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1
Marmarou, Anthony, Ross Bullock, Cees Avezaat, Alexander Baethmann, Donald Becker, Mario Brock, Julian Hoff, Hajime Nagai, Hans-J. Reulen, and Graham Teasdale, eds. Intracranial Pressure and Neuromonitoring in Brain Injury. Vienna: Springer Vienna, 1998. http://dx.doi.org/10.1007/978-3-7091-6475-4.
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Ratcliff, Jonathan J., and David W. Wright. Neuroprotection for Traumatic Brain Injury. Edited by David L. Reich, Stephan Mayer, and Suzan Uysal. Oxford University Press, 2017. http://dx.doi.org/10.1093/med/9780190280253.003.0008.
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Traumatic brain injury (TBI) is a common, clinically complex, heterogeneous global public health problem. Neuroprotection strategies focus on preventing secondary injury by creating a physiologic environment devoid of extremes while targeting normal physiologic parameters. Careful attention must be paid to aggressively avoid and treat hypoxia, hypotension, hypoglycemia, intracranial hypertension, and cerebral hypoperfusion (low cerebral perfusion pressure). Aggressive management of intracranial pressure and cerebral perfusion pressure through optimal patient positioning, appropriate use of sedation and analgesia, and administration of hyperosmolar therapy remain the hallmark for the care of the TBI patient. Surgical decompressive craniectomy and hypothermia hold promise but remain controversial and should be used in carefully selected clinical situations. Early identification of injury progression is aided through careful monitoring by clinical examination and cerebral physiological monitoring. Multimodal monitoring provides an early warning system to guide appropriate clinical responses to identified deranged physiology.
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Gibson, Alistair A., and Peter J. D. Andrews. Management of traumatic brain injury. Oxford University Press, 2016. http://dx.doi.org/10.1093/med/9780199600830.003.0343.
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Traumatic brain injury (TBI) is a leading cause of death and disability worldwide and although young male adults are at particular risk, it affects all ages. TBI often occurs in the presence of significant extracranial injuries and immediate management focuses on the ABCs—airway with cervical spine control, breathing, and circulation. Best outcomes are achieved by management in centres that can offer comprehensive neurological critical care and appropriate management for extracranial injuries. If patients require transfer from an admitting hospital to a specialist centre, the transfer must be carried out by an appropriately skilled and equipped transport team. The focus of specific TBI management is on the avoidance of secondary injury to the brain. The principles of management are to avoid hypotension and hypoxia, control intracranial pressure and maintain cerebral perfusion pressure above 60 mmHg. Management of increased intracranial pressure is generally by a stepwise approach starting with sedation and analgesia, lung protective mechanical ventilation to normocarbia in a 30° head-up position, maintenance of oxygenation, and blood pressure. Additional measures include paralysis with a neuromuscular blocking agent, CSF drainage via an external ventricular drain, osmolar therapy with mannitol or hypertonic saline, and moderate hypothermia. Refractory intracranial hypertension may be treated surgically with decompressive craniectomy or medically with high dose barbiturate sedation. General supportive measures include provision of adequate nutrition preferably by the enteral route, thromboembolism prophylaxis, skin and bowel care, and management of all extracranial injuries.
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Wecksell, Matthew, and Kenneth Fomberstein. Traumatic Brain Injury and C-Spine Management. Edited by David E. Traul and Irene P. Osborn. Oxford University Press, 2018. http://dx.doi.org/10.1093/med/9780190850036.003.0020.
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Traumatic brain injury encompasses two different types of pathology: that caused at the time of the initial physical insult, called primary injury, and then further, secondary injury caused by either host cellular responses such as oxidative injury and inflammation or by physiological insults such as ischemia, hypoxia, hypo- or hypercapnia, intracranial hypertension, and hypo- or hyperglycemia. While primary injury falls to the realm of public health (e.g., encouraging helmet use for sports, discouraging impaired driving, etc.), many secondary injuries are avoidable with proper medical management. As the stem case for this chapter, an older patient experiences a fall and is incoherent on presentation to the emergency room. This case concerns her initial management, stabilization, diagnosis, and airway management. With progression of her traumatic brain injury, the authors discuss intracranial pressure management, surgical management, and resuscitation as well as likely postoperative sequelae.
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Aisiku, Imoigele, and Claudia S. Robertson. Epidemiology and pathophysiology of traumatic brain injury. Oxford University Press, 2016. http://dx.doi.org/10.1093/med/9780199600830.003.0341.
