Table Of ContentTHE PRACTICE OF EMERGENCY
AND CRITICAL CARE NEUROLOGY
S E C O N D E D I T I O N
THE PRACTICE
OF EMERGENCY
AND CRITICAL CARE
NEUROLOGY
EELCO F. M. WIJDICKS, MD, PhD, FACP, FNCS, FANA
Professor of Neurology, Mayo Clinic College of Medicine
Chair, Division of Critical Care Neurology
Consultant, Neurosciences Intensive Care Unit
Mayo Clinic Hospital, Saint Marys Campus
Mayo Clinic Rochester, Minnesota
1
1
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Library of Congress Cataloging-in-Publication Data
Wijdicks, Eelco F. M., 1954- , author.
The practice of emergency and critical care neurology / Eelco F.M. Wijdicks. — Second edition.
p. ; cm.
Includes bibliographical references and index.
ISBN 978–0–19–025955–6 (alk. paper)
I. Title.
[DNLM: 1. Critical Care—methods. 2. Neurologic Manifestations. 3. Central Nervous System Diseases—diagnosis.
4. Central Nervous System Diseases—therapy. 5. Emergency Treatment—methods. WL 340]
RC350.N49
616.8′0428—dc23
2015033653
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CONTENTS
List of Capsules vii 14. The Neurosciences Intensive
Care Unit 147
Preface to the Second Edition ix
Preface to the First Edition xi
PART V: General Principles of Management
Acknowledgments xiii
of Critically Ill Neurologic Patients in the
Neurosciences Intensive Care Unit
PART I: General Principles of Recognition 15. General Perspectives of Care 157
of Critically Ill Neurologic Patients in the
Emergency Department 16. Agitation and Pain 177
17. Mechanical Ventilation 191
1. The Presenting Neurologic Emergency 3
18. Nutrition 205
2. Criteria of Triage 9
19. Volume Status and Blood Pressure 218
PART II: Evaluation of Presenting Symptoms 20. Anticoagulation and Thrombolysis 231
Indicating Urgency
21. Fever and Cooling 243
3. Confused and Febrile 17
22. Increased Intracranial Pressure 250
4. A Terrible Headache 25
5. Blacked Out and Slumped Down 36 PART VI: Technologies in the Neurosciences
Intensive Care Unit
6. See Nothing, See Double, See Shapes 43
23. Monitoring Devices 271
7. Spinning 53
24. Transcranial Doppler Ultrasound
8. Moving, Jerking, and Spasm 58
and Neurophysiology 287
25. Multimodal Monitoring
PART III: Evaluation of Presenting
and Biomarkers 309
Symptoms Indicating Critical Emergency
9. Can’t Walk or Stand 67
PART VII: Management of Specific
10. Short of Breath 78 Disorders in Critical Care Neurology
11. Seizing 92 26. Aneurysmal Subarachnoid
Hemorrhage 317
12. Comatose 104
27. Ganglionic and Lobar Hemorrhages 347
PART IV: Organization of the Neurosciences 28. Cerebellum and Brainstem
Intensive Care Unit Hemorrhages 370
13. The Responsibilities of the 29. Major Hemispheric Ischemic Stroke
Neurointensivist 139 Syndromes 384
vi Contents
30. Acute Basilar Artery Occlusion 414 53. Acute Kidney Injury 722
31. Cerebellar Infarct 429 54. Endocrine Emergencies 730
32. Cerebral Venous Thrombosis 439
PART XI: Management of Systemic
33. Acute Bacterial Meningitis 453
Complications
34. Brain Abscess 468
55. Management of Pulmonary
35. Acute Encephalitis 481 Complications 739
36. Acute Spinal Cord Disorders 500 56. Management of Cardiac
Complications 753
37. Acute White Matter Disorders 517
57. Management of Acid– Base
38. Acute Obstructive Hydrocephalus 532
Disorders, Sodium
39. Malignant Brain Tumors 542 and Glucose Handling 772
40. Status Epilepticus 551 58. Management of Gastrointestinal
Complications 791
41. Traumatic Brain Injury 566
59. Management of Nosocomial
42. Guillain- Barré Syndrome 587
Infections 803
43. Myasthenia Gravis 608
60. Management of Hematologic
Complications and Transfusion 816
PART VIII: Postoperative Neurosurgical
61. Management of Complications
and Neurointerventional Complications
Associated with Vascular Access 823
44. Complications of Craniotomy
62. Management of Drug Reactions 829
and Biopsy 629
45. Complications of Carotid
PART XII: Decisions at the End of Life
Endarterectomy and Stenting 641
