Continuum : lifelong learning in neurology
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Continuum (Minneap Minn) · Jun 2012
Review Comparative StudyOsmotherapy for intracranial hypertension: mannitol versus hypertonic saline.
Hyperosmolar therapy is one of the core medical treatments for brain edema and intracranial hypertension, but controversy exists regarding the use of the most common agents, mannitol, and hypertonic saline. This article describes the relative merits and adverse effects of these agents using the best available clinical evidence. ⋯ Both mannitol and hypertonic saline are effective and have an acceptable risk profile for use in the treatment of elevated intracranial pressure secondary to brain edema.
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The Uniform Determination of Death Act indicates that "an individual who has sustained either (1) irreversible cessation of circulatory and respiratory functions, or (2) irreversible cessation of all functions of the entire brain, including the brain stem, is dead," with brain death being determined based on "accepted medical standards." The AAN has published practice guidelines providing medical standards for the determination of brain death. The most recent AAN guideline update notes that "because of the deficiencies in the evidence base, clinicians must exercise considerable judgment when applying the criteria in specific circumstances" and that "ancillary tests can be used when uncertainty exists about the reliability of parts of the neurologic examination or when the apnea test cannot be performed. This article presents two cases commonly encountered in clinical practice in which the findings of the guideline-specified clinical neurologic assessment may be difficult to interpret, hampering the clinical determination of brain death. In these circumstances, ancillary testing specifically assessing for cerebral circulatory arrest may be helpful.
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Continuum (Minneap Minn) · Jun 2012
ReviewPrognosis of coma after cardiac arrest in the era of hypothermia.
Outcome prediction is more difficult in comatose survivors of cardiac arrest who are treated with hypothermia than in those who are kept normothermic. This article compares prognostication measures in these two groups of patients. ⋯ This article compares and contrasts prognostication before and after the introduction of hypothermia in an attempt to provide new guidance on predicting outcomes.
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This article summarizes the most common etiologies and approaches to management of metabolic encephalopathy. ⋯ Recognition and treatment of encephalopathy is critical to improving outcomes in critically ill patients.
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This article provides an update on the latest diagnostic and therapeutic trials relating to the management of intracerebral hemorrhage (ICH). ⋯ Despite advances in other areas of stroke, there has been no significant improvement in the morbidity and mortality after ICH. The cause of ICH has been shifting from chronic hypertension to other etiologies. Current understanding of the pathophysiologic processes involved with hematoma expansion and the development of secondary injury after ICH has focused the treatment strategies on prevention of these potential complications. Care for the patient after ICH includes basic medical care, prevention of hematoma expansion, and treatment of potential secondary complications. Trials are underway to evaluate the effect of acute blood pressure control on hematoma expansion and the development of cerebral edema. Similarly, new surgical techniques are being explored for clot removal, and medical therapies are being developed to prevent secondary neurotoxic damage.