Handbook of Neurocritical Care (eBook)

Foreword 6
Preface 8
Special Introduction 10
Contents 12
Contributors 16
Part I General Principles of Neurocritical Care 22
Chapter 1: Establishing and Organizing a Neuroscience Critical Care Unit 23
Key Points 31
Suggested Reading 31
Chapter 2: Electrolyte and Metabolic Derangements 33
Acid – Base Disorders 33
Primary Acid: Base Disorders 34
Electrolyte Disorders 35
Potassium 41
Magnesium 43
Calcium 45
Phosphate 47
Metabolic Disorders and Endocrinopathies 48
Hashimoto Encephalopathy 51
Thyroid Storm 52
Adrenal Crises (Acute Adrenal Insufficiency) 53
Key Points 55
Suggested Reading 55
Chapter 3: Fever and Infections 56
Fever 56
Thoracic Infections 58
Abdominal Infections 62
CNS Infections 64
Special Considerations 67
Key Points 67
Suggested Reading 68
Chapter 4: Cerebral Blood Flow and Metabolism: Physiology and Monitoring 69
Cerebral Physiology 69
Pathophysiology 71
Monitoring 74
Key Points 77
Suggested Reading 78
Chapter 5: Multimodality Monitoring in Acute Brain Injury 79
Introduction 79
When is Monitoring Helpful in the ICU? 80
Most Commonly Used Neurologic Monitoring Tools 80
Less Commonly Used Neuromonitoring Tools 84
Rarely Used Neuromonitoring Tools 86
Key Points 90
Suggested Reading 90
Chapter 6: Cerebral Edema and Intracranial Hypertension 91
Etiology 91
Clinical Presentation 93
Diagnosis and Differential Diagnoses 95
Management 97
Key Points 106
Suggested Reading 106
Chapter 7: Cardiac Dysfunction, Monitoring, and Management 107
Epidemiology 107
Etiology 108
Clinical Presentation (Symptoms and Signs) 108
Diagnosis and Differential Diagnoses 109
Management 112
Outcomes 114
Key Points 115
Suggested Reading 115
Chapter 8: Airway Management and Mechanical Ventilation in the NCCCU 116
Introduction 116
Neurologic Conditions that Require Intubation in the NCCU 116
Intubation 117
Central Control of Ventilation 118
Gas Exchange 119
Hyperventilation and ICP 119
Effects of Ventilatory Modes on ICP 121
Effects of High-Frequency Ventilation on ICP 122
Other Ventilation Issues that Affect ICP 122
Ventilation Issues that Affect ICP and Brain Oxygenation 123
Protocol of the Acute Respiratory Distress Syndrome Network and Permissive Hypercapnia 123
Direct Effects of Neurologic Injury on the Pulmonary System 124
Neurogenic Pulmonary Edema 124
Stunned or Neurogenic Myocardium 126
Liberation from Mechanical Ventilation in Neurologic Disorders 127
Strategies for Extubation of the Neurologically Impaired Patient 127
Weaning in Pure Type II Respiratory Failure 128
Cervical Cord Injury 129
Key Points 130
Suggested Reading 130
Chapter 9: Blood Pressure Management 131
Introduction 131
Pathophysiology of Hypertension 132
Intracerebral Hemorrhage 132
Ischemic Stroke 133
Pharmacologic Treatment of Acute Hypertensive Response (Table 9.2) 135
Key Points 137
Suggested Reading 137
Chapter 10: Nutrition in Neurocritical Care 138
Epidemiology and Etiology 138
Clinical Presentation (Signs and Symptoms) 139
Management 144
Key Points 157
Suggested Reading 158
Chapter 11: Sedation, Analgesia, and Neuromuscular Paralysis 159
General Issues of ICU Sedation 159
Identifying Need for “Sedation” 159
Management of Pain: Recognition 160
Tools for Pain Assessment 160
Classes of Analgesics 161
Anxiolysis 161
Delirium 162
Therapy for Sedation 163
Monitoring of Sedation 163
Physiologic and Brain Function Monitors 168
Classes of Sedative Agents 168
Key Points 183
Suggested Reading 184
Chapter 12: Postoperative Care 186
General Issues 186
Procedure-Related Issues 190
Anesthetics and Anesthetic Techniques 200
Intraoperative Problems that May Impact on Patient Management in the NCCU 206
Common Postoperative Problems 211
Key Points 228
Selected References 228
Chapter 13: Care Following Neurointerventional Procedures 230
Carotid Occlusive Disease and Stent-Assisted Revascularization 230
Incidence 230
Etiology 231
Classification of Carotid Stenosis 231
Clinical Presentation 231