and Other Responsibilities
46. Complications of Interventional
63. The Diagnosis of Brain Death 839
Neuroradiology 652
64. Donation after Cardiac Death 857
PART IX: Emergency Consults in the General 65. Organ Procurement 864
Intensive Care Unit
66. Ethical and Legal Matters 868
47. Neurology of Transplant Medicine 663
48. Neurology of Cardiac and PART XIII: Formulas and Scales
Aortic Surgery 674
Formulas and Tables for Titrating Therapy 881
49. Neurology of Resuscitation Medicine 688
50. Neurology of Pregnancy 698 PART XIV: Guidelines
Guidelines, Consensus Statements,
PART X: Critical Care Support and Evidence- Based Reviews Related
to Critical Care Neurology 891
51. Shock 707
52. Cardiopulmonary Arrest 716 Index 897
LIST OF CAPSULES
1.1 Injury Severity Score 5 15.2 Preventing Deep Vein
Thrombosis 167
2.1 Intensive Care Resources and Bed
Rationing 10 16.1 Patient- controlled Analgesia 185
3.1 DSM- 5 Diagnostic Criteria for 17.1 Ventilator Bundle 194
Delirium 18
18.1 Obesity and Critical Illness 206
4.1 Acute Serious Headache in the
19.1 The Frank- Starling Curve 220
Emergency Department 26
20.1 The Fibrinolytic System 236
4.2 Blood in Cerebrospinal Fluid 31
21.1 Origin of Fever 244
5.1 Autonomic Control in Neurally
Mediated Syncope 39 22.1 Brain Edema: Physiology and
Pathology 252
6.1 Degree of Visual Loss 44
22.2 Brain Compartments and
7.1 Systemic Illness and Drug-i nduced
Consequences 257
Dizziness 54
23.1 Cerebral Blood Flow and Brain
8.1 Rigidity and Hyperthermia 62
Tissue Oxygen 277
9.1 Localizing Spinal Cord
24.1 Continuous
Lesions 70
Electroencephalographic
10.1 Neural Control of Breathing and Monitoring 298
Abnormal Patterns 80
24.2 Spreading Depolarization 299
11.1 No Intravenous Access 98
25.1 Requirements for Monitoring 310
11.2 Antiepileptic Drugs and Side
26.1 Aneurysmal Rupture 318
Effects 99
27.1 Cerebral Amyloid Angiopathy
12.1 Ascending Reticular Activating
and Cerebral Hemorrhage 354
System 112
28.1 Surgical Options in Pontine
12.2 Mechanisms of Toxin-i nduced
Hemorrhage 378
Coma 118
29.1 Decompressive Hemicraniectomy
12.3 Functional MRI in Coma 127
and Outcome 404
13.1 The Neurocritical Care Society 140
30.1 The Classic Brainstem
13.2 Simulation Training 143 Syndromes 415
14.1 Costs of ICU Care 151 31.1 Vascularization of the Cerebellum 430
15.1 The Pathophysiology of Being 32.1 Pathology of Cerebral Venous
Supine 164 Occlusion 446
viii List of Capsules
33.1 Pathogenesis of Acute Bacterial 50.1 Putative Mechanism of
Meningitis 455 Eclampsia 700
34.1 Neuropathology of Abscess 469 51.1 Mechanism of Sepsis 708
35.1 Paraneoplastic Neuronal Antineural 51.2 Fluids and Shock 710
Antibodies and Encephalitis 485 52.1 Feedback of CPR with
36.1 Injury Mechanism in Acute Capnography 718
Spinal Cord Injury 513
53.1 Pathogenesis of Acute Renal
37.1 Diagnostic Clinical and Injury 723
Laboratory Criteria for Multiple
53.2 Osmotic Shifts and Treatment of
Sclerosis 526
Kidney Injury 728
38.1 Pathophysiology of Acute
54.1 Glucose and the Brain 731
Hydrocephalus 534
55.1 Bronchoscopy in the NICU 742
39.1 WHO Grading of Tumors
of the Central Nervous System 545 56.1 Autonomic Nervous System
and the Heart 754
40.1 Neuronal Damage Associated
with Status Epilepticus 553 56.2 Asystole and Aneurysmal Rupture 756
41.1 Gunshots to the Head 578 57.1 The Vaptans 782
42.1 Immunoglobulin 598 57.2 Cerebral Salt Wasting Syndrome
and Fludrocortisone 783
43.1 Molecular Footprint
of Myasthenia Gravis 614 58.1 Stress- related Mucosal Disease 792
44.1 Pathophysiology of Remote 59.1 Antibiotic Template 810
Hemorrhages After Craniotomy 631 60.1 Anemia and Brain Physiology 818
45.1 Carotid Endarterectomy 642 61.1 Teaching Procedures 824
46.1 Pericoil Edema 655 62.1 DRESS Syndrome 833
47.1 Mechanism of Brain Edema
63.1 International Brain Death Criteria 840
in Fulminant Hepatic Failure 668
64.1 Maastricht Classification
48.1 Cardiopulmonary Bypass
of Non- Heart- Beating Donors 858
