T H E P R AC T I C E O F   E M E R G E N C Y AND CRITICAL CARE NEUROLOGY SECOND EDITION T H E P R AC T I C E OF EMERGENCY AND CRITICAL CARE NEUROLOGY E E L C O F M W I J D I C K S , 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 Oxford University Press is a department of the University of Oxford It furthers the University’s objective of excellence in research, scholarship, and education by publishing worldwide.Oxford is a registered trade mark of Oxford University Press in the UK and certain other countries Published in the United States of America by Oxford University Press 198 Madison Avenue, New York, NY 10016, United States of America © 2016 Mayo Foundation for Medical Education and Research First Edition published in 2010 Second Edition published in 2016 All rights reserved No part of this publication may be reproduced, stored in a retrieval system, or transmitted, in any form or by any means, without the prior permission in writing of Oxford University Press, or as expressly permitted by law, by license, or under terms agreed with the appropriate reproduction rights organization Inquiries concerning reproduction outside the scope of the above should be sent to the Rights Department, Oxford University Press, at the address above You must not circulate this work in any other form and you must impose this same condition on any acquirer 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 9 8 7 6 5 4 3 2 1 Printed by Walsworth, USA This material is not intended to be, and should not be considered, a substitute for medical or other professional advice Treatment for the conditions described in this material is highly dependent on the individual circumstances And, while this material is designed to offer accurate information with respect to the subject matter covered and to be current as of the time it was written, research and knowledge about medical and health issues is constantly evolving and dose schedules for medications are being revised continually, with new side effects recognized and accounted for regularly Readers must therefore always check the product information and clinical procedures with the most up-to-date published product information and data sheets provided by the manufacturers and the most recent codes of conduct and safety regulation The publisher and the authors make no representations or warranties to readers, express or implied, as to the accuracy or completeness of this material Without limiting the foregoing, the publisher and the authors make no representations or warranties as to the accuracy or efficacy of the drug dosages mentioned in the material The authors and the publisher not accept, and expressly disclaim, any responsibility for any liability, loss or risk that may be claimed or incurred as a consequence of the use and/or application of any of the contents of this material CONTENTS List of Capsules Preface to the Second Edition  Preface to the First Edition  Acknowledgments  vii ix xi xiii PART I:  General Principles of Recognition of Critically Ill Neurologic Patients in the Emergency Department The Presenting Neurologic Emergency  Criteria of Triage  PART II:  Evaluation of Presenting Symptoms Indicating Urgency Confused and Febrile  17 A Terrible Headache  25 Blacked Out and Slumped Down  36 See Nothing, See Double, See Shapes  43 Spinning  53 Moving, Jerking, and Spasm  58 PART III:  Evaluation of Presenting Symptoms Indicating Critical Emergency Can’t Walk or Stand  67 10 Short of Breath  78 11 Seizing  92 14 The Neurosciences Intensive Care Unit  147 PART V:  General Principles of Management of Critically Ill Neurologic Patients in the Neurosciences Intensive Care Unit 15 General Perspectives of Care  157 16 Agitation and Pain  177 17 Mechanical Ventilation  191 18 Nutrition  205 19 Volume Status and Blood Pressure  218 20 Anticoagulation and Thrombolysis  231 21 Fever and Cooling  243 22 Increased Intracranial Pressure  250 PART VI:  Technologies in the Neurosciences Intensive Care Unit 23 Monitoring Devices  271 24 Transcranial Doppler Ultrasound and Neurophysiology  287 25 Multimodal Monitoring and Biomarkers  309 PART VII:  Management of Specific Disorders in Critical Care Neurology 26 Aneurysmal Subarachnoid Hemorrhage  317 27 Ganglionic and Lobar Hemorrhages  347 PART IV:  Organization of the Neurosciences Intensive Care Unit 28 Cerebellum and Brainstem Hemorrhages  370 13 The Responsibilities of the Neurointensivist  29 Major Hemispheric Ischemic Stroke Syndromes  384 12 Comatose  104 139 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 33 Acute Bacterial Meningitis  453 34 Brain Abscess  468 35 Acute Encephalitis  481 36 Acute Spinal Cord Disorders  500 37 Acute White Matter Disorders  517 38 Acute Obstructive Hydrocephalus  532 39 Malignant Brain Tumors  542 40 Status Epilepticus  551 41 Traumatic Brain Injury  566 42 Guillain-​Barré Syndrome  587 43 Myasthenia Gravis  608 PART VIII:  Postoperative Neurosurgical and Neurointerventional Complications 44 Complications of Craniotomy and Biopsy  629 45 Complications of Carotid Endarterectomy and Stenting  641 46 Complications of Interventional Neuroradiology  652 PART IX:  Emergency Consults in the General Intensive Care Unit 47 Neurology of Transplant Medicine  48 Neurology of Cardiac and Aortic Surgery  55 Management of Pulmonary Complications  739 56 Management of Cardiac Complications  753 57 Management