Jon-Emile S. Kenny MD [@heart_lung] “I am a necessary part of an important search to which there is no end.” -Keith Haring Background With PARAMEDIC-2, the role of epinephrine in cardiac arrest, and especially its effects on cerebral perfusion and neurological outcome, have been appropriately questioned. Recall that Perkins and colleagues studied epinephrine in out-of-hospital cardiac arrest in a [… read more]
Brain damage with severe cognitive and functional impairment are common after cardiac arrest, but far from universal. Even after thorough testing, most comatose patients receive an indeterminate neurologic prognosis post-arrest. Physicians faced with this uncertainty have a difficult task in counseling family members trying to make decisions to maximize their loved one’s chances for recovery [… read more]
Jon-Emile S. Kenny [@heart_lung] “We do not live in a privileged frame of reference.” -Carl Sagan It is a common human experience to feel that one is the exception. Indeed, the study of cosmology has demoted our – once privileged – place in the cosmos. We have fallen from the center of the universe to [… read more]
Jon-Emile S. Kenny [@heart_lung] “… it is a tale. Told by an idiot, full of sound and fury, signifying nothing.” Macbeth: Act V, Scene V The results of the ATACH II trial are out; we have even more guidance when managing the blood pressure of hypertensive patients with supratentorial, intra-cerebral hemorrhage of less than 60 cm3 [… read more]
Jon-Emile S. Kenny [@heart_lung] The Journal of Intensive Care has newly published a series of sepsis-related organ dysfunction reviews. Additionally, a comprehensive yet concise overview of the cerebral circulation was just disseminated. This summary draws on both of these terrific primary resources as a point-of-departure for discussion of sepsis-associated delirium [SAD]. Cerebral blood flow [CBF] ultimately [… read more]
Another educational video from Dr. Richard Savel on neuro critical care, discussing the management of subarachnoid hemorrhage, elevated intracranial pressure, subdural hematoma, and more. Courtesy Richard Savel, MD, Maimonides Medical Center, Albert Einstein College of Medicine, New York, NY
Endovascular Therapy Improves Outcomes from Ischemic Stroke By Parth Rali, MD and Igor Titoff, DO Endovascular therapy for ischemic stroke has long been an attractive treatment modality for ischemic strokes, but until recently large randomized trials have not confirmed a benefit [1,2,3]. Two of these—IMS III1 and SYNTHESIS2—failed to prove the benefit of endovascular therapy (with-or-without tissue plasminogen activator) [… read more]
In the early 1990s, the clot-busting drug alteplase (intravenous recombinant tissue plasminogen activator or rTPA) revolutionized stroke treatment when it was shown to significantly increase the chances of a good outcome after ischemic stroke when given in the first 4.5 hours since symptom onset. But alteplase is not a miracle drug. In a meta-analysis of 9 randomized trials, rTPA improved [… read more]
Scott Aberegg, M.D., M.P.H. Oh, my, what a predicament. Jahi McMath has been released from Oakland Hospital to the custody of the coroner and her family. She has been issued a death certificate. And she’s being transferred to an undisclosed care center, where it is hoped she will begin receiving artificial nutrition. This is the height [… read more]
No Improvement in Cardiac Arrest Outcomes With Hypothermia Therapeutic hypothermia, or targeted temperature management, has become a standard component of post-cardiac arrest care. The evidence supporting this practice came from two small-to-medium-sized randomized trials, both published in the New England Journal of Medicine in 2002: Among 273 patients with out-of-hospital cardiac arrest due to shockable [… read more]
ICU-related Dysphagia and Swallowing Disorders More than 700,000 people develop respiratory failure requiring mechanical ventilation each year in the U.S. alone, and those that survive are at elevated risk for developing swallowing dysfunction. The aspiration syndromes that follow can be devastating, especially if not recognized and addressed early. Denver’s Madison Macht et al provide a clinical [… read more]
image: Wikipedia Rapid Blood Pressure Control Doesn’t Hurt, May Help in Intracerebral Hemorrhage Strokes caused by intracerebral hemorrhage — sudden bleeding into the brain — are as devastating as they sound. Almost half of people with intracerebral hemorrhage (ICH) die within a month, and most of the survivors end up in nursing homes or needing [… read more]
Intubation for Out-of-Hospital Cardiac Arrest May Harm, Not Help by Blair Westerly, MD Out of hospital cardiac arrest is a major public-health problem, and despite advances in care, survival is still low. Improved survival has been associated with early CPR, rapid defibrillation, and integrated post cardiac arrest care, but pre-hospital “advanced airway management” (i.e., intubation [… read more]
Tranexamic Acid: Underused for Uncontrolled Bleeding? Tranexamic acid is a simple little molecule, just a synthetic derivative of the amino acid lysine. But it’s also a potent pro-hemostatic drug that binds plasminogen and plasmin and stops the degradation of fibrin (the stuff in blood clots). In the U.S., tranexamic acid is sold as Lysteda (oral) [… read more]
Hypertonic Saline & Mannitol for Raised Intracranial Pressure (More PulmCCM Topic Updates) Acute brain injuries of all sorts increase the pressure inside the skull (intracranial pressure). Traumatic brain injury, bleeding in or around the brain, severe ischemic stroke, and acute hepatic failure all raise intracranial pressure, and increased intracranial pressure often becomes the most severe [… read more]
Webb and Samuels (Emory neuro-intensivists) report on a brain-injured patient who, after induced hypothermia and rewarming, had absent brainstem function and a confirmatory apnea test. However, in the O.R. for organ donation 24 hours later, brainstem function transiently returned and the surgery had to be aborted. They urge caution to the rest of us in [… read more]
Targeted temperature management in critical care: A report and recommendations from five professional societies. Nunnally ME et al. Crit Care Med 2011;39:1113-1125. Hypothermia for cardiac arrest guideline. Hypothermia after cardiac arrest review.
Intracranial hemorrhage is a subject neuro-intensivists spend years learning about and refining their knowledge and skills on. A few key points: Myocardial “stunning” with depressed ejection fraction and pulmonary edema should be expected, due to a form of tako-tsubo cardiomyopathy, most commonly in subarachnoid hemorrhage. It’s not due to ischemia and gets better over weeks. [… read more]
Thanks to defibrillators, burly-armed EMTs, speedier cardiac revascularization, and induced hypothermia, the mortality rates after ventricular tachycardia or fibrillation have improved markedly for both in- and out-of-hospital cardiac arrests. But mortality rates after PEA and asystole remain stubbornly steady, seemingly resistant to any of the above interventions. Background: People suffering cardiac arrest in an ICU have the advantage [… read more]
Here’s a free “head-to-head” discussion with arguments for and against implementation of routine mild hypothermia for all patients with out-of-hospital cardiac arrest. The benefits of hypothermia after out-of-hospital ventricular fibrillation cardiac arrests are reasonably well-established, and multiple society guidelines (SCCM’s, AHA’s) advocate the practice. The question is whether to induce mild hypothermia / targeted temperature management in all [… read more]
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