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Core Curriculum and Competencies for Advanced Training in Neurological Intensive Care United Council for Neurologic Subspecialties Guidelines Stephan A

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Core Curriculum and Competencies for Advanced Training in Neurological Intensive Care United Council for Neurologic Subspecialties Guidelines Stephan A Neurocritical Care Copyright © 2006 Humana Press Inc. All rights of any nature whatsoever are reserved. ISSN 1541-6933/06/5:159–165 ISSN 1556-0961 (Online) DOI: 10.1385/Neurocrit. Care 2006;05:159–165 Special Article Core Curriculum and Competencies for Advanced Training in Neurological Intensive Care United Council for Neurologic Subspecialties Guidelines Stephan A. Mayer , William M. Coplin , Cherylee Chang , Jose Suarez , Daryl Gress , Michael N. Diringer , Jeffery Frank , J. Claude Hemphill , Gene Sung , Wade Smith , Edward M.Manno , Andrew Kofke , Arthur Lam and , Thorsten Steiner , on behalf of the Neurocritical Care Society , the American Academy of Neurology Section on Critical Care and Emergency Neurology , and the Society of Neurosurgical Anesthesia and Critical Care Introduction dates of cognitive and procedural skills nec- These guidelines regarding the program essary for a training program. Each director content of advanced training in neurological determines the specific content of his or her intensive care were preliminarily endorsed program. on October 20, 2005 by the United Council of Neurological Subspecialties (UCNS), and are A. Cognitive Skill Set based on existing criteria developed by the Acquisition of the following cognitive Society of Critical Care Medicine (SCCM) and skills by trainees can be accomplished through by the Accreditation Council for Gradute the use of any number of techniques, includ- Medical Education (ACGME). These guide- ing supervised direct patient care, didactic lines have been reviewed and adapted by the sessions, journal clubs, or literature reviews. authors to ensure that they combine basic aspects of general critical care medicine that are relevant to neurocritical care, as well as I. Neurological Disease States: specialized skills that are specific to neuro- Pathology, Pathophysiology, and critical care. The following is a listing of Therapy cognitive and procedural skills that are The following are specific diseases, con- fundamental to the training of specialists ditions, and clinical syndromes commonly in neurocritical care, regardless of whether managed by a neurointensivist: a training program is based in neurology, neuro surgery , internal medicine, anesthesi- ology, pediatrics, or another specialty. This A. Cerebrovascular Diseases *Correspondence to: list also includes pertinent aspects on general 1 . Infarction and ischemia Mari E. Mellick critical care, such a cardiac, pulmonary, and a. Massive hemispheric infarction United Council for infectious disease management. b. Basilar artery occlusion and stenosis Neurologic Subspecialties, Fellowship program directors may choose c. Carotid artery occlusion and stenosis 1080 Montreal Avenue, to include additional cognitive or procedural d. Crescendo transient ischemic attacks St. Paul, MN 55116. skills to augment this listing in order to suit e. Occlusive vasculopathies (Moya- E-mail: [email protected] their goals for advanced training for physi- Moya, sickle cell) cians in neurocritical care. These guidelines f. Spinal cord infarction should be used as recommendations for 2 . Intracerebral hemorrhage training directors to use in the development a. Supratentorial of each program. They are not intended to b. Cerebellar constrain any training program. They pro- c. Brainstem vide the basic framework for future man- d. Intraventricular 159 160 Mayer et al. 3 . Subarachnoid hemorrhage (SAH) — aneurysmal and other 3. Drug overdose and withdrawal (e.g., barbiturates, 4. Vascular malformations narcotics, alcohol, cocaine, acetaminophen). a. Arteriovenous (AV) malformations 4. Temperature-related injuries (hyperthermia, hypothermia) b. AV fistulas c. Cavernous angiomas H. Inflammatory and Demyelinating Diseases d. Venous angiomas 5. Dural sinus thrombosis 1. Multiple sclerosis (Marburg variant, transverse myelitis) 6. Carotid-cavernous fi stulae 2. Neurosarcoidosis 7. Cervical and cerebral arterial dissections 3. Acute disseminated encephalomyelitis (ADEM) 4. Central nervous system vasculitis 5. Chemical or sterile meningitis (i.e., posterior fossa B. Neurotrauma syndrome, nonsteroidal anti-infl ammatory drug-induced) 1. Traumatic brain injury 6 . Central pontine myelinolysis a. Axonal shearing injury 7 . Others b. Epidural hematoma c. Subdural hematoma I. Encephalopathies d. Skull fracture 1. Eclampsia, including hemolysis, elevated liver enzymes, e. Contusions and lacerations low platelet count (HELLP) Syndrome f. Penetrating craniocerebral injuries 2 . Hypertensive encephalopathy and posterior reversible g. Traumatic SAH encephalopathy syndrome (PRES) 2. Spinal cord injury 3. Hepatic encephalopathy a. Traumatic injury (transection, contusion, concussion) 4. Uremic encephalopathy b. Vertebral fracture and ligamentous instability 5. Hypoxic-ischemic encephalopathy 3. Electrical injury (e.g., lightning) 6. Mitochondrial encephalopathy, lactic acidosis, and strokelike (episodes) (MELAS) and related disorders C. Seizures and Epilepsy J. Neuroendocrine Disorders 1. Status epilepticus (SE) 1. Pituitary apoplexy a. Convulsive 2. Diabetes insipidus (including triple phase response) b. Nonconvulsive (partial-compex and “ subtle ” second- 3 . Panhypopituitarism arily generalized SE) c. Myoclonic K. Movement Disorders 1. Severe dystonia and opisthotonus D. Neuromuscular Diseases 2 . Hemiballismus 3 . Acute dystonic reactions 1 . Myasthenia gravis 2 . Guillain-Barré syndrome L. Clinical Syndromes 3 . Amyotrophic lateral sclerosis 4 . Rhabdomyolysis and toxic myopathies 1. Coma 5 . Critical illness myopathy and neuropathy 2. Herniation syndromes 3. Elevated intracranial pressure (ICP) 4. Intracranial hypotension/hypovolemia E. Infections 5. Hydrocephalus 1. Encephalitis (viral, bacterial, parasitic) 6. Cord compression 2 . Meningitis (viral, bacterial, parasitic) 7. Brain death 3 . Brain and spinal epidural abscess 8. Vegetative state 4 . Tetanus 9. Delirium 5 . Botulism 10. Abulia 11. Dysautonomia (central fever, hyperventilation, et cetera) 12. Reversible posterior leukoencephalopathy syndrome F. Neuro-Oncology 13. Psychiatric emergencies 1. Brain tumors and metastases 2. Spinal cord tumors and metastases M. Perioperative Neurosurgical Care 3. Carcinomatous meningitis 1. Postcraniotomy hypertension 4. Paraneoplastic syndromes 2 . Postcraniotomy pain 3 . Wound cerebrospinal fl uid (CSF) leaks 4 . Postcraniotomy CSF hypovolemia G. Toxic-Metabolic Disorders 5 . Wound infections 1. Neuroleptic malignant syndrome/malignant hyperthermia 6 . Postoperative brain edema 2 . Serotonin syndrome 7. Postcraniotomy intracranial hemorrhage Neurocritical Care ♦ Volume 5, 2006 Core Curriculum for Neurological Intensive Care 161 8 . Postcarotid endarterectomy/stenting hyperperfusion d. Barotrauma, airway pressures (including permissive syndrome hypercapnia) 9 . Postcervical spine surgery airway management e . Criteria for weaning and weaning techniques 8. Pleural diseases a. Empyema N. Neurorehabilitation b. Massive effusion O. Pharmacotherapeutics c. Pneumothorax 9. Pulmonary hemorrhage and massive hemoptysis II. General Medical Disease States: Pathology, 10. Chest X-ray interpretation Pathophysiology, and Therapy 11. End tidal CO2 monitoring 12 . Sleep apnea The following are medical conditions and skill require- 13 . Control of breathing ments often encountered by neurointensivists: C. Renal Physiology, Pathology, Pathophysiology, A. Cardiovascular Physiology, Pathology, and Therapy Pathophysiology, and Therapy 1. Renal regulation of fl uid and water balance and electrolytes 1. Shock (hypotension) and its complications (vasodilatory 2 . Renal failure: prerenal, renal, and postrenal and cardiogenic) 3. Derangements secondary to alterations in osmolality 2. Myocardial infarction and unstable coronary syndromes and electrolytes 3. Neurogenic cardiac disturbances (electrocardiographic 4. Acid-base disorders and their management [ECG] changes, stunned myocardium) 5 . Principles of hemodialysis 4 . Cardiac rhythm and conduction disturbances; use of 6 . Evaluation of oliguria and polyuria antiarrhythmic medications; indications for and types of 7. Drug dosing in renal failure pacemakers 8 . Management of rhabdomyolysis 5. Pulmonary embolism 9 . Neurogenic disorders of sodium and water regulation 6 . Pulmonary edema: cardiogenic versus noncardiogenic (cerebral salt wasting and secretion of antidiuretic hormone (including neurogenic) [SIADH]) 7. Acute aortic and peripheral vascular disorders (i.e., dis- section, pseudoaneurysm) 8. Recognition, evaluation, and management of hyperten- D. Metabolic and Endocrine Effects of sive emergencies and urgencies Critical Illness 9 . Calculation of derived cardiovascular parameters, 1 . Enteral and parenteral nutrition including systemic and pulmonary vascular resistance, 2 . Endocrinology alveolar-arterial gradients, oxygen transport, and a. Disorders of thyroid function (thyroid storm, myx- consumption edema coma, sick euthyroid syndrome) b. Adrenal crisis B. Respiratory Physiology, Pathology, c. Diabetes mellitus Pathophysiology, and Therapy i. Ketotic and hyperglycemic hyperosmolar coma ii. Hypoglycemia 1 . Acute respiratory failure d. Pheochromocytoma a. Hypoxemic respiratory failure (including acquired e. Disorders of calcium and magnesium balance respiratory distress syndrome [ARDS]) 3. Systemic infl ammatory response syndrome (SIRS) b. Hypercapnic respiratory failure 4 . Fever, thermoregulation, and cooling techniques 2 . Aspiration 3. Bronchopulmonary infections 4. Upper airway obstruction E. Infectious Disease Physiology,
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