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Although medical management of traumatic brain injury (TBI) may have improved in developed countries, TBI is still a major cause of mortality and morbidity. The demographics are skewed towards the younger patient population, and affects males more than females, but in general follow a bimodal distribution with peaks affecting young adults and the elderly. As a result, the loss of functional years is devastating. Pathology due to brain trauma is a complex two-hit phenomenon, frequently divided into ‘primary’ and ‘secondary’ injury. Hypoxia, ischaemia, and inflammation all play a role, and the importance of each component varies between patients and in an individual patient over time. The initial injury may increase intracranial pressure and reduce cerebral perfusion due to the presence of mass lesions or diffuse brain swelling. Further secondary insults, such as hypotension, reduced cerebral perfusion pressure, hypoxia, or fever may exacerbate swelling and inflammation, and further compromise cerebral perfusion. Although there are currently no specific effective treatments for TBI, an improved understanding of the pathophysiology may eventually lead to treatments that will reduce mortality and improve long-term functional outcome.
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Mathews, Letha, and John Barwise. Refractory Intracranial Hypertension. Edited by Matthew D. McEvoy and Cory M. Furse. Oxford University Press, 2017. http://dx.doi.org/10.1093/med/9780190226459.003.0067.
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Intracranial pressure remains constant in adults at 10–15 mmHg under normal conditions with some fluctuations associated with respirations, coughing, sneezing, and so forth. Refractory intracranial hypertension (ICH) is defined by recurrent episodes of intracranial pressure elevation above 20 mmHg for sustained periods (10–15 min) despite medical therapy. The common causes of ICH are traumatic brain injury, brain tumors, subarachnoid hemorrhage, and brain infarction from arterial occlusion, cerebral venous thrombosis, and anoxic encephalopathy. Intracranial infections, abscesses, acute liver encephalopathy, and idiopathic ICH are also recognized causes of ICH. For the purposes of this chapter, the discussion is limited to ICH related to traumatic brain injury.
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Rhodes, Jonathan K. J., and Peter J. D. Andrews. Intracranial pressure monitoring in the ICU. Oxford University Press, 2016. http://dx.doi.org/10.1093/med/9780199600830.003.0223.
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Intracranial pressure (ICP) measurement is an established monitoring modality in the ICU and can aid prognostication after acute brain injury. ICP monitoring is recommended in all patients with severe traumatic brain injury (TBI), and an abnormal cranial computed tomographic (CT) scan and the ability to control ICP is associated with improved outcome after TBI. The lessons from TBI studies can also be applied to other acute pathologies of the central nervous system where ICP can be increased. ICP measurement can warn of impending disaster and allow intervention. Furthermore, measurement of ICP allows the calculation of cerebral perfusion pressure (CPP) and maintenance of CPP may help to ensure adequate cerebral oxygen delivery. Various systems exist to monitor ICP. A recent trial in two South American countries suggested that ICP-guided management and management guided by clinical examination and repeated imaging produced equivalent outcomes. Although this trial currently provides the best evidence regarding the impact of monitoring ICP on outcome following TBI, but because of the inadequate power and questionable external validity, the generalizability of the results remain to be confirmed.
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Prout, Jeremy, Tanya Jones, and Daniel Martin. Neuroanaesthesia and neurocritical care. Oxford University Press, 2014. http://dx.doi.org/10.1093/med/9780199609956.003.0022.
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This chapter describes the general conduct of anaesthesia for neurosurgery with particular reference to techniques for reducing intracranial pressure, safe positioning, and recognition and management of air embolus. Management for specific common procedures such as shunt surgery, haematomas, traumatic brain injury and pituitary surgery is described. Neurosurgical conditions such as cerebral aneurysms and arteriovenous malformations may be managed in neuroradiology and the special considerations for the provision of anaesthesia for these cases are detailed. The principles of management of traumatic brain injury in critical care which aim to reduce secondary brain injury are explained.
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Ferioli, Simona, and Lori Shutter. Normal anatomy and physiology of the brain. Oxford University Press, 2016. http://dx.doi.org/10.1093/med/9780199600830.003.0219.