of Acid–​Base Disorders, Sodium and Glucose Handling  772 58 Management of Gastrointestinal Complications  791 59 Management of Nosocomial Infections  803 60 Management of Hematologic Complications and Transfusion  816 61 Management of Complications Associated with Vascular Access  823 62 Management of Drug Reactions  829 PART XII:  Decisions at the End of Life and Other Responsibilities 63 The Diagnosis of Brain Death  839 64 Donation after Cardiac Death  857 65 Organ Procurement  864 66 Ethical and Legal Matters  868 663 PART XIII:  Formulas and Scales 674 49 Neurology of Resuscitation Medicine  688 50 Neurology of Pregnancy  PART XI:  Management of Systemic Complications 698 PART X:  Critical Care Support 51 Shock  707 52 Cardiopulmonary Arrest  716 Formulas and Tables for Titrating Therapy  881 PART XIV:  Guidelines Guidelines, Consensus Statements, and Evidence-​Based Reviews Related to Critical Care Neurology  891 Index  897 LIST OF CAPSULES 1.1 Injury Severity Score  15.2 Intensive Care Resources and Bed Rationing  Preventing Deep Vein Thrombosis  2.1 167 10 16.1 Patient-​controlled Analgesia  185 3.1 DSM-​5 Diagnostic Criteria for Delirium  18 17.1 Ventilator Bundle  194 4.1 Acute Serious Headache in the Emergency Department  18.1 Obesity and Critical Illness  206 26 19.1 The Frank-​Starling Curve  220 4.2 Blood in Cerebrospinal Fluid 31 20.1 The Fibrinolytic System  236 5.1 Autonomic Control in Neurally Mediated Syncope  21.1 Origin of Fever  244 39 22.1 6.1 Degree of Visual Loss  44 Brain Edema: Physiology and Pathology  252 7.1 Systemic Illness and Drug-​induced Dizziness  22.2 54 Brain Compartments and Consequences  257 8.1 Rigidity and Hyperthermia  62 23.1 9.1 Localizing Spinal Cord Lesions  Cerebral Blood Flow and Brain Tissue Oxygen  277 70 24.1 10.1 Neural Control of Breathing and Abnormal Patterns  80 Continuous Electroencephalographic Monitoring  298 11.1 No Intravenous Access  98 24.2 Spreading Depolarization  299 11.2 Antiepileptic Drugs and Side Effects  25.1 Requirements for Monitoring  310 99 26.1 Aneurysmal Rupture  318 12.1 Ascending Reticular Activating System  27.1 112 Cerebral Amyloid Angiopathy and Cerebral Hemorrhage  354 12.2 Mechanisms of Toxin-​induced Coma  28.1 118 Surgical Options in Pontine Hemorrhage  378 12.3 Functional MRI in Coma 127 29.1 13.1 The Neurocritical Care Society  140 Decompressive Hemicraniectomy and Outcome  404 13.2 Simulation Training 143 30.1 The Classic Brainstem Syndromes  415 14.1 Costs of ICU Care  151 31.1 Vascularization of the Cerebellum  430 15.1 The Pathophysiology of Being Supine  164 32.1 Pathology of Cerebral Venous Occlusion  446 viii List of Capsules 33.1 Pathogenesis of Acute Bacterial Meningitis  455 50.1 Putative Mechanism of Eclampsia  700 34.1 Neuropathology of Abscess  469 51.1 Mechanism of Sepsis  708 35.1 Paraneoplastic Neuronal Antineural Antibodies and Encephalitis 485 51.2 Fluids and Shock  710 36.1 Injury Mechanism in Acute Spinal Cord Injury  52.1 Feedback of CPR with Capnography  718 37.1 Diagnostic Clinical and Laboratory Criteria for Multiple Sclerosis  53.1 Pathogenesis of Acute Renal Injury 723 526 53.2 38.1 Pathophysiology of Acute Hydrocephalus  Osmotic Shifts and Treatment of Kidney Injury 728 534 54.1 Glucose and the Brain  731 39.1 WHO Grading of Tumors of the Central Nervous System  55.1 Bronchoscopy in the NICU  742 545 56.1 40.1 Neuronal Damage Associated with Status Epilepticus  Autonomic Nervous System and the Heart  754 553 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 43.1 Molecular Footprint of Myasthenia Gravis  Cerebral Salt Wasting Syndrome and Fludrocortisone  783 614 58.1 Stress-​related Mucosal Disease  792 44.1 Pathophysiology of Remote Hemorrhages After Craniotomy  631 59.1 Antibiotic Template  810 45.1 Carotid Endarterectomy  642 60.1 Anemia and Brain Physiology  818 46.1 Pericoil Edema  655 61.1 Teaching Procedures  824 47.1 Mechanism of Brain Edema in Fulminant Hepatic Failure  62.1 DRESS Syndrome  833 668 63.1 International Brain Death Criteria 840 48.1 Cardiopulmonary Bypass and Changes in pH 64.1 676 Maastricht Classification of Non-​Heart-​Beating Donors  858 48.2 Vascular Anatomy of the Spinal Cord 65.1 682 49.1 Neuronal Destruction from Anoxic-ischemic Injury UNOS Board of Directors Recommendations on Organ Donation 865 689 Self-​fulfilling Prophecy in Neurocritical Care  870 513 66.1 P R E FAC E TO   T H E S E C O N D E D I T I O N A legitimate subspecialty allows neurointensivists to manage patients with acute and critical neurologic disease Here is what I think—​ the neurointensivist is now a more recognized specialist and provides better care of patients with large scale clinical problems associated with acute neurologic disease The disorders that shape this field are better defined, and all of us in the trenches, so to speak, have now a good idea of how to approach these problems Revisions of textbooks—​and also this one—​are required to assimilate and critique new information and to put more modern approaches into practice Single authored textbooks will remain useful not only because it forces the author to discipline approaches to patient management, but also to bring a consistent practical perspective to the whole of it’s care I hope this book not only provides an adequate grounding for newcomers, but also appeals to a broad audience of experienced practitioners This new edition