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Neurocritical Care By Eelco F. M. Wijdicks, MD, PhD, FACP

Neurocritical Care
by Eelco F. M. Wijdicks, MD, PhD, FACP

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This consecutive volume in the 'What Do I Do Now?' series provides clinicians with specific focus and insight on interventions in acute neurologic disorders. Written in a conversational tone, using a case-based approach, Neurocritical Care explains how to handle comparatively common clinical problems emergently.
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Neurocritical Care Summary

Neurocritical Care by Eelco F. M. Wijdicks, MD, PhD, FACP

Patients in the neurointensive care unit pose many clinical challenges for the attending physician. Even experienced clinicians occasionally arrive at the point where diagnostic, work-up, treatment, or prognostic thinking becomes blocked. Neurocritical Care is the next volume in the "What Do I Do Now?" series and provides the clinician with specific focus and insight on interventions in acute neurologic disorders. Neurocritical care in daily practice pertains to managing deteriorating patients, treatment of complications but also end-of-life care assisting families with difficult decisions. Written with a conversational tone and using a case- based approach, Neurocritical Care emphasizes how to handle comparatively common clinical problems emergently.

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Neurocritical Care Reviews

"In this unique text, Drs. Wijdicks and Rabinstein - true masters of both the practice and science of critical care neurology - deftly combine nuanced interpretation of the most pertinent scientific literature with unparalleled experience and incisive reasoning to provide explicit guidance for making the most difficult of these decisions. Neurocritical Care - What Next? is written in a style that makes it suitable for both reading in its entirety and as a reference. It is a must read for anyone who regularly cares for critically ill neurologic and neurosurgical patients. Furthermore, due to its pragmatic approach, it should be readily available in all emergency departments and intensive care units as a first-line reference when a difficult neurocritical care issue arises." -- Joseph D. Burns, MD, Attending Neurointensivist, Boston Medical Center, Departments of Neurology and Neurosurgery, Boston University School of Medicine

"Neurocritical Care by Wijdicks and Rabinstein is an innovative and highly effective text to educate physicians about this rapidly growing field. The book is original and practical; it approaches the educational matter in a real-life manner, with the presentation of cases followed by honest and down-to-earth discussions of the basics and nuances of management...[and] provide[s] the appropriate amount of evidence for the reader to understand the essentials of management...They provide "key points" at the culmination of each chapter, giving the reader salient take home messages that allow for easy digestion. In an age in which it is difficult to know what to read Neurocritical Care is refreshingly straightforward and downright enjoyable to read. It should be a staple on every neurologist's or critical care physician's desk." -- David M. Greer, MD, MA, FCCM, Vice Chair, Department of Neurology, Yale University School of Medicine

"Eelco Wijdicks and Alejandro Rabinstein have teamed up again to deliver another well-written, innovative text in the fundamentals of neurocritical care. In a field where there continues to be an explosion of new evidence every year, clinicians are still faced with many areas of uncertainty in the day-to-day decision-making of complex illness. To this end, this collection of cases, accounts based on actual patients seen by the authors, helps the reader frame an approach that can be individualized to a particular patient. The authors have designed the structure of the chapters based not on topic areas but rather by practical issues of management that neurologists, neurosurgeons, and intensivists have to face every day in the complex care of critically ill neurologic patients." -- Kevin N. Sheth, MD, Section Editor, Current Treatment Options in Neurology

"Drs. Wijdiks and Rabinstein, 2 masters of the emerging science of critical care neurology,
have produced a superb and enjoyably distilled short and practical guide to the field that offers valuable information to even the most experienced clinicians...The authors present easily digestible information primarily about the interventions encountered in neurocritical care. It is a must-read book for any neurologist, neurosurgeon, or any other clinician taking care of these patients." -- Timea Hodics, MD, Archives of Neurology

About Eelco F. M. Wijdicks, MD, PhD, FACP

EELCO F. M. WIJDICKS, M.D., Ph.D., F.A.C.P., Professor of Neurology, College of Medicine, Chair, Division of Critical Care Neurology, Consultant, Neurosciences Intensive Care Unit, Saint Marys Hospital, Mayo Clinic, Rochester, Minnesota ALEJANDRO A. RABINSTEIN, M.D., Professor of Neurology, College of Medicine, Division of Critical Care Neurology, Medical Director and Consultant, Neurosciences Intensive Care Unit, Saint Marys Hospital, Mayo Clinic, Rochester, Minnesota