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An understanding of the normal anatomy of the brain is essential to the diagnosis of a number of conditions that may be encountered in patients in the intensive care unit (ICU). Common structural cerebral conditions causing patients to be admitted to the ICU include cerebral trauma (traumatic brain injury), cerebrovascular accidents (both ischaemic and haemorrhagic), and infections. Cerebral conditions with a structural basis occurring after admission to the ICU are not as common as functional abnormalities, such as delirium, and peripheral complications, such as critical illness neuropathy and myopathy. An understanding of brain physiology, in particular factors that control or influence intracranial pressure (ICP) and cerebral blood flow (CBF) underpin much of the theory behind the management of acute brain injuries and syndromes.
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Adam, Sheila, Sue Osborne, and John Welch. Neurological problems. Oxford University Press, 2017. http://dx.doi.org/10.1093/med/9780199696260.003.0008.
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This chapter provides an overview of the care and management of neurological disorders commonly seen in critical care, starting with an outline of the anatomy and physiology of the nervous system. The concepts of awareness, consciousness, and arousal, and the use of the Glasgow Coma Scale (GCS) to assess conscious level are discussed. The management and monitoring of raised intracranial pressure, cerebral perfusion pressure, and the impact on cerebral blood flow are detailed. The management of sodium and water balance, including diabetes insipidus, is outlined. There are overviews of the management and nursing of patients who have suffered traumatic brain injury, subarachnoid haemorrhage, status epilepticus, myasthenia gravis, Guillain–Barré syndrome, meningitis, encephalitis, and intracranial abcess. The concept, ethics, and testing of brainstem death, organ donation, and the care of the family are detailed.
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Evans, Charlotte, Anne Creaton, Marcus Kennedy, and Terry Martin, eds. Neurology and neurosurgery. Oxford University Press, 2016. http://dx.doi.org/10.1093/med/9780198722168.003.0012.
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Neurological and neurosurgical emergencies require a time-critical response from retrieval services. Critical care interventions must be performed efficiently and the patient transferred to definitive care for intervention. Retrieval practitioners have a big role to play in preventing secondary brain injury by instituting neuroprotective measures early to ensure the best possible outcomes. Close monitoring is required to detect complications such as seizures and rising intracranial pressure. Skilled assessment and management of traumatic and non-traumatic intracranial haemorrhage is core business for retrieval services. New interventions for acute stroke have developed, further highlighting the requirement to get the right patient to the right facility at the right time. It is acknowledged that critical care interventions are not always appropriate for all patients. Local clinicians must also be supported by retrieval services to provide end of life care locally.
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Evans, Charlotte, Anne Creaton, Marcus Kennedy, and Terry Martin, eds. Bariatric retrieval. Oxford University Press, 2016. http://dx.doi.org/10.1093/med/9780198722168.003.0015.
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Neurological and neurosurgical emergencies require a time-critical response from retrieval services. Critical care interventions must be performed efficiently and the patient transferred to definitive care for intervention. Retrieval practitioners have a big role to play in preventing secondary brain injury by instituting neuroprotective measures early, to ensure the best possible outcomes. Close monitoring is required to detect complications such as seizures and rising intracranial pressure. Skilled assessment and management of traumatic and non-traumatic intracranial haemorrhage is core business for retrieval services. New interventions for acute stroke have developed, further highlighting the requirement to get the right patient to the right facility at the right time. It is acknowledged that critical care interventions are not always appropriate for all patients. Local clinicians must also be supported by retrieval services to provide end of life care locally.
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Mason, Peggy. Following the Nutrients. Oxford University Press, 2017. http://dx.doi.org/10.1093/med/9780190237493.003.0008.
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Consciousness depends on oxygen delivered to the brain by arterial blood. Compromises to this delivery by an increase in intracranial pressure or decrease in available oxygen can produce syncope. The blood supply to the forebrain stems from the internal carotids that serve the anterior circulation. The posterior circulation is fed by the vertebral arteries and supplies blood to the brainstem. Redundancy to the brain’s blood supply is served by anastomoses, a connection between the posterior and anterior circulations, and by the Circle of Willis. The clinical characteristics of common brainstem and cerebral strokes are described. Similarly, the characteristics and clinical prognosis of different types of intracranial bleeds are explained. The text covers mechanisms that normally protect the brain and the consequences of traumatic brain injury that overwhelms these protections. A description of the production and circulation of cerebrospinal fluid allows the student to understand hydrocephalus.
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Wise, Matt, and Paul Frost. Hypothermia. Edited by Patrick Davey and David Sprigings. Oxford University Press, 2018. http://dx.doi.org/10.1093/med/9780199568741.003.0078.