of The Practice of Emergency and Critical Care Neurology continues the same organizational principles My approach has been to pose the significant questions differently: How does the patient with an acute neurologic condition present to us? What are the distinguishing characteristics of the clinical picture, and how we best anticipate clinical worsening? What we to stabilize the patient neurologically and medically? This book is much less about theorizing and more about management— progressing from an initial relatively straight­ ​ forward approach to more complex decisions in a rapidly deteriorating situation What practitioners need is an operational definition of the degree of deterioration and what can lead to bad outcomes The chapters have been revised to incorporate new information and new ideas The management of the patient changes when information changes Because there is a considerable proportion of patients with a new medical critical illness after a neurocritical illness, I have added a new section on critical care support adapted to the critically ill neurologic patient Such an addition is needed to update neurointensivists on practice changes in critical care medicine Other new sections are on multimodal monitoring, cooling techniques, and on the quality improvement in the NICU—​topics that have been heavily written about in the years since the previous edition Although a companion monograph on the neurological complications of critical illness has been published, (Neurologic Complications of Critical Illness (Contemporary Neurology Series) third edition Oxford University Press, 2009) I felt it necessary to summarize common requests for consults in other ICUs in four new chapters In total this new edition has 12 new chapters, over 50 new original illustrations and neuroimaging figures and I have added numerous new sections, subsections and capsules, which further complete the work As with prior editions, this book has a pocketbook with a selection of the most relevant tables and figures This pocket book can physically accompany practitioners, but it is also easily downloaded on portable devices This book before you is as recent and updated as possible, and we will be planning future editions every years to keep the information fresh All that said, I hope this textbook—​a work which originally started as a volume work and now is condensed in a nearly 1000 page volume— will continue its lineage So what follows I hope is a book which provides practical and data-​driven advice to any physician caring for seriously ill neurologic patients E F. M Wijdicks P R E FAC E TO   T H E F I R S T E D I T I O N The specialty of critical care neurology considers its province acute neurologic disease presenting in the emergency department or the neurosciences intensive care unit and neurologic complications of medical or surgical critical illness The Practice of Emergency and Critical Care Neurology combines two monographs previously published with Oxford University Press, amalgamating the unique structure of each book, but in a more condensed form after eliminating overlap I believe that with these changes, it is now a many-​sided textbook on the management of a patient with an acute, definitely serious, and primarily critical neurologic disorder (The neurologic complications of medical or surgical critical illness have been published last year in a companion monograph, also with Oxford University Press and now in a third edition.) The Practice of Emergency and Critical Care Neurology follows patients from the very moment they enter the emergency department (ED)—​where the neurologist makes on-​the-​spot decisions—​to their admission to the neurologic intensive care unit (NICU)—​where mostly specialists in the neurosciences assume full responsibility for patient care This book differs from conventional textbooks by specifically following the time course of clinical complexities as they emerge and change Part I introduces the presenting neurologic emergency and the responsibilities of specialists interacting in the ED Triage of acute neurologic disease has been defined arbitrarily, but many neurologists opt for brief observation in an intensive care setting rather than admission to the ward Guidance for more appropriate triage is provided Part II encompasses the evaluation of presenting symptoms that indicate urgency, and their conversational titles echo the patient’s main concerns or common requests for urgent consultation As one would expect, the differential diagnosis of these symptoms is very broad However, the intentionally brief chapters emphasize the red flags They are intended only to orient readers, and to set the priorities and direction of the clinical approach Part III discusses the four most common presenting symptoms that indicate a critical neurologic emergency and, above all, require prompt action These conditions often need immediate care even before the patient is triaged out of the ED Part IV discusses the organization of intensive care units (ICUs), including options for different types and models that can be used in ICUs all over the world In some hospitals, the closed unit form fits nicely; in others, logistics, manpower, and economics may not allow such a model In two chapters, the main attributes of a physician practicing critical care neurology and the organization of NICUs are explained These