and Changes in pH 676
65.1 UNOS Board of Directors
48.2 Vascular Anatomy of the
Recommendations on Organ
Spinal Cord 682
Donation 865
49.1 Neuronal Destruction from
66.1 Self- fulfilling Prophecy
Anoxic-ischemic Injury 689
in Neurocritical Care 870
PREFACE TO THE SECOND EDITION
A legitimate subspecialty allows neurointensiv- of the patient changes when information changes.
ists to manage patients with acute and critical Because there is a considerable proportion of
neurologic disease. Here is what I think— the patients with a new medical critical illness after a
neurointensivist is now a more recognized neurocritical illness, I have added a new section on
specialist and provides better care of patients critical care support adapted to the critically ill neu-
with large scale clinical problems associated with rologic patient. Such an addition is needed to update
acute neurologic disease. The disorders that shape neurointensivists on practice changes in critical care
this field are better defined, and all of us in the medicine. Other new sections are on multimodal
trenches, so to speak, have now a good idea of how monitoring, cooling techniques, and on the quality
to approach these problems. Revisions of text- improvement in the NICU—t opics that have been
books—a nd also this one—a re required to assimi- heavily written about in the years since the previ-
late and critique new information and to put more ous edition. Although a companion monograph on
modern approaches into practice. Single authored the neurological complications of critical illness has
textbooks will remain useful not only because it been published, (Neurologic Complications of Critical
forces the author to discipline approaches to Illness (Contemporary Neurology Series) third edition
patient management, but also to bring a consis- Oxford University Press, 2009) I felt it necessary to
tent practical perspective to the whole of it’s care. summarize common requests for consults in other
I hope this book not only provides an adequate ICUs in four new chapters.
grounding for newcomers, but also appeals to a In total this new edition has 12 new chapters,
broad audience of experienced practitioners. over 50 new original illustrations and neuroim-
This new edition of The Practice of Emergency aging figures and I have added numerous new
and Critical Care Neurology continues the same sections, subsections and capsules, which further
organizational principles. My approach has been complete the work. As with prior editions, this
to pose the significant questions differently: How book has a pocketbook with a selection of the
does the patient with an acute neurologic condi- most relevant tables and figures. This pocket book
tion present to us? What are the distinguishing can physically accompany practitioners, but it is
characteristics of the clinical picture, and how also easily downloaded on portable devices.
do we best anticipate clinical worsening? What This book before you is as recent and updated
do we do to stabilize the patient neurologically as possible, and we will be planning future edi-
and medically? This book is much less about tions every 5 years to keep the information fresh.
theorizing and more about management— All that said, I hope this textbook—a work
progressing from an initial relatively straight- which originally started as a 3 volume work and
forward approach to more complex decisions in a now is condensed in a nearly 1000 page volume—
rapidly deteriorating situation. What practitioners will continue its lineage. So what follows I hope is
need is an operational definition of the degree of a book which provides practical and data- driven
deterioration and what can lead to bad outcomes. advice to any physician caring for seriously ill
The chapters have been revised to incorporate neurologic patients.
new information and new ideas. The management
E. F. M. Wijdicks