Recurrent Events 231
Management 232
Cas 232
Acute Ischemic Stroke and Emergent Endovascular Revascularization 236
Rationale for Interventional Treatment for Ischemic Stroke 236
Indications for Emergent Endovascular Intervention in Acute Stroke 237
Relative Contraindications During Acute Stroke 237
Types of Emergent Endovascular Procedures in Acute Ischemic Stroke Management 238
Efficacy of Endovascular Therapy 239
Endovascular Revascularization End Point and Assessment 239
Qureshi Grading System (Table 13.1) 240
Predictors of Good Outcome 241
Preoperative Medical Management 241
Perioperative Anesthetic Consideration 241
Intraoperative and Postoperative Medical Management 242
Complications and Their Management 244
Endovascular Treatment of Unruptured and Ruptured Intracranial Aneurysms 245
Intracranial AVMs 256
Current Treatments 256
Indication for Endovascular Embolization of AVMs 257
Preoperative Management Care 257
Operative Management 257
Postoperative Care 257
Follow-up 258
Box 13.1 Elective aneurysmal coiling post-procedure checklist 249
Box 13.2 Ruptured aneurysm coiling post-procedure checklist 253
Key Points 258
Suggested Reading 258
Chapter 14: Ethical Issues and Withdrawal of Life-Sustaining Therapies 259
Introduction 259
Ethical Issues 259
Informed Consent 260
Advance Directives 262
Communicating Prognosis 263
Withdrawal of Life-Sustaining Therapies 266
Palliative Care 267
Goals of “Comfort Measures” 267
How to Withdraw Life-Sustaining Treatment 268
Pitfalls in Withdrawal of Life-Sustaining Therapies 268
Managing Symptoms (Table 14.1) 270
Dosing and Titration of Medications 273
Withdrawing Ventilatory Support 273
Specific Situations 274
Key Points 275
Suggested Reading 276
Chapter 15: Collaborative Nursing Practice in the Neurosciences Critical Care Unit 277
Introduction 277
Registered Nurse 277
Clinical Nurse Mentor 279
Nurse Manager 279
Advanced Practial Registered Nurse (APRN) 280
Key Points 283
References 284
Part II Specific Problems in Neurocritical Care 286
Chapter 16: Coma and Disorders of Consciousness 287
Definitions 287
Terminology used to Describe Disturbances in Consciousness 288
Etiology 289
Assessment of Coma and Stupor 291
Management 293
Prognosis 294
Key Points 295
Suggested Reading 295
Chapter 17: Acute Encephalopathy 297
Nomenclature and Classification 297
Epidemiology 298
Pathophysiology 298
Diagnosis 302
Differential Diagnosis 303
Management of Encephalopathy 305
Selected Encephalopathy Syndromes 307
Key Points 314
Suggested Reading 314
Chapter 18: Traumatic Brain Injury 316
Epidemiology of Traumatic Brain Injury 316
Pathogenesis of TBI 317
Taxonomy of TBI 318
Clinical Management 321
Prognosis 328
Key Points 329
Suggested Reading 329
Chapter 19: Acute Myelopathy 331
Introduction 331
Definitions 331
Etiology 332
Epidemiology 333
Pathophysiology 334
Clinical Presentation 336
Specific Spinal Cord Syndromes 336
Physical Examination 338
Differential Diagnosis 339
Diagnosis 340
Management of Acute Myelopathy in the ICU 341
Prognosis 345
Key Points 347
Suggested Reading 347
Chapter 20: Ischemic Stroke 348
Definitions 348
Epidemiology 348
Ischemic Stroke Subtypes 349
Risk Factors 349
Specific Stroke Mechanisms by Etiology 349
Symptoms by Subtype 351
Symptoms by Location 352
Investigations 354
Treatment 355
Management of Acute Stroke in ED 356
Complications 357
Subsequent Care 358
Key Points 358
Suggested Reading 359
Chapter 21: Intracerebral Hemorrhage 360
Epidemiology 360
Pathophysiology (Table 21.1) 360
Clinical Presentation 362
Diagnosis (Table 21.1) 362
Indication for Cerebral angiogram/CTA (any of the following) 363
Prognosis 364
Management 364
Management of Primary Injury.Hematoma Stabilization (Tables 21.3 and 21.4) 365
IV Medications that May be Considered for Control of Elevated Blood Pressure in Patients with ICH 365
Management of Secondary Injury 366
Surgical Options 366
Other Management Issues 367
ICH Recurrence Prevention (Figs. 21.1) 367
