Table Of ContentFRONMCFM_i_xii-hr4 3-03-2009 15:50 Page i
Decision Making in
Neurocritical Care
Thieme
FRONMCFM_i_xii-hr4 3-03-2009 15:50 Page ii
FRONMCFM_i_xii-hr4 3-03-2009 15:50 Page iii
Decision Making in
Neurocritical Care
Jennifer A. Frontera, MD
Assistant Professor
Departments of Neurology and Neurosurgery
Medical Director
Neuroscience Intensive Care Unit
Mount Sinai School of Medicine
New York, New York
Thieme
New York • Stuttgart
FRONMCFM_i_xii-hr4 3-03-2009 15:50 Page iv
Dedicated to my parents, Alfred and Veronica Frontera,
who have guided me both intellectually and spiritually.
Thieme Medical Publishers, Inc.
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Library of Congress Cataloging-in-Publication Data
Decision making in neurocritical care / [edited by] Jennifer Frontera.
p. ; cm.
Includes bibliographical references and index.
ISBN 978-1-60406-047-8
1. Neurological intensive care—Decision making. [DNLM: 1. Nervous System Diseases—
diagnosis. 2. Nervous System Diseases—therapy. 3. Critical Care—methods. 4. Trauma,
Nervous System—diagnosis. 5. Trauma. I. Frontera, Jennifer. Nervous System—
therapy. WL 141 D294 2009]
RC350.N49D43 2010
616.8’0428—dc22
2008042540
Copyright © 2009 by Thieme Medical Publishers, Inc. This book, including all parts
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Printed in the United States
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ISBN 978-1-60406-047-8
FRONMCFM_i_xii-hr4 4-03-2009 12:59 Page v
Contents
Foreword . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . vii
Preface . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ix
1 Subarachnoid Hemorrhage . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1
Harshpal Singh, Joshua B. Bederson, and Jennifer A. Frontera
2 Traumatic Brain Injury . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20
Chad Miller
3 Intracerebral Hemorrhage . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 36
Stanley Tuhrim
4 Antiplatelet- and Anticoagulation-Associated
Intracranial Hemorrhage . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 52
Fred Rincon, Andres Fernandez, and Stephan A. Mayer
5 Status Epilepticus . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 63
Jan Claassen and Lawrence J. Hirsch
6 Malignant Ischemic Stroke . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 76
Katja E. Wartenberg
7 Cerebral Sinus Thrombosis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 95
Isabel Fragata and Aman Patel
8 Acute Spinal Cord Injury . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 106
Scott Meyer, Jennifer A. Frontera, Arthur Jenkins III,
andTanvirChoudhri
9 Hypoxic Ischemic Encephalopathy . . . . . . . . . . . . . . . . . . . . . . . . . 121
Adam Webb and Owen Samuels
10 Neurologic Infections . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 134
Stephen Krieger
v
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vi Contents
11 Myasthenic Crisis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 149
Mark Sivak and Jennifer A. Frontera
12 Guillain-Barré Syndrome . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 162
Jennifer A. Frontera
13 Critical Illness Polyneuropathy and Myopathy . . . . . . . . . . . . . . 174
Valerie Dechant, Eduardo Adonias de Sousa,
and Kiwon Lee
14 Brain Death and Organ Donation . . . . . . . . . . . . . . . . . . . . . . . . . . . 182
Jennifer A. Frontera
15 Management of Elevated Intracranial Pressure . . . . . . . . . . . . . . 195
David Seder, Stephan A. Mayer, and
Jennifer A. Frontera
16 Airway Management and Sedation . . . . . . . . . . . . . . . . . . . . . . . . . 219
David C. Kramer, Irene Osborn, and Meagen Gaddis
17 Ventilator Management . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 234
Mariana Nunez, Roopa Kohli-Seth, Zinobia Khan,
Moses Bachan, and Jennifer A. Frontera
18 Prophylaxis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 252
Sherry Hsiang-Yi Chou
19 Glucose Management and Nutrition . . . . . . . . . . . . . . . . . . . . . . . . 270
Jennifer A. Frontera
20 Induced Normothermia and Hypothermia . . . . . . . . . . . . . . . . . . 283
Katja E. Wartenberg and Stephan A. Mayer
21 Basics of Neuroimaging . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 299
Chitra Venkatasubramanian and Christine A. Wijman
22 Grades of Recommendations Based on Level of Evidence . . . . 317
Jennifer A. Frontera
Index . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 323
FRONMCFM_i_xii-hr4 3-03-2009 15:50 Page vii
Foreword
Neurocritical care is one of the newest and most exciting specialties in
medicine today. As recently as the late 1980s, neurocritical care in the
modern sense did not exist. Neurosurgical intensive care units (ICUs)
had been established in larger teaching hospitals, but the patient’s
ticket into the unit was via the operating room. Neurosurgeons under-
stood that close clinical monitoring during the postoperative period
was essential for attaining good outcomes; it would be tragic if all of
their hard work and surgical skill would go for naught because a post-
operative complication was not picked up and managed in a timely
fashion. In those days, neurosurgeons directed the care of their pa-
tients, the units were open, and consultants were abundant. Apart from
specially trained neuro-nurses, intracranial pressure monitors, and the
novel use of a pulmonary artery catheter to apply hypertensive hyper-
volemic therapy for vasospasm, there was little to differentiate the
neurologic ICU from any medical or surgical ICU.