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Hypothermia is defined by a core body temperature of <35.0°C, and may be further characterized as mild (32.0°C–34.9°C), moderate (28.0°C–31.9°C), or severe (<28.0°C). Primary hypothermia is the result of environmental exposure, while in secondary hypothermia there is an underlying medical condition which perturbs thermoregulation. Mild hypothermia (32.0°C–34.0°C) is used as a therapeutic modality in intensive care for traumatic brain injury (to lower intracranial pressure) and following out-of-hospital cardiac arrest (to improve neurological outcomes). Hypothermia and even hypothermic circulatory arrest are also used during cardiac surgery and aortic root replacement surgery.
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Weaver, Sheena M. Traumatic Brain Injury. Edited by Matthew D. McEvoy and Cory M. Furse. Oxford University Press, 2017. http://dx.doi.org/10.1093/med/9780190226459.003.0066.
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Traumatic brain injury accounts for over a million emergency room visits each year and frequently results in the need for escalated levels of care, including surgical intervention, at acute care facilities. This chapter reviews the pertinent concepts integral to the perioperative assessment and management of traumatic brain injury, specifically that of acute traumatic subdural and epidural hemorrhages. It discusses that this management hinges on the ability of the clinician to quickly recognize primary injury and its associated pathophysiology, to prevent or reduce secondary injury (including intracranial hypertension), and to adhere to anesthetic principles and evidence-based guidelines linked to improved clinical outcomes. This chapter also reviews the most recent international consensus guidelines, as well as summarizing the decision-making for neurosurgical intervention.
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Andrews, Peter J. D., and Jonathan K. J. Rhodes. Assessment of traumatic brain injury. Oxford University Press, 2016. http://dx.doi.org/10.1093/med/9780199600830.003.0342.
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Traumatic brain injury (TBI) accounts for the majority of traumatic deaths and most disability due to trauma in people aged less than 40 years old. Current trends suggest this burden of disease will increase dramatically over the next 20 years. Successful management of patients after traumatic brain injury requires recognition of patients at risk of deterioration, appropriate investigation, including imaging, and prevention of systemic and intracranial secondary injury processes. Unlike trauma affecting other body systems, outcome from TBI has not improved in the last 10–15 years. Assessment of a patient with traumatic brain injury includes clinical examination and diagnostic imaging both of which can be quantified or graded using scores such as the Glasgow Coma Score (GCS) and the Marshall score for grading cranial computed tomographic (CT) scans. Clinical examination and diagnostic imaging can both aid in prognostication (http://www.crash.lshtm.ac.uk/Risk%20calculator/).
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Cantu, Robert C., and Robert V. Cantu. Moderate to Severe Traumatic Brain Injury in Sports. Edited by Ruben Echemendia and Grant L. Iverson. Oxford University Press, 2014. http://dx.doi.org/10.1093/oxfordhb/9780199896585.013.4.
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Traumatic brain injury in sports encompasses a spectrum including injuries such as concussion, skull fracture, intracranial hemorrhage, malignant brain edema syndrome, and axonal shear. Knowledge of these injuries and their signs and symptoms is important for medical personnel covering a sporting contest or practice. The authors discuss each of these injuries, how they typically occur, and what the initial treatment entails.
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(Editor), Anthony Marmarou, Ross Bullock (Editor), Cees Avezaat (Editor), Alexander Baethmann (Editor), Donald Becker (Editor), Mario Brock (Editor), Julian Hoff (Editor), Hajime Nagai (Editor), Hans-J. Reulen (Editor), and Graham Teasdale (Editor), eds. Intracranial Pressure and Neuromonitoring in Brain Injury: Proceedings of the Tenth International ICP Symposium, Williamsburg, Virginia, May 25-29, 1997 (Acta Neurochirurgica Supplementum). Springer, 1998.
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19
Hoff, Julian, Alexander Baethmann, Ross Bullock, Mario Brock, Anthony Marmarou, Hans-J. Reulen, Hajime Nagai, Donald Becker, Cees Avezaat, and Graham Teasdale. Intracranial Pressure and Neuromonitoring in Brain Injury: Proceedings of the Tenth International ICP Symposium, Williamsburg, Virginia, May 25–29, 1997. Springer, 2012.
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20
Baethmann, Alexander, Ross Bullock, Anthony Marmarou, Donald Becker, and Cees Avezaat. Intracranial Pressure and Neuromonitoring in Brain Injury: Proceedings of the Tenth International ICP Symposium, Williamsburg, Virginia, May 25-29 1997. Springer, 2012.
