Neurologic clinics
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Intensive care technologies have led to an increase in patients who are neurologically devastated and deceased. The practical, moral, and ethical situations encountered can be varied and challenging to manage. Decisions and discussions surrounding withdrawal of care, death by neurologic criteria, and organ donation require significant knowledge of the prognosis, ancillary testing, and definitions of these processes. Experience and skill are often required on the part of physicians and staff to guide families through these most difficult of circumstances.
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Less than 3% of all patients who have out-of-hospital cardiac arrests have return of spontaneous circulation (ROSC), survive the hospitalization, and have a reasonable functional recovery. The fact that many patients who have ROSC ultimately die or fail to have favorable neurologic recovery suggests that processes that occur after hospitalization, especially in the ICU, have an impact on survival and neurologic recovery. This article addresses the acute care, with emphasis on the cardiac and neurologic aspects,that patients who have post cardiac arrest are provided in the cardiac ICU.
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The use of IH for 24 hours in patients who remain comatose following resuscitation from out-of-hospital cardiac arrest improves outcomes. How-ever, the induction of hypothermia has several physiologic effects that need to be considered. ⋯ Hypothermia (33 degrees C) should be maintained for 24 hours, followed by rewarming over 12 hours. Particular attention must be paid to potassium and glucose levels during hypothermia.
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Electrophysiologic testing continues to play an important role in injury stratification and prognostication in patients who are comatose after cardiac arrest. As discussed previously, however, the adage about treating whole patients, not just the numbers, is relevant in this situation. EEG and SSEP can offer high specificity for discerning poor prognosis as long as they are applied to appropriate patient populations. ⋯ Aside from prognostication, electrophysiologic testing holds great promise in defining the basic anatomy and physiology of coma emergence after cardiac arrest. In addition, quantitative EEG and automated evoked potentials have the potential to render these tools less subjective and arcane and more applicable for monitoring patients in the period during and immediately after resuscitation. Quantitative EEG also has great potential asa tool to define the time window for neuroprotective intervention and the means to track the response to such therapies in real time.
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Neuronal injury following global cerebral ischemia continues to bea central problem of patients in the postresuscitation phase following cardiocirculatory arrest. In addition to measures focusing on rapid restoration of spontaneous circulation, the most effective treatment after cardiac arrest, as shown by large randomized trials,is the use of therapeutic mild hypothermia. ⋯ At present there is no specific neuroprotective treatment available. Promising animal experimental data concerning the use of thrombolytic agents during cardiopulmonary resuscitation have led to a large European multicenter trial (TROICA trial) that will provide its data in 2006.