Key Points 367
Suggested Reading 369
Chapter 22: Intraventricular Hemorrhage 371
Epidemiology 371
Pathophysiology 373
Clinical Presentation 373
Management 374
Key Points 374
Suggested Reading 374
Chapter 23: Subarachnoid Hemorrhage 376
Definition 376
Epidemiology 376
Clinical Presentation 379
Diagnosis 381
Management 385
Key Points 393
Suggested Reading 393
Chapter 24: Brain Injury Following Cardiac Arrest 394
Introduction 394
Neuronal Injury After Cardiac Arrest 394
Approach to Brain Injury After Cardiac Arrest 396
Brain Injury and the Immediate Post-resuscitative Period 396
First 24 h: Therapeutic Hypothermia and Other Neuroprotective Strategies 397
Clinical Impact and Post-trial Experience of Therapeutic Hypothermia 399
Delivery of Therapeutic Hypothermia 399
Management of Shivering 402
Complications of Hypothermia 402
Managing Neurologic Complications Post-CPR 403
Post 24 h: Prognostication 405
Neurologic Prognostication After Therapeutic Hypothermia 410
Key Points 411
Suggested Reading 411
Chapter 25: Meningitis and Encephalitis 413
Meningitis 413
Definitions and Epidemiology 413
Etiology 414
Clinical Presentation 414
Diagnosis 415
Management (Fig. 25.1) 416
Acute Viral Encephalitis 419
Definitions and Epidemiology 419
Clinical Presentation 420
Diagnosis 421
Management 423
Key Points 423
Suggested Reading 424
Chapter 26: Cerebral Venous Sinus Thrombosis 425
Epidemiology 425
Etiology 425
Anatomy 427
Pathophysiology 428
Clinical Presentation 429
Clinical Differential Diagnosis 430
Diagnostic Tests 430
Management of CVST 433
Complications and Their Management 435
Outcome 436
Key Points 437
Suggested Reading 438
Chapter 27: Neuroleptic Malignant Syndrome, Malignant Hyperthermia, and Serotonin Syndrome 439
Neuroleptic Malignant Syndrome 439
Malignant Hyperthermia 441
Serotonin Syndrome 444
Key Points 446
Suggested Reading 447
Chapter 28: Brain Tumors 448
Epidemiology 448
Etiology 448
Clinical Presentation (Symptoms and Signs) 459
Diagnosis and Differential Diagnosis 462
Management 463
Treatment of Brain Tumors 467
Key Points 470
Suggested Reading 470
Chapter 29: Hydrocephalus 471
Introduction 471
Epidemiology 471
Classification 471
Key Points 476
Suggested Reading 476
Chapter 30: Neuromuscular Disorders 477
General Considerations 477
Bedside Assessment 478
Differential Diagnosis 479
GBS: Acute Inflammatory Demyelinating Polyneuropathy 479
Myasthenia Gravis 483
Critical Illness Neuropathy/Myopathy 485
Prolonged Neuromuscular Blockade 487
Tetanus 487
Botulism 489
Key Points 490
Suggested Reading 490
Chapter 31: Status Epilepticus 491
Definition 491
Epidemiology 491
Subtypes of SE: Three Major Categories 492
Anatomy of SE 492
Etiologies of Seizures and SE 493
In-Hospital-Based Seizures and SE 495
Morbidity from SE 496
Ncse 497
Monitoring 497
Typical EEG Presentation of GCSE and NCSE (Table 31.4) 498
Treatment 501
Medical and Pharmacologic Treatment of SE (Table 31.8) 502
Drug Toxicity-Induced SE: Need for Nonconventional Therapy 502
Drug Interactions 504
Key Points 505
Suggested Reading 505
Chapter 32: Deep Venous Thrombosis and Pulmonary Embolism 506
Epidemiology of Venous Thromboembolism 506
Clinical Presentation of DVT 509
Clinical Presentation of PE 509
Differential Diagnosis for PE (Acute Respiratory Distress) 509
Diagnostic Tests 510
Diagnostic Approach 512
Management Algorithms for PE 513
Management 514
Risk Stratification After PE and Treatment of Massive PE 518
Key Points 521
Suggested Reading 522
Chapter 33: Neurocritical Illness During Pregnancy and Puerperium 523
Introduction 523
Neurologic Conditions in Pregnancy 525
Special Considerations for Critically Ill Obstetric Patients 529
Prediction of Maternal Death 530
Key Points 530
Suggested Reading 531
Chapter 34: Brain Death and Organ Donation 532
Basic Principles 532
Clinical Criteria for Brain Death 533
Ancilary Tests for Brain Death 535
Documentation 537
Organ Donation 537
Key Points 538
Suggested Reading 538
Index 539