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21
Watkins, Laurence, and David G. T. Thomas. Traumatic injuries to the head. Oxford University Press, 2010. http://dx.doi.org/10.1093/med/9780199204854.003.0241003.
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Head injuries cause 1% of all deaths, including 15 to 20% of those in people aged 5 to 35 years, with many survivors facing long-term disability.Pathophysiology—brain injury may be (1) primary—axonal injury and focal contusions are caused at the moment of impact; or (2) secondary—causes are (a) extracranial—e.g. hypoxia and hypotension, and (b) intracranial—e.g. haematoma, brain swelling, and infection....
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Whittle, Ian. Head injury. Oxford University Press, 2011. http://dx.doi.org/10.1093/med/9780198569381.003.0589.
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Head injury or traumatic brain injury is a ubiquitous phenomenon in all societies and affects up to 2 per cent of the population per year (Bullock et al. 2006). Although the causes of head injury and its distribution within populations vary, it can have devastating consequences both for the patient and family (Tagliaferri et al. 2006). In some countries severe traumatic brain injury is the commonest cause of death in people under 40 years (Lee et al. 2006), and it is estimated that the sequelae of head injury cost societies billions of dollars per year. Understanding of the pathophysiology, diagnosis, and management have all improved dramatically in the last few decades (Steudel et al. 2005). However within western society, perhaps one of the greatest benefits has been the reduction in severe craniocerebral injuries following motor vehicle accidents. This has arisen because of increased safety in car design, seat-belt legislation, the introduction of air-bags, enforcement of speed limits, and the societal conformity to drink-driving legislation. For instance, because of these changes, in the last 15 years the number of severe head injuries managed in the Clinical Neuroscience unit in Edinburgh has decreased by around 66 per cent. Unfortunately in some developing countries one legacy of increased traffic, particularly of motor cycles, is an epidemic of head injuries amongst young adults (Lee et al. 2006). With the number of severe head injuries declining in many countries the challenge will be to provide better care for patients with minor head injury, about 10 times more common than severe injury (Steudel et al. 2005).Ageing patients who tend to fall over, falls associated with increased alcohol consumption, and domestic or social assaults probably now contribute to the majority of head injuries (Flanagan et al. 2005; Steudel et al. 2005; Tagliaferri et al. 2006). Sporting injuries are fortunately uncommon as a cause of severe craniocerebral injury, although horse riding accidents can sometimes be devastating particularly in teenage girls. In some countries injuries from hand guns and other missiles are common (Aryan et al. 2005), but in European countries many such injuries are self-inflicted. Prompt management of intracranial haematoma, which occurs in 25–45 per cent of severe head injuries, 3–12 per cent of moderate injuries, and 0.2 per cent of minor injuries, and the rehabilitation of patients with head injury are now important areas in clinical neuroscience (Flanagan et al. 2005; Bullock et al. 2006b, c).
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Waldmann, Carl, Neil Soni, and Andrew Rhodes. Neurological monitoring. Oxford University Press, 2011. http://dx.doi.org/10.1093/med/9780199229581.003.0008.
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Intracranial pressure monitoring 130Intracranial perfusion 132EEG and CFAM monitoring 134Other forms of neurological monitoring 138In adults, the normal resting intracranial pressure (ICP) is 0–10mm Hg. ICP may rise to 50mm Hg or so during straining or sneezing, with no impairment in function. It is not, therefore, ICP alone that is important but rather the interpretation of the measurement in pathological conditions. Many of the clinicopathological changes associated with brain injury are the result of pressure differences between the intracranial compartments, with consequent shift of brain structures, rather than the absolute level of ICP....
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Harley, Kim, and Sue Jones. Neurological and spinal surgery. Oxford University Press, 2016. http://dx.doi.org/10.1093/med/9780199642663.003.0023.
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Neurological assessment is performed on admission for surgery, as a routine part of medical examination. This is done to diagnose whether symptoms of illness in the patient are due to neurological conditions and, if so, where in the nervous system the pathological lesions are located. Hydrocephalus is either an acute or chronic condition whereby the cerebrospinal fluid pressure rises, causing symptoms of raised intracranial pressure. Patients at risk of raised intracranial pressure should be nursed by staff trained and experienced in neurological assessment using the Glasgow coma scale. This chapter looks at neurological assessment, raised intracranial pressure, head injuries, and brain and spinal tumours. This chapter also discusses the management of subarachnoid haemorrhage, cerebral aneurysm, arteriovenous malformations, and epilepsy. Finally, the chapter provides an overview of degenerative diseases of the spine and peripheral nerve injury.