Things could not be more different today. Neurocritical care is now
recognized as a bona fide subspecialty of medicine. The Neurocritical
Care Society was incorporated in 2002, the journal Neurocritical Care
began publication in 2004, and the first U.S. Neurocritical Care Board
Examination was given in 2007. The past 20 years have witnessed an
explosion of therapies for conditions that were long considered un-
treatable, including reperfusion therapies for acute ischemic stroke, hy-
pothermia for cardiac arrest, and hemostatic and local thrombolytic
therapy for intracerebral hemorrhage. Proof of effectiveness varies for
these treatments, but clearly the rules have changed, and new battle
lines have been drawn. Even more exciting are the transformational in-
sights into the comatose human brain that have come from the appli-
cation of newer sophisticated neuromonitoring modalities. It is now
feasible to continuously monitor brain tissue oxygenation and blood
flow, neurochemistry, and electrical function in real time. The chal-
lenge that confronts us today is how to make optimal use of this infor-
mation in ways that can improve clinical outcomes.
vii
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viii Foreword
Perhaps nothing reflects the spirit of neurocritical care more, how-
ever, than the forward-looking attitudes that neurointensivists have
regarding prognosis. Our patients are the sickest of the sick. A devas-
tating injury to the brain—unlike any other organ—threatens a person’s
“being” like nothing else can. The diseases that we now consider to be
our greatest challenges are exactly those that were typically consid-
ered untreatable just 10 or 20 years ago. We have discarded the ther-
apeutic nihilism of older days and replaced it with hope and a
newfound respect for the resilience of the human brain. We still have
a long, long way to go, but as we continue to challenge, probe, explore,
and test new approaches to treating severe brain injury, we have every
reason to be optimistic.
Dr. Frontera’s Decision Making in Neurocritical Careis a succinct
and highly utilitarian introduction to the basics of managing patients
in the neurologic ICU. The emphasis is on rapid, focused clinical evalu-
ation and evidence-based management strategies. Medication dosages
and management protocols are spelled out in a clear and direct fash-
ion. When there is a lot of variability and controversy regarding how a
disease state or condition should best be treated, this is highlighted and
the therapeutic options are spelled out. Whether you are a nurse, med-
ical student, resident, fellow, or attending physician, it is the perfect
quick reference for managing critically ill neurologic patients.
Stephan A. Mayer, MD, FCCM
Associate Professor
Director of the Division
of Neurocritical Care
Columbia University
New York, New York
FRONMCFM_i_xii-hr4 3-03-2009 15:50 Page ix
Preface
The aim of this book is to provide a basic overview of the new and rap-
idly developing subspecialty of neurocritical care in a format that is
easily accessible. As neurocritical care develops and becomes more spe-
cialized with new diagnostic, monitoring and therapeutic modalities,
neurologists, neurosurgeons, and critical care medicine physicians will
find themselves managing patients with unique physiologic needs. In
addition, with the trend toward an increased number of beds in inten-
sive care units, more physicians will be treating more patients with a
critical illness.
This book is structured to deal with adult neurocritical care diag-
nosis, evaluation, and therapeutic decision-making as it would arise for
the typical provider. The focus on flowchart algorithms and decision
trees allows for a streamlined overview of each topic. The book con-
tains all of the important evidence-based elements essential to man-
agement in a format that is portable and allows for easy reference. Each
chapter begins with a case example and provides bulleted essentials of
diagnosis, including epidemiologic data and a differential diagnosis, ex-
amination features and suggestions for laboratory, imaging, and spe-
cial diagnostic studies. Evaluation and treatment options are discussed
and each chapter ends with “Pearls and Pitfalls” in evaluation and man-
agement.
Decision Making in Neurocritical Care will also prove to be a useful
study guide, as it covers specific topics that appear on the United
Council of Neurological Subspecialties Neurocritical Care Board
Examination.
ix
