More books at www.FlingPublisher.com # goo.gl/QOUDJ the Fling Publisher Guide to itchener et al. Critical Care in Neurolog itchener, Hashem, Wahba, halaf, Zarif, Mansoor Critical Care in Neurolog F P F F P Kitchener – Hashem – Wahba – Khalaf – Zarif – Mansoor Critical Care in Neurology Nabil Kitchener Saher Hashem Mervat Wahba Magdy Khalaf Bassem Zarif Simin Mansoor The Flying Publisher Guide to Critical Care in Neurology 2012 Edition Flying Publisher 4 | Correspondence: [email protected] Disclaimer Neurocritical care is an ever-changing field. The publishers and author of The Flying Publisher Guide to Critical Care in Neurology have made every effort to provide information that is accurate and complete as of the date of publication. However, in view of the rapid changes occurring in medical science, as well as the possibility of human error, this site may contain technical inaccuracies, typographical or other errors. It is the responsibility of the reading physician who must rely on experience and knowledge about the patient to determine the best treatment and care pathway. The information contained herein is provided “as is”, without warranty of any kind. The contributors to this book, including Flying Publisher & Kamps, disclaim responsibility for any errors or omissions or for results obtained from the use of information contained herein. This work is protected by copyright both as a whole and in part. Copy editing: Nilly Nagy and Rob Camp © 2012 by Flying Publisher & Kamps / Design: Attilio Baghino ISBN: 978-3-942687-07-2 | 5 Prologue Neurointensive care is a relatively new field that has developed as a subspecialty of critical care and neurology. The goal of neurointensive care, and the neurointensivist, is to treat and prevent primary and secondary brain (or other nervous system) injury. Inherent in this goal are the monitoring tools unique to the neurointensive care unit, including the most basic but perhaps the most important tool, the neurologic examination. In the era of the subspecialty of critical care neurology, the neurologist is working now as an aggressive interventionalist who manages life-threatening disorders of the nervous system. The neurointensivist’s role is to help follow the neurologic status and treat the patient while integrating his/her knowledge of other organ systems and expertise in critical care, to provide the most comprehensive care possible for the patient. Critical care neurology is practiced in emergency rooms, in consultations in general medical and surgical intensive care units, in intermediary care units such as stroke units, and in specialized neurointensive care units where patients are frequently on life-support systems involving ventilators, intravascular lines, and monitoring and treatment devices. Data has shown that care provided by clinicians specializing in neurologic injury, and within dedicated neurointensive care units, improves patient functional outcome, and reduces hospital mortality, length of stay and resource utilization. This book emphasizes the clinical and practical aspects of management in the neurointensive care unit. This book is written, mainly, for the neurologist working in, or directing, a specialized neurointensive care unit (neurointensivists), as well as other specialists including stroke neurologists, neurosurgeons, pulmonary/critical care specialists, anesthesiologists, nurse practitioners, critical care registered 5 6 | nurses, and therapists all working together towards improved neurologic recovery. We hope this book can provide a new addition to the emerging literature of critical care neurology, and heighten the recognition by general medical and surgical intensivists of the importance and complexities of nervous system dysfunction in critically ill and injured patients. The Editors Nabil Kitchener, Saher Hashem, Mervat Wahba Egypt, USA, January 2012 7 | Editors Authors Nabil Kitchener, MD, PhD Magdy Khalaf, MD Professor of Neurology, GOTHI, Consultant Neurologist and Egypt Chairman of Neurocritical Care President of Egyptian Cerebro- Unit Cardio-Vascular Association GOTHI, Egypt (ECCVA) and Board Director of World Stroke Organization Bassem Zarif, MD (WSO) Lecturer of Cardiology www.ECCVA.com National Heart Institute, GOTHI, [email protected] Egypt Saher Hashem, MD Simin Mansoor, MD Professor and Chairman of Department of Neurology Neurology and Neurocritical University of Tennessee Health Department Sciences Center, UTHSC, USA Cairo University, Egypt Mervat Wahba, MD, FCCP Assistant Professor of Neurology Department of Neurology University of Tennessee Health Sciences Center, UTHSC, USA 8 | | 9 Table of Contents 1. Assessment of Patients in Neurological Emergency............... 13 History ...................................................................................... 15 Physical Exam .......................................................................... 16 1. Mental status ................................................................... 16 2. Cranial nerve (CN) exam ................................................ 16 3. Motor exam ..................................................................... 18 4. Reflexes ............................................................................ 18 5. Sensory exam .................................................................. 18 6. Coordination and balance ............................................. 18 7. Neuroanatomical localization ....................................... 19 Conclusions .............................................................................. 20 2. How to Approach an Unconscious Patient .............................. 21 Diagnosis .................................................................................. 23 Basic assessments ............................................................... 24 General Care of the Comatose Patient .................................. 27 Permanent Vegetative State .................................................. 27 Diagnosis .............................................................................. 29 Management ....................................................................... 29 Locked-in Syndrome ............................................................... 30 Brain Death .............................................................................. 31 3. Documentation and Scores ........................................................ 32 Scoring and Documentation .................................................. 34 Delirium .................................................................................... 38 10 | 4. Brain Injuries ............................................................................... 39 Types of Brain Injuries ........................................................... 39 Primary brain injuries ....................................................... 39 Secondary brain injuries ................................................... 42 Management of Special Issues ............................................... 44 Traumatic brain injury ...................................................... 44 Acute stroke ........................................................................ 45 Status epilepticus (SE) ........................................................ 46 Neuromuscular emergencies ............................................ 47 Management of subarachnoid hemorrhage .................... 50 5. Basic Hemodynamic Monitoring of Neurocritical Patients ... 53 6. Neurocritical Monitoring ........................................................... 59 Neuro-Specific Monitoring .................................................... 59 Clinical Assessment ................................................................. 60 The Glasgow Coma Scale .................................................... 60 Pupillary response .............................................................. 60 Invasive Monitoring ................................................................ 61 Measuring ICP ..................................................................... 62 Indications for ICP monitoring ......................................... 62 Intracranial Pressure Waveforms and Analysis.............. 63 Jugular Venous Oximetry (SjvO2) ...................................... 67 Brain Tissue Oximetry ....................................................... 69 Noninvasive Monitoring ......................................................... 71 Continuous measures of CBF by Transcranial Doppler.. 71 Near Infrared Spectroscopy .............................................. 73 Electrophysiological Monitoring ........................................... 73 Application of the EEG in the ICU: .................................... 76 Multimodal Monitoring .......................................................... 77 Conclusions .............................................................................. 77 7. Cerebral Edema ........................................................................... 79 Types of Cerebral Edema ........................................................ 81 Management of Cerebral Edema ........................................... 82 | 11 8. General Neurological Treatment Strategies ............................ 84 Swallowing Disturbances ....................................................... 85 Respiratory Management in Neurocritical Care ................. 86 Infection Control in Neurocritical Care ................................ 89 Pain Relief and Sedation