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Chapter 36 - Building a Case for a Neurocritical Care Unit
- Edited by Michel T. Torbey, Ohio State University
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- Book:
- Neurocritical Care
- Published online:
- 24 July 2019
- Print publication:
- 18 July 2019, pp 421-429
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Summary
The birth of neurocritical care (NCC) can be traced to Harvey Cushing’s “anesthesia chart” and to Walter Dandy, who opened the first three-bed unit in the USA for postoperative neurosurgical patients at Johns Hopkins Hospital in Baltimore, Maryland [1]. Modern NCC is a new field that began in the early 1980s in a few isolated hospitals in the USA and Europe. This new area of expertise was needed to provide specialized care for patients with neurological and neurosurgical problems, which until that time was only offered in general intensive care units (ICUs) or in units of less acuity, such as stroke units. In fact, acute neurologic disorders were estimated to occur in 45% of medical ICU patients and neurologic complications to occur in 33% of patients admitted for non-neurological reasons [2]. Because enlightened neurosurgeons, neurologists, and general intensivists realized that a substantial number of ICU patients could be better served by specialists, Neuro-ICUs (NICUs) were gradually established throughout the USA and Europe during the 1990s, often directed and staffed by neurologists with special interest in internal medicine or anesthesiology. Then in 2002, the Neurocritical Care Society (NCS) was formed, with close to 200 members. In 2005, the United Council for Neurological Subspecialties (UCNS) recognized NCC as a new neurological subspecialty and a process was created to accredit US NCC programs and develop an NCC physician certification. In 2008, Leapfrog recognized neurointensivists (NIs) as part of the critical care pool of physicians – an important development since, except for UCNS certification, no American Board of Medical Specialties (ABMS) critical care certification path had existed for NIs. This boosted the subspecialty to new heights, and the NCS grew to over 2500 members (please visit www.neurocriticalcare.org/practitioners/physicians for more information).
14 - Status Epilepticus
- from SECTION III - MANAGEMENT OF SPECIFIC DISORDERS IN THE NEUROCRITICAL CARE UNIT
- Edited by Michel T. Torbey
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- Book:
- Neurocritical Care
- Published online:
- 27 April 2010
- Print publication:
- 14 September 2009, pp 185-198
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Summary
Traditionally, status epilepticus (SE) has been arbitrarily defined as either a single generalized seizure lasting greater than 30 minutes, or a group of repetitive seizures between which the patient had not fully recovered. Recently, exactly when a prolonged seizure or set of recurrent seizures is deemed to have become SE has further evolved. In light of data now demonstrating the time-dependent risk of early neuronal injury, and the necessity to treat this disorder prior to irreversible cerebral insult, shorter seizure epochs have been emphasized. Since typical seizures last no longer than 1–2 minutes, and injury can be documented histologically by 30 minutes, it is reasonable to consider as SE any seizure events greater than 5–10 minutes in length. This epoch has been now adopted by both the American Academy of Neurology and the American Epilepsy Society.
THE PHENOTYPE OF STATUS EPILEPTICUS
There are three main subtypes of SE:
▪ The most common is generalized convulsive SE (GCSE).
▪ Focal Motor SE (FMSE), or epilepsy partialis continuans, is relatively uncommon and typically manifests as continuous motor twitching of a single limb or side of face.
▪ It is not clear whether FMSE may result in substantive injury to the cerebral cortex.
▪ Reasonable attempts at control are advocated, but high-risk therapies such as induced pharmacologic coma are rarely considered appropriate.
▪ Nonconvulsive SE (NCSE) incorporates a variety of continuous non-motor electrical paroxysms, often described as complex-partial SE, subtle SE, non tonic-clonic SE, or subclinical SE.
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17 - Encephalopathy
- from SECTION III - MANAGEMENT OF SPECIFIC DISORDERS IN THE NEUROCRITICAL CARE UNIT
- Edited by Michel T. Torbey
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- Book:
- Neurocritical Care
- Published online:
- 27 April 2010
- Print publication:
- 14 September 2009, pp 220-226
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Summary
Encephalopathy is a common complication of systemic illness or direct brain injury. It can manifest as a spectrum that begins with subtle cognitive changes, progresses as a full-blown syndrome of brain dysfunction, and eventually leads to coma or brain death (the latter two are described in separate chapters). In this chapter, we focus on the detection, etiologic diagnosis, and management of noncomatose, critically ill, encephalopathic patients. Their condition has been traditionally known with several interchangeable names such as acute confusional state, acute organic brain syndrome, and acute cerebral insufficiency, but is most commonly referred to as delirium.
Delirium contributes significantly to lengthened hospital stay, increased morbidity and mortality, increased overall medical costs, and worse long-term neurocognitive outcomes. Despite the awareness of its existence since the earliest historical medical documents, timely detection, workup, and appropriate management continue to present challenges for the treating physicians. Delirious patients in the Intensive Care Unit (ICU) form a particularly understudied population with unique characteristics.
▪ Delirium has been described as an acute alteration of consciousness and higher cognitive functions.
▪ It typically develops over a short period of time and has a fluctuating course.
▪ It is a well-defined syndrome that may be precipitated by several diverse pathological processes.
▪ The current edition of the Diagnostic and Statistic Manual (DSM-IV TR) lists criteria for the diagnosis of delirium due to a general medical condition (Table 17.1).
The incidence of delirium has been estimated as between 5% and 40% for hospitalized patients in general and between 11% and 80% for critically ill patients.
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