Table of Contents

SECTION 1: ACUTE INTERVENTIONS ; CHAPTER 1: SURGERY FOR CEREBRAL HEMORRHAGE ; Cerebral hemorrhage sometimes requires neurosurgical evacuation.Surgery becomes an option when a patient has deteriorated. The indications for intervention are discussed, and particularly when. This chapter also reviews the available evidence from clinical surgical trials. ; CHAPTER 2: REVERSAL OF ANTICOAGULATION AFTER CEREBRAL HEMORRHAGE ; Anticoagulation associated cerebral hemorrhage often results in expansion and worsening of the clinical condition. Early reversal of an increased INR is key to reduce the hemorrhage volume. Traditionally it involves administration of fresh frozen plasma and vitamine K, but this chapter discusses new pharmacologic approaches. ; CHAPTER 3: MEDICAL CARE OF TRAUMATIC BRAIN INJURY ; New traumatic brain contusions may rapidly result in increased intracranial pressure. This chapter discusses how to recognize early increased intracranial pressure (ICP) and indications for placement of a monitoring device. The first line of ICP control is provided in this chapter. The effects and side effects of different osmotic diuretics are discussed. ; CHAPTER 4: ANTIBIOTICS AND CORTICOSTEROIDS FOR BACTERIAL MENINGITIS ; Outcome in acute bacterial meningitis is dependent on early initiation of antibiotic treatment. This chapter discusses the pros and cons of corticosteroids, choice of antibiotics, how to rapidly assess the severity of the illness and how to find the source. ; CHAPTER 5: SORTING OUT AND TREATING ENCEPHALITIS ; The diagnosis of encephalitis is easy, finding the cause is not. The differential diagnosis of the main forms of acute encephalitis is discussed here. Medical therapy and indications for brain biopsy are mentioned. ; CHAPTER 6: RESPIRATORY SUPPORT IN NEUROMUSCULAR RESPIRATORY FAILURE ; How to confidently assess the need for respiratory support in acute neuromuscular disease is difficult. This chapter discusses indications of triage to the intensive care unit, the benefits and risks of noninvasive mechanical ventilation and indications of intubation in acute neuromuscular disorders such as Guillain-Barre syndrome and myasthenia gravis. ; CHAPTER 7: ENDOVASCULAR RECANALIZATION IN ACUTE STROKE ; Major hemispheric stroke from large intracranial vessel occlusion may not respond to intravenous thrombolysis and may require a more aggressive endovascular approach. How to make that determination using CT angiogram and CT perfusion is discussed. This chapter mentions currently used mechanical devices and what they can achieve. ; CHAPTER 8: DECOMPRESSIVE CRANIECTOMY IN ACUTE STROKE ; Large hemispheric strokes may swell and decompressive craniectomy is the only way to salvage the patient from certain neurologic death. Not everyone is persuaded by this last resort measure. Who benefits and how much is discussed in this chapter. ; CHAPTER 9: NEUROLOGIC WORSENING IN SUBARACHNOID HEMORRHAGE ; Patients with a subarachnoid hemorrhage have a proclivity to deteriorate. Common causes include rebleeding, hydrocephalus and vasospasm. Prevention of complications -neurologic and medical- is key to reduce morbidity. Diagnostic and therapeutic clues are provided in this chapter. ; CHAPTER 10: OPTIONS IN ACUTE SPINAL CORD COMPRESSION ; For patients there is an immediate urgency to prevent permanent paralysis. For many physicians this is one of the most uncomfortable situations. The immediate medical treatment with corticosteroids and indications for acute neurosurgical decompression are discussed. ; CHAPTER 11: CHOICES IN REFRACTORY STATUS EPILEPTICUS ; Many seizures stop with benzodiazepines and fosphenytoin, but what are the options when seizures return? What are the readily available choices and treatment algorithms? These options are discussed in this chapter ; CHAPTER 12: DETERIORIORATION AFTER BRAIN METASTASIS ; Deteriorating patients with metastasis or malignant brain tumor in close proximity to the brainstem may be due to hemorrhage or brain edema. Options for stabilization and indications for urgent debulking are discussed. ; CHAPTER 13: HYPOTHERMIA AFTER CARDIOPULMONARY RESUSCITATION ; Hypothermia protocols are increasingly used to treat comatose patients after CPR.The indications, management and implications for neurologic prognostication are discussed. ; CHAPTER 14: ANTIDOTES FOR THE INTOXICATED PATIENT ; How to manage a comatose patient with a serious intoxication is discussed in this chapter. Options for antidotes, dialysis and other measures to correct laboratory abnormalities are concisely reviewed. ; CHAPTER 15: FAILURE TO AWAKEN AFTER SURGERY ; Failure to awaken fully after surgery is a common reason