chapters are included for readers who want to pursue a career in this field or set up a NICU Part V is devoted to the basic treatment of patients with critical neurologic illness and, next to the section on complex nursing care, includes the basic principles of pain and agitation management, mechanical ventilation, nutritional requirements, and fluid management The use of anticoagulation, or its reversal in some instances, and the current practice of thrombolytic therapy in acute ischemic stroke are presented in detail All these measures may have an impact on existing brain injury, and therefore this section concludes with the management of increased intracranial pressure 908 Index Magnetic resonance venography (MRV), 439, 442, 443f Mallory-​Weiss tears, 793, 793f hemorrhage from, 793 Malnutrition, physical signs of, 207t Manikin-​based simulation, 824c Mannitol, 129, 131, 260–​261, 357, 375, 400, 462, 547, 635, 776, 780 Marburg variant multiple sclerosis (MS), 523f Maternal cardiac arrest anoxic-​ischemic encephalopathy after, 702 causes of (BEAU-​CHOPS), 702t Mechanical Embolus Removal in Cerebral Ischemia (MERCI), 396 Mechanical ventilation, 192, 527 See also Tracheostomy controlled, 196 indications for, 191–​192 modes of, 194, 195t physiologic principles and standard, 192–​197 weaning from, 199–​200 criteria for, 199–​200, 199t extubation and, 198, 200 Medulloblastoma, 543f Meningitis, 481, 591t See also Bacterial meningitis hyponatremia in, 780 pneumococcal, 535f Meningococcal meningitis, 456 chemoprophylaxis options for, 462t Mesencephalon infarct, third-​nerve palsy due to, 49f Metabolic acidosis, 774–​775 causes of, 774t Metabolic alkalosis, 775 causes of, 775t Metamorphopsia, 50 Methanol, 122–​123 Methicillin-​resistant Staphylococcus aureus (MRSA), 810 Methotrexate, 519 Methotrexate leukoencephalopathy, 524f Methylprednisolone, 397, 510, 514 Methylprednisolone pulse therapy, 618 Metoclopramide, 210, 432 Metoprolol, 762, 764, 767 Metronidazole, 473, 474t, 808 Microdialysis, 276–​277 Microdialysis catheter, 276 Micropsia, 50 Midazolam, 99c, 181–​182, 328, 561 Midbrain hemorrhages, 371 Middle cerebral artery (MCA), 287–​290f, 296, 384–​385 aneurysm, ruptured, 318 hyperdense MCA sign, 390, 390, 389f occlusion, 301f, 384–​386, 389f Miller Fisher syndrome (MFS), 590t Mini-​sleep test, 608, 610 Miosis, 616, 843 Mistakes, disclosure of, 874–​875 Monitoring multimodal, 309–​310 of the critically ill neurologic, options in, 311f rationale for, 308–​309, 309c Monitoring devices, 271 See also specific topics future directions for, 282 Monocular blindness, 43 Monro-​Kellie doctrine, 250 Morphine, 185, 579 Mosquito-​borne eastern equine encephalomyelitis (EEE), 482–​483 Motor axonal neuropathy, acute, 587 Movement disorders, 58 clinical assessment of, 58–​61 line of action in, 61–​62 MR angiography See Magnetic resonance angiography (MRA) MRI See Magnetic resonance imaging (MRI) Mucosal disease, stress-​related, 792c Multifocal atrial tachycardia (MAT), 764 Multiple sclerosis (MS) See also Fulminant multiple sclerosis (MS) clinical and laboratory criteria for, 526c Marburg variant, 523f Muscle strength, grading, 501, 501t, 611 Muscle weakness, 67 Mutism, 348, 519 Myasthenia gravis, 591t, 608 causes and management of deterioration in, 618–​620 clinical recognition of, 608–​611 diagnosis of, 608, 611 diagnostic tests in, 613t exacerbation of, 608 in-​hospital deterioration in, 619 initial management of, 615–​618, 615t molecular footprint of, 614c neuroimaging and laboratory tests, 611–​613 outcome, 620 outcome algorithm in, 621f pharmaceutical agents with potential to aggravate, 616t respiratory failure in, 608, 610–​611 seronegative, 613 Myasthenia Gravis Foundation of America, 611 Mycophenolate mofetil (CellCept), 528, 619 Mycoplasma pneumoniae, 587 Myelitis See Transverse myelitis Myelopathy, 73, 502–​503 causes of, 69t treatment of, 514 Myocardial ischemia, acute, 753 Myoclonus, 58, 59t Myoclonus status epilepticus, 94–​95 Myorhythmias, 58 Myxedema coma, 732 precipitating factors in, 732, 731t N-​acetylcysteine (NAC), 124 Naloxone, 121, 131, 133, 186 Nasogastric tube, placement of, 209, 209f complications of, 209–​210 Nasojejunal tubes, 210 Index National Institutes of Health Stroke Scale (NIHSS), 384 modified, 885t Natriuretic peptides, 778–​779, 779f Near-​infrared spectroscopy, 279, 281f Necrotic myelopathy, 511 Neisseria meningitides, 453 Neostigmine, 608, 612, 796 Nephrotoxicity, 619 Nerve biopsy, in GBS, 591–​592 Neurocritical Care Society (NCS), 140c Neurocysticercosis, 551 Neuroendovascular procedures See Endovascular techniques Neurointensivist legitimacy of, 139–​141 responsibilities of, 139–​145, 141t competencies, 144 morale, 141–​142, 141f procedures, 142 rounds, 144, 145t training, 144, 145c Neuroleptic malignant syndrome (NMS), 61, 832 Neurologic emergency See also specific topics assessment of, 4–​6 presentations of, 3–​4 principles of, 3–​8 Neurologic-​neurosurgical intensive care unit practice models, 147–​149, 148t Neuromonitors See also Monitoring questions to consider when evaluating, 310c Neuromuscular complications in transplant medicine, 671–​672 Neuromuscular respiratory failure See also Respiratory failure bedside assessment of, 82f clinical features of imminent, 82t pulmonary function tests in monitoring, 83t Neuron-​specific enolase (NSE), 693 Neuropathy acute motor axonal, 592 anterior