
ReviewNeurologic Prognostication: Neurologic Examination and Current Guidelines.
Clinical examination is paramount for prognostication in patients who are comatose after resuscitation from cardiac arrest. At 72 hours from recovery of spontaneous circulation (ROSC), an absent or extensor motor response to pain (M ≤ 2) is a very sensitive, but not specific predictor of poor neurologic outcome. Bilaterally absent pupillary or corneal reflexes are less sensitive, but highly specific predictors. ⋯ In patients who have not been treated using targeted temperature management (TTM), the 2006 Practice Parameter of the American Academy of Neurology suggested a unimodal approach for prognostication within 72 hours from ROSC, based on status myoclonus (SM) within 24 hours, SSEP, or NSE at 24 to 72 hours and ocular reflexes or M ≤ 2 at 72 hours. The 2015 guidelines from the European Resuscitation Council and the European Society of Intensive Care Medicine suggest a multimodal prognostication algorithm, to be used in both TTM-treated and non-TTM-treated patients with M ≤ 2 at ≥ 72 hours from ROSC. Ocular reflexes (pupillary and corneal) and SSEPs should be used first, followed by a combination of other predictors (SM, EEG, NSE, imaging) if results of the first predictors are normal.
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An increasing number of patients are successfully resuscitated from cardiac arrest (CA) and subsequently treated in an intensive care unit due to unconsciousness. Approximately half of these patients will die during the first weeks postarrest, typically after a determination of a poor neurologic prognosis and a decision to withdraw life-sustaining therapy (WLST). ⋯ Recent studies indicate that premature decisions to withdraw care may be common. This topical review will focus on the decision of WLST for patients remaining unconscious after CA, the guiding ethical principles, and the interaction with neurologic prognostication and outcome.
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In this review, the author summarizes the incidence, causes, and survival associated with out-of-hospital cardiac arrest (OHCA) and in-hospital cardiac arrest (IHCA). The resuscitation guideline process is outlined, and the impact of resuscitation interventions is discussed. The incidence of OHCA treated by emergency medical services varies throughout the world, but is in the range of 30 to 50 per 100,000 of the population. ⋯ Cardiac disease accounts for the vast majority of OHCAs; however, although it is a common cause of IHCAs, many other diseases are also common causes of IHCA. Five yearly reviews of resuscitation science have been facilitated in recent years by the International Liaison Committee on Resuscitation; these have been followed by the publication of regional resuscitation guidelines. There is good evidence that increasing rates of bystander cardiopulmonary resuscitation and earlier defibrillation are both contributing to improving the survival rate after an OHCA.
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Seminars in neurology · Dec 2016
ReviewCritical Care of Traumatic Cervical Spinal Cord Injuries: Preventing Secondary Injury.
The incidence of traumatic spinal cord injury (SCI) has not changed much over the years due to an aging population suffering falls, yet advances have been made in quality of life and survival time. In addition to initial medical and surgical stabilization, modern intensive care unit (ICU) care throughout the critical early period following SCI is essential to avoid continued secondary injury to the spinal cord. Cervical SCI patients are particularly prone and sensitive to periods of cardiovascular instability and respiratory failure directly resulting from their injuries. Preclinical and class III clinical data suggest improved outcomes by maintaining the mean arterial pressure > 85 mm Hg and avoiding hypoxemia at least for 7 days following cervical SCI, and this level of monitoring and support should occur in the ICU.
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Pediatric neurocritical care is a growing subspecialty of pediatric intensive care that focuses on the management of acute neurological diseases in children. A brief history of the field of pediatric neurocritical care is provided. Neuromonitoring strategies for children are reviewed. Management of major categories of acute childhood central neurologic diseases are reviewed, including treatment of diseases associated with intracranial hypertension, seizures and status epilepticus, stroke, central nervous system infection and inflammation, and hypoxic-ischemic injury.