for consultation. One example of a patient with a postoperative stroke is presented. ; CHAPTER 16: STUPOR AFTER BRAIN SURGERY ; Successful brain surgery, but no awakening of the patient. Evaluation, interpretation of neuroimaging and potential causes are discussed in this chapter. ; SECTION 2: CALLS, PAGES AND OTHER ALARMS ; CHAPTER 17. ACUTE DELIRIUM ; Perhaps one of the most difficult disease states to handle well. Acute agitation may be a time consuming issue for the nursing staff and physician. Inadequate use of medication may only lead to further complications. ; CHAPTER 18: EARLY HYPOTENSION AND FEVER ; The sudden appearance or fever and hypotension in any patient with an acute brain injury requires a quick evaluation and intervention. How to successfully approach this problem is illustrated in a typical case scenario. ; CHAPTER 19: ACUTE PULMONARY EDEMA AFTER TRAUMA ; Diffuse pulmonary infiltrates on chest X- ray and oxygen desaturation may indicate several acute conditions. How to differentiate neurogenic from cardiogenic from aspiration and how to best treat these conditions initially is discussed in this chapter. ; CHAPTER 20: SYMPATHETIC HYPERACTIVITY SYNDROME ; An underappreciated and undertreated condition which may cause potentially life threatening complications. The difficulties with management and short and long term pharmacologic approaches are discussed. ; CHAPTER 21: ACUTE HYPERTENSION AFTER STROKE ; Blood pressure goals after acute ischemic and hemorrhagic stroke are commonly established early on. The rationale for treatment but also the uncertainties of when to treat are discussed in detail. ; CHAPTER 22: ACUTE CARDIAC ARRHYTMIA AFTER ACUTE BRAIN INJURY ; EKG changes are common and vary from simple ST segment changes to new complex cardiac arrhythmias. In addition critically ill patients often have underlying cardiac disease and the most common problem is flaring up of atrial fibrillation. The pharmacologic choices to initially treat the increased heart rate and options for long term control are discussed in this chapter. ; CHAPTER 23: AUTONOMIC FAILURE AFTER GUILLAIN - BARRE SYNDROME ; Dysautonomia is common in severe forms of GBS, paralytic ileus is a concern in all immobilized bedridden patients with GBS. Treatment of these autonomic disorders is provided here. ; CHAPTER 24: WEANING OF THE VENTILATOR IN MYASTHENIA GRAVIS ; Weaning from the ventilator after intubation after treatment for myasthenic crisis is difficult with a high probability of reintubation. Stategies for successful weaning and extubation are discussed. ; CHAPTER 25: ACUTE HYPONATREMIA AFTER SAH ; Hyponatremia is a very common electrolyte abnormality in the NICU and in particular after subarachnoid hemorrhage. Evaluation and treatment are discussed. How to calculate rate of infusion of fluids is highlighted in this chapter. ; CHAPTER 26: DIABETES INSIPIDUS AFTER BRAIN TUMOR SURGERY ; Diabetes insipidus is a difficult management problem after surgery for resection of a centrally located brain tumor. Fluid management, administration of vasopressin and monitoring of effect of treatment are discussed. ; CHAPTER 27: DRUG INTERACTIONS ; Drug interactions are common, but frequently not noticed. Some are very concerning and clinically relevant. An example of how antiepileptic drugs interact with warfarin is discussed. ; SECTION 3: LONGTERM SUPPORT, END OF LIFE CARE AND PALLIATION ; CHAPTER 28: DECISIONS IN PERSISTENT VEGETATIVE STATE ; Early on -after a major brain injury-the diagnosis of a persistent vegetative state and its important long term implications remains tentative at best . Long term care of debilitated neurologic patients requires placement of a tracheostomy and percuteous gastrostomy. Timing and indications are discussed in this chapter. ; CHAPTER 29: DNR/DNI ORDERS AND WITHDRAWAL OF LIFE SUPPORT ; Discussion of DNR/DNI orders and interpretation of advance directives with family members. Who brings this up?How to go about withdrawing of support and how to provide best palliation is discussed. ; CHAPTER 30: PITFALLS OF BRAINDEATH DETERMINATION ; Brain death determination and confounders. This chapter lists the potential for errors and how to avoid them. ; CHAPTER 31: APPROACH TO ORGAN DONATION ; Physicians have the obligation to approach an organ procurement agency after brain death or after withdrawal of support. The two main procedures -donation after brain death and donation after cardiac death- are discussed in this chapter.

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Neurocritical Care by Eelco F. M. Wijdicks, MD, PhD, FACP
Eelco F. M. Wijdicks, MD, PhD, FACP
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