ischemic optic, 51 vasculitic, 591t Neuroradiologic procedures, interventional, 652 See also Endovascular techniques Neurosciences intensive care unit (NICU), 9, 150 See also specific topics criteria for admission, 11–​12t organization and layout of, 147, 148f costs, 149, 151, 151c design, 147–​149 quality control, 150, 150–​152 quality improvement, 150–​152, 150t staffing, 149, 149f Nicardipine, 227, 334 Nifedipine, 28 Nimodipine, 328, 566, 577 Nitroprusside, 227 909 Non-​heart-​beating donors (NHBDs) See also Donation after cardiac death (DCD) Maastricht classification of, 858c Nonsteroidal anti-​inflammatory agents (NSAIDs), 186–​187 Normoglycemia, 784–​785 Nosocomial bronchopneumonia, clinical diagnosis of, 804–​805 Nosocomial gastrointestinal infections, 813 antimicrobial treatment of, 808, 808t Nosocomial infections, 803 antibiotic-​resistance problem and, 809–​810, 812 clinical features and evaluation of, 804–​805 definition of, 803 in implantable CNS devices, 808–​809, 809t pneumonia, 246t, 803–​804 prevalence studies of, 803 related to IV catheters, 806–​807 urinary tract infections (UTIs), 807–​808, 808t Nuchal rigidity, 454 Nuclear brain scan, 848 Nursing care, general, 157–​166 Nutrition, 205–​214 enteral, 209–​211 indications for gastrostomy, 211–​213 parenteral, 213–​214 Nutritional needs and maintenance, 205–​208 Nystagmus in acute lesions of central vestibular system, 54t central, 53, 55 peripheral vestibular and congenital, 55 positional, 55 Obesity and critical illness, 206c Obstructive hydrocephalus, acute, 532 causes and management of deterioration in, 538 clinical recognition of, 532–​533 initial management of, 537–​538, 538t masses causing, 533t neuroimaging and laboratory tests, 533, 535f–​537f, 543–​544 outcome, 539, 540f pathophysiology of, 534c Ocular bobbing, 370, 371 Ocular movements, 844 Oculogyric crises, 58–​59, 60f Oculomotor palsy, 47, 371, 542 Ogilvie syndrome, causes of, 796t Omeprazole, 794, 830t Ondansetron, 629 Ophthalmologic disorders, 45t See also Visual loss Ophthalmoplegia, bilateral pseudointernuclear, 610, 610f Opiate overdose, differential diagnosis and failure to reverse coma from alleged, 133t Opiates, 121, 186–​187 See also specific drugs adverse effects, 187t Optic nerve sheath, ultrasound of, 280–​281 Optic nerve sheath diameter (ONSD), 280–​281 910 Index Optic neuritis, 45 Optic neuropathy, anterior ischemic, 51 Oral care, 159–​160 Organ donation See also Transplant medicine discussion of, 172 multistep process of, 865f Organ donation requests, 864–​866 Organ donors, brain dead management of, 851–​852 Organ procurement organizations (OPOs), 864–​866 Oscillopsia, 53 Osmolality, 129, 218, 261, 261t, 547 effective, 218 Osmolar gap, 118, 123, 129, 881 Osmotic diuresis, 260–​261, 261t, 576, 782, 784 Otitis, due to herpes zoster, 56f Otogenic brain abscesses, 469, 471 Otologic emergencies, 53, 54t, 56 Oximetry, noninvasive, 282–​283 Oximetry monitoring, brain tissue, 276–​277 Oxygen, brain tissue, 277c Oxygenation, cerebral clinical guide to improve, 278t Oxygenation monitoring, cerebral indications for, 276t Oxygenation parameters, monitoring of, 281 Pain, physiologic effects of, 183f Pain management, 177, 183–​185 pharmaceutical agents for, 185–​1187 (see also specific drugs) Palinopsia, 50 Palsy cranial nerve, 47t oculomotor, 45, 371, 542 third-​nerve, 48f, 49f Pantoprazole, 399, 794 Papilledema, 439, 454, 520 Paradoxical breathing, 80, 81f Paralytic ileus See also Ileus causes of, 796t Paraneoplastic limbic encephalitis, 485 Paraneoplastic neuronal antineural antibodies and encephalitis, 485c Paraplegia acute, 68–​69, 69t after aortic surgery, 680–​681, 681t Parenchymal hemorrhages, 370 Parenteral nutrition, 213–​214 Parinaud syndrome, 371, 532 Paroxysmal sympathetic hyperactivity, 568, 569f, 579 Patient-​controlled analgesia (PCA), 185, 185c Patient hand-​offs, essentials of, 12t Patient transfers and transports, in-​hospital, 12t, 166 precautions before, 168t transfer out of ICU, 9–​10 Penicillins, 795, 809, 810 Pentobarbital, 561 Penumbra System (PS), 396 Perched facet, 505 Percutaneous endoscopic gastrostomy (PEG), 212, 213f placement technique of, 213f Perimesencephalic hemorrhage See Pretruncal subarachnoid hemorrhage (SAH) Periodic lateralized epileptiform discharges (PLEDs), 300, 555 Periorbital edema and ecchymosis, 567f Peripherally inserted central venous catheter (PICC), 824–​826 Peritumoral edema, glioblastoma with, 547f Perphenazine, 552t PERRLA (pupils equal, round, reactive to light and accommodation), 43 pH See Acid-​base abnormalities and disorders Pharmacodynamics and pharmacokinetics, principles of, 829–​830 Pharyngeal reflex, 844 Phencyclidine (PCP), 120 Phenobarbital, 636 Phenytoin, 97, 98, 99c, 328, 475, 557, 830t Phlebitis, 807 Phrenic nerve injury, 78–​79, 85f Physical therapy in NICUs, 157, 163 See also Nursing care Pineal germinoma, 537 Pineal gland tumors, 532 Pineal parenchymal neoplasms, 537 Pineal region tumors, 532, 537 Pineoblastoma, 537, 539 Pineocytoma, 539 Pituitary apoplexy, 733–​734 presenting signs of, 733, 733t pressure effects of, 733f Pituitary surgery, hyponatremia after, 780 Plasma agents, 222, 223t Plasma exchange, 527t, 596–​698 adverse effects of due to IVIG and, 833 benefits of, 596 complications during and after, 597t contraindications to, 596 Plasmapheresis, 528 Plasminogen See Tissue plasminogen activator (tPA) Platelet