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CASE 21-1

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A 55-year-old male smoker with no known past medical history complained to family members of acute onset of severe headache, nausea, and stiff neck before becoming confused and lethargic at home. The patient was transported to the emergency department, where he was found to be confused but able to follow simple commands. A head CT was performed, demonstrating subarachnoid hemorrhage with mild hydrocephalus. CT angiogram reveals a 3 mm anterior communicating artery aneurysm. Upon return from the CT scanner, the patient was noted to be slower with commands, with sluggishly reactive pupils. What neurocritical care interventions are appropriate at this time?

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OVERVIEW

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How is neurocritical care delivered to patients?

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  • Neuroscience intensive care units (NICUs) specialize in providing care for critically ill neurologic and neurosurgical patients.

  • NICUs have seen tremendous growth recently in the United States.

  • Despite this growth, at many US hospitals, ICU patients with primarily neurological conditions are admitted to general medical or surgical ICUs, with the neurology and neurosurgery teams co-managing the patients with the ICU teams.

  • This chapter provides an overview of neurocritical care and general critical care. Techniques are highlighted that may allow a consulting hospital neurologist to interface more effectively with the rest of the team providing care to critically ill neurology and neurosurgery patients.

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What are the roles of different providers in the NICU?

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  • There are multiple models for ICU care:

    • In a closed ICU, a single intensivist or team of intensivists has primary responsibility for the unit.

    • In an open ICU, multiple providers (eg, surgeons, etc.) admit and manage their patients with or without intensivists consulting.

    • In a cooperative ICU, some patients will be admitted to the intensivist team, and others may be admitted under multiple providers; typically, the intensivist team will round on or at least consult on all the patients.

  • The specific type of system and role of a consulting neurologist will vary from hospital to hospital; nevertheless, an understanding of neurologic and general critical care is essential to optimizing patient care in any of these settings.

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What are indications for admission to the NICU?

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  • The fundamental goal of an NICU is to improve the mortality rate and functional status of the most critically ill neurology and neurosurgery patients.

  • There are two basic reasons for NICU admission: to provide monitoring and to provide interventions that cannot take place elsewhere.

    • The specifics are institutionally dependent, and an ICU intervention in one facility may be successfully performed in a stepdown unit or on the floor in another.

  • Examples of monitoring include:

    • Frequent neurologic examination checks by nursing staff

    • Continuous arterial blood pressure monitoring

    • Intracranial pressure monitoring

    • Multimodality monitoring

    • Pulmonary artery catheters

    • Frequent lab draws

  • Interventions may include:

    • Mechanical ventilation

    • Vasopressor support

    • Antihypertensive infusions

    • Drainage of cerebrospinal fluid (CSF)

  • For many disease processes, NICU care has been demonstrated to improve ...

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