transfusions, 819 Platinum coils, 330 detachable, 329 Pleocytosis, 507 Pleural effusions, 743–​744 Pneumococcal meningitis, 535f Pneumococci, penicillin-​resistant, 810 Pneumocystis carinii, 398 Pneumonia See also Aspiration pneumonia; Bronchopneumonia; Ventilator-​associated pneumonia (VAP) nosocomial, 246t, 803–​804 Pneumonitis See Aspiration pneumonitis Pneumothorax, 739, 743f, 723–​825 Index Poisoning, coma from acid-​base abnormalities and, 128–​129 assessment of, 117, 118–​125 changes in vital signs in, 107t laboratory studies, 126–​130 mechanisms, 118c Polycythemia vera, 388, 394–​395 Polymerase chain reaction (PCR), 23, 458, 489–​491, 517 Polytrauma, 739 Pontine hemorrhages, 371–​373, 377, 375 gastric mucosa protection in, 377 surgical options in, 378c types of, 375f Porphyria, 590 Positioning of patients, 161–​163, 162f Positive end-​expiratory pressure (PEEP), 600, 636, 741, 746 Positron emission tomography (PET), 544 Post-​cardiac arrest syndrome, 719–​720 pathophysiology, clinical manifestations, and potential treatments, 719t Posterior cerebral artery (PCA), 288 Posterior cranial fossa See Tight posterior fossa Posterior fossa epidural hematoma, 590 Posterior inferior cerebellar artery (PICA) infarct, 429 Posterior reversible encephalopathy syndrome (PRES), 519, 699f Potassium See Hyperkalemia Praziquantel, 474t Pregnancy, 698 clinical syndromes in, 698–​702 general principles of the neurology of, 698 neurologic disorders of, 703t Pregnancy risk categories, FDA, 699t Pregnant patient, neurocritical care in a, 702–​703 PRES (posterior reversible encephalopathy syndrome), 519, 699f Pressure-​control ventilation, 196 Pressure mapping, 158, 159f Pressure-​support ventilation, 196 Pressure-​support weaning, 200 Pressure ulceration, 157 common areas of, 158f Pretruncal subarachnoid hemorrhage (SAH), 322, 324f Procainamide, 764 Progressive multifocal leukoencephalopathy (PML), 669, 670f Promethazine, 629 Propafenone, 764 Propanolol, 579 Propofol, 99c, 179–​181, 263, 328, 447, 547, 560 Propofol infusion syndrome (PRIS), 181, 558 Propranolol, 762t Protamine sulfate, 358, 359 prothrombin complex concentrate 358, 359 Proteus mirabilis, 808 911 Proton magnetic resonance spectroscopy, 543 Pseudomonas aeruginosa, 453, 457t, 803, 810t Psychogenic status epilepticus, 94 Ptosis, 608, 609f, 610f, 611 cerebral, 385f complete, 48 Puerperum, neurologic disorders of, 703t Pulmonary disease, 739 See also specific topics Pulmonary edema, 819f acute development of, 85f neurogenic, 745, 746f clinical features and management of, 746 Pulmonary embolism, 338, 747 clinical features and management of, 747–​749 Pulmonary infection score, modified, 806t Pulsatility index, 287 Pulse oximetry, 282–​283 Pupil abnormalities brain death and, 843 coma and, 110, 111f, 114, 115 Pupils equal, round, reactive to light and accommodation (PERRLA), 42 Putaminal hemorrhages, 347–​349, 350f Pyrazinamide, 474–​475, 474t Pyridostigmine, 610, 613 Pyridoxine, 474 Pyrimethamine, 474t, 494 Q fever, 484 Quadriplegia, 595 Quantitative electroencephalography (qEEG), 298c Quinidine, 764 Rabies encephalitis, 483 “Raccoon eyes,” 567f Radial artery catheterization, 282 Radiologic landmarks, 431 See also Endovascular techniques (and complications of interventional neuroradiology) Ranitidine, 794, 795 Rapid sequence intubation, 89, 90t Rapid shallow breathing index, 200, 201f Real-​time myocardial perfusion contrast echocardiography (RTP-​CE), 758 Rebleeding in subarachnoid hemorrhage, 295 Reflexes, 844 brainstem reflex, 843 vestibulospinal reflex, 55 Remifentanil hydrochloride, 743 Renal replacement therapy (RRT) criteria for initiation of, 727t types of, 727f Reperfusion hemorrhage, after carotid stenting, 657f Respiration, definition of, 846 Respiratory acidosis, 775 causes of, 775t Respiratory alkalosis, 776 causes of, 776t Respiratory care, 159–​160 See also specific topics 912 Index Respiratory distress, acute in mechanically ventilated patients, 740–​743 algorithm for, 741f differential diagnosis of, 743t pathophysiology of, 739–​740 Respiratory failure, 610–​611, 613, 615 See also Neuromuscular respiratory failure acute hypercapnic, initial bedside approach to, 740t acute hypoxemic, initial bedside approach to, 740t causes of, 78–​85, 79f, 80t Respiratory muscles, anatomy of, 81f Respiratory paradox See Paradoxical breathing Respiratory pulse, 80 Resuscitation medicine clinical examination of the comatose patient, 689–​690 management, 691 neurology of, 688 pathophysiological concepts, 688–​689 prediction of prognosis, 691–​693 Retroperitoneal hematoma, 816 Reverse urea hypothesis, 728c Rhabdomyolysis, 671, 775 Richmond Agitation-​Sedation Scale (RASS), 180t Rickettsial diseases, 483 Rifampin, 462t, 809 RIFLE criteria (renal failure), 722, 723t Rigidity hyperthermia and, 62c nuchal, 454 Riker Sedation-​Agitation Scale (SAS), 179t RIPE therapy, 474–​475 Risk prevention and the law, 875 Rituximab, 619 Rocking horse breathing See Paradoxical breathing Rocky Mountain spotted fever, 483, 484, 489 Rounds, 144, 145t Saddle anesthesia, 501 Salicylates poisoning, 123 Sedation, pharmaceutical agents for, 178–​182 Sedation-​Agitation Scale (SAS), 179t Seizures, 92, 301f See also Paroxysmal sympathetic hyperactivity; Status epilepticus as complication of craniotomy and biopsy, 629, 636–​637 recurrent, 92 management of, 95, 97 tests, 95, 97t Seizure threshold, pharmaceutical agents that can reduce, 552t Selective serotonin reuptake inhibitors (SSRIs), 119–​120 Self-​fulfilling prophecy in neurocritical care, 870c Sensory ataxia, 67–​68 Sensory dermatomes, 70f Sepsis catheter-​related, 806 antimicrobial treatment of, 806t definition of, 709t mechanism of, 708c in NICU, 807, 808 severe, 709t Septic shock, 459 diagnostic criteria for, 709t management of, 709–​711 Serratia marcescens, 808 Shivering thermoregulation and, 244c treatment options in, 247t Shock, 707 fluids and, 710c Shock index (SI), 711–​712, 712f Shock states, 711–​713 See also Septic shock assessment of, 707–​709 Sickle-​cell syndromes, 387–​388 Simulation training, 142, 143c Sinus bradycardia, 762 Sinus bradycardia arrhythmia, 762 Sinusitis, 248t Sinus tachycardia, 755, 760, 761–​762 Sirolimus, 519 Skin abnormalities and assessment of coma, 106t Skin care, 157–​158 Skin lesions in coma, 106 Skin rash, drug-​induced, 831, 832t Sodium and water homeostasis, disorders of, 776 See also Hyponatremia hypotonic and hypertonic states, 776–​784 Somatosensory evoked potentials (SSEPs), 302, 304, 391, 643, 692–​693, 849 Sotalol, 764 Spasm, 58 Spastic gait, 67 Spetzler-​Martin grading system for arteriovenous malformations, 360t Spinal cord vascular anatomy of, 682c vascular supply of, 682c Spinal cord disorders, acute, 500 causes and management of deterioration in, 511 clinical recognition of, 500–​504 diagnostic considerations in, 509t initial management of, 507–​511, 510t injury mechanism in, 513c major acute spinal cord syndromes, 73t neuroimaging and laboratory tests, 504–​507 outcome, 511, 514f Spinal cord injury, neurogenic bowel in, 797 Spinal cord ischemia, acute, 683t Spinal cord lesions, localizing, 70–​72c Spindle coma, 302 Spinning, 53 clinical assessment of, 53–​56 line of action in, 55–​56 Spreading depolarization, 299c Staffing, in NICU, 149, 149 Staphylococcus aureus, 803, 812 Starling curve, 220c Statins, 830t Index Status dystonicus, 59 Status epilepticus, 92, 301f, 551 See also Convulsive status epilepticus cardiac manifestations in, 760 causes and management of deterioration in, 557–​560 causes of, 94t classification of, 92–​95, 93f clinical recognition of, 551–​552 management of, 97–​100 initial, 555–​557, 556t MRI in, 554f neuroimaging and laboratory tests, 95, 552–​555 EEG patterns, 96f, 297, 300–​301 neuronal damage associated with, 553c nonconvulsive, 93 outcome, 560–​561 presentation of, 92–​95 systemic effects of, 552f treatment-​refractory, 554f algorithm for, 561f Stenting, 396, 397f, 398t, 655, 657 See also Carotid artery stenting Stereotactic aspiration, 472 St Louis encephalitis, 483, 484t, 487, 492, 495 Streptococcus milleri, 472 Streptococcus pneumoniae, 388, 453, 457t, 472 Streptococcus species, 745 Stress cardiomyopathy, 328 Stress-​related mucosal disease, 792c Striatocapsular infarct, 385 Striatum, 347, 348 Stroke See also Hemorrhagic stroke; Ischemic stroke acute gastrointestinal bleeding after, 793 glucose handling and, 784 EEG in, 297 following cardiac surgery, management of, 680t Subarachnoid hemorrhage (SAH), 6–​7, 292–​294, 319f, 320f See also Aneurysmal subarachnoid hemorrhage; Aneurysmal subarachnoid hemorrhage (SAH) electrocardiographic changes in, 755, 757f, 757t, 758f nonaneurysmal, 324f pretruncal, 322, 324f Subdural empyema and epidural abscess, empirical antibiotic therapy in, 463t Subdural/​epidural ICP monitors, 271–​272 Subdural hematoma, 567, 571, 574f–​576f Suicide wounds, 578c Sulfadiazine, 474t, 494 Sulfamethoxazole, 474t Sulfisoxazole, 474t Superior cerebellar artery (SCA) occlusion, 429, 430c Swallowing, 209f Swallowing mechanism, abnormal features suggesting, 208t Swelling See also Edema cerebral, treatment options for, 406, 406t malignant brain swelling, 578–​579 913 Synchronized intermittent-​mandatory ventilation (SIMV), 194, 196 Syncope, 36 algorithm for evaluation of, 41f causes of, 38t clinical assessment of, 36–​41 definition of, 36 line of action in, 38–​39, 41 neurally mediated, 37 autonomic control in, 39c Syndrome of inappropriate antidiuretic hormone (SIADH), 777 Systemic inflammatory response syndrome (SIRS), diagnostic criteria for, 709t Tachycardia, 376 Tacrolimus, 522, 526, 528, 664–​665 Telemedicine, 7 Temporal lobe burst hematoma, 568, 511f Terson syndrome, 319f Thalamic hematoma, 349 warfarin-​associated, 355f Thalamic hemorrhage, 350f, 351f Theophylline, 795 Therapeutic hypothermia (TH), 691–​693 See also Hypothermia Thermoregulation and shivering, 244c Thiamine deficiency, 207 Thioridazine, 182 Thrombin, 361 Thrombin inhibitor, 361 Thrombocytopenia, 817–​819 causes of new-​onset, 818t heparin-​induced, 232, 818 Thromboembolic complications of neuroendovascular procedures, 654 Thromboembolic events, treatment of acute, 654 Thromboembolism, 246t prevention of, 163, 165–​166 Thrombolysis, 445, 446 Thrombolytic therapy, 231, 235, 237 contraindications for, 238t Thromboplastin time, activated partial, 231 Thrombotic thrombocytopenic purpura, 388, 394 Thrombus, 749f Thunderclap headache, 25, 26, 28t Thymectomy, in myasthenia gravis, 617–​620 Thymoma, 617 Thyroid, 731–​733 Thyroid storm, 732–​733 Thyrotoxicosis, 762–​763 Tight posterior fossa, 373 Tissue plasminogen activator (tPA), 231, 360, 390, 420 Tongue bite, 93f Tonic-​clonic status epilepticus, 92–​93 Tonic fits, 417 Tonicity, 218 Top-​of-​the-​basilar artery syndrome, 414, 416–​417, 423 Torcular herophili, 439 914 Index Torsades de pointes, 765 Total parenteral nutrition (TPN), 213–​214 formulation of, 213t Towne’s projection, 325 Toxoplasma gondii, 474 Toxoplasma infestation, 484 Toxoplasmic encephalitis, 484 T-​piece usage for weaning from mechanical ventilation, 196, 200 Tracheal reflex, 844 Tracheostomy, 197–​198, 503, 595 Tramadol, 327–​329 Transcranial Doppler ultrasonography (TCD), 287, 444, 848–​849 acute neurologic conditions, 292–​296 in brain death, 296, 302–​304, 848–​849 general principles of, 287–​292 sequential, in SAH, 294f submandibular technique, 293f temporal window technique, 287–​288, 289f through occipital window, 292f through orbital window, 291f Transfers and transports of patients See Patient transfers and transports Transfusion-​related acute lung injury (TRALI), 819 Transplant medicine, 663 See also Organ donation complications of CNS infections, 670–​671 neuromuscular, 671–​672 organ-​specific, 665–​670 general principles of, 663–​665 Transverse myelitis, 73–​74, 518, 525f, 527, 528, 591t acute, 73 causes of, 518t Trauma, 739 Trauma activation, Level 1, 4t Traumatic brain injury (TBI), 566 See also Head injury abdominal trauma and, 797 biomarkers in, 310, 311t causes and management of deterioration in, 577–​579 clinical recognition of, 566–​568 CT scan abnormalities in, 570t EEG in, 300 glucose handling and, 784 gunshots to head, 578c initial management of, 577t neuroimaging and laboratory tests, 568, 570–​572 outcome, 579–​580 transcranial Doppler in, 296 Tremor, 60, 61t Trephined, syndrome of the, 35 Triage, criteria of, 9–​12 Tricyclic antidepressants, 119 Trigeminal neuralgia, refractory, 28, 33 Trimethoprim, 474t, 808 Tromethamine (THAM), 262, 576 Troponin, 766 Tuberculosis (TB), brain abscesses associated with, 475f Tuberculous (TB) meningitis, 457 Tumors of CNS See also Brain tumors WHO grading of, 545–​546c Ultrasonography See Transcranial Doppler ultrasonography (TCD) Uniform Determination of Death Act, 839, 857 United Network of Organ Sharing (UNOS), 857, 864 UNOS Board of Directors recommendations, 865c Urea, 728c Urinary care, 161 Urinary tract infections (UTIs), 246t antimicrobial treatment of, 808, 808t nosocomial, 808–​809, 809t Vagal spells, 760 Valproate, 97, 560, 636 Valproic acid, 433, 830t Valve surgery, complications with, 678–​679 Vancomycin, 132, 461t, 462, 463, 804, 806–​809, 812 Vancomycin extravasation, 834f Vaptans, 781, 782c Varicella zoster virus (VZV) encephalitis, 482, 487, 488f Vascular cannulation and procedure complications, 823–​825 Vascular territories, brain, 388, 389–​390f Vasculitic neuropathy 591 Vasoactive drugs commonly used for shock, 710c Vasospasm See Cerebral vasospasm Vasovagal response See Syncope Venezuelan equine encephalitis, 483 Venous access, complications associated with, 823–​826 central venous catheter infection, 826 central venous catheter-​related thrombosis, 825–​826 manikin-​based simulation of, 824c Ventilation See also Mechanical ventilation noninvasive, 196–​197, 197t, 198f Ventilator, settings of, 192–​193, 193f Ventilator-​associated pneumonia (VAP), 803 distribution of onset of, 803–​804, 804f initial antimicrobial treatment for, 806t Ventilator bundle, 194c Ventricular dysfunction, left, 753 Ventricular fibrillation, AHA consensus algorithms for, 717f Ventricular tachycardia, 765 Ventriculitis, 808–​809 Ventriculostomy, 264, 274f, 336–​339, 434, 435, 538, 539 Ventriculostomy-​associated hemorrhage, 631, 633, 634f, 634t, 636f Verapamil, 334, 764 Vermis, LVAD-​associated hemorrhage in, 679f Vertigo and otologic emergencies, 54t Very important persons (VIPs) and VIP syndrome, 170 Vestibular migraine, 57 Vestibulospinal reflexes, disorders of, 55 VIP syndrome, 170 Viral serology, 526 Visual loss, 42–​44, 43c clinical assessment, 43–​50 Index line of action, 50–​51 crucial steps in neuro-​ophthalmology, 50f Vitamin B1 (thiamine) deficiency, 207 Volume-​expanding agents, 222, 223t Volume status, 218 See also Fluid replacement products and strategy clinical indicators of, 219–​220, 219t Walking, impairment of, 67 clinical assessment of, 67–​73 line of action in, 73–​75 Wallenberg syndrome, 422, 429 Warfarin, 234–​235, 448 drugs that potentiate or interfere with the action of, 235t, 830t Warfarin-​associated thalamic hematoma, 355f 915 Wernicke-​Korsakoff syndrome, 207 Western equine encephalomyelitis (WEE), 483, 489 West Nile encephalitis, 83 White matter disorders, acute, 518 causes and management of deterioration in, 538 clinical recognition of, 517–​520 initial management of, 527t neuroimaging and laboratory tests, 520–​526 outcome, 528 Wilson’s disease, dystonia in, 59 Withdrawal of care, 171–​172 World Federation of Neurological Surgeons (WFNS), 295, 320 Xanthochromia, 29 in aneurysmal subarachnoid hemorrhage, 322 ... presenting in the emergency department or the neurosciences intensive care unit and neurologic complications of medical or surgical critical illness The Practice of Emergency and Critical Care Neurology. .. University Press and now in a third edition.) The Practice of Emergency and Critical Care Neurology follows patients from the very moment they enter the emergency department (ED)—​where the neurologist... E N C Y AND CRITICAL CARE NEUROLOGY SECOND EDITION T H E P R AC T I C E OF EMERGENCY AND CRITICAL CARE NEUROLOGY E E L C O F M W I J D I C K S , MD, PhD, FACP, FNCS, FANA Professor of Neurology,