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Cantu, Robert V., and Robert C. Cantu. Injuries to the head and cervical spine. Edited by Neil Armstrong and Willem van Mechelen. Oxford University Press, 2017. http://dx.doi.org/10.1093/med/9780198757672.003.0046.
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Traumatic brain and cervical spine injuries in young athletes encompass a wide spectrum, with some injuries occurring in otherwise ‘safe’ sports, and others in high-risk sports where head and cervical spine injuries are the norm. Athletic brain injuries include concussion, intracranial haemorrhage, malignant brain oedema syndrome, and axonal shear. In the cervical spine, injuries include muscle strains, contusions, fractures, or ligamentous disruptions with nerve root or spinal cord injury. Knowledge of these injuries and their signs and symptoms is important for the physician covering a sporting contest or practice. Additionally, preparedness for potential head or cervical spine injury must be addressed by health professionals providing sporting event coverage. This chapter reviews how traumatic brain and cervical spine injuries typically occur in young athletes. It also discusses what the initial treatment of these injuries should entail, along with a discussion of return to play considerations.
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Padover, Alyssa, and Jennifer K. Lee. Nonaccidental Trauma. Edited by Kirk Lalwani, Ira Todd Cohen, Ellen Y. Choi, and Vidya T. Raman. Oxford University Press, 2018. http://dx.doi.org/10.1093/med/9780190685157.003.0061.
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Nonaccidental trauma from child abuse presents unique challenges to the anesthesiologist. Diagnosing abuse is difficult because children may present with nonspecific symptoms and vague clinical histories. Multiple organ systems may be involved, but the greatest risk of death stems from abusive head trauma. Anesthesiologists must know the pediatric traumatic brain injury treatment guidelines and be prepared to treat the complex disease processes of child abuse and abusive head trauma. This chapter discusses anesthesia for nonaccidental pediatric trauma, including abusive head trauma. Topics covered include cervical instability, intracranial hypertension, seizures, and anesthetic agents. Debriefing after a poor outcome is also covered.
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Vespa, Paul M. Electroencephalogram monitoring in the critically ill. Oxford University Press, 2016. http://dx.doi.org/10.1093/med/9780199600830.003.0221.
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Electroencephalography monitoring provides a method for monitoring brain function, which can complement other forms of monitoring, such as monitoring of intracranial pressure and derived parameters, such as cerebral perfusion pressure. Continuous electroencephalogram (EEG) monitoring can be helpful in seizure detection after brain injury and coma. Seizures can be detected by visual inspection of the raw EEG and/or processed EEG data. Treatment of status epilepticus can be improved by rapid identification and abolition of seizures using continuous EEG. Quantitative EEG can also be used to detect brain ischaemia and seizures, to monitor sedation and aid prognosis.
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Jolly, Elaine, Andrew Fry, and Afzal Chaudhry, eds. Neurology and neurosurgery. Oxford University Press, 2016. http://dx.doi.org/10.1093/med/9780199230457.003.0014.
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Chapter 14 covers the basic science and clinical topics relating to neurology and neurosurgery which trainees are required to learn as part of their basic training and demonstrate in the MRCP. It covers the approach to the neurological Patient, neurological examination, neurological investigations, coma, acquired brain injury, encephalopathies, alcohol and the nervous system, brainstem disorders, common cranial nerve disorders, migraine, other primary headaches, secondary headache, neuro-ophthalmology, vertigo and hearing loss, seizures and epilepsy, intracranial pressure, stroke, central nervous system infections, neuro-oncology, multiple sclerosis, Parkinson disease, other movement disorders, spinal cord disorders (myelopathy), spinal nerve root disorders (radiculopathies), motor neurone disease, peripheral nerve disorders, mitochondrial disease and channelopathies, neuromuscular junction and muscle Disorders, sleep disorders, neurological disorders in pregnancy, the neurology of HIV infection, and functional neurology.
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Subhas, Kamalakkannan, and Martin Smith. Intensive care management after neurosurgery. Oxford University Press, 2016. http://dx.doi.org/10.1093/med/9780199600830.003.0369.
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The post-operative management of neurosurgical patients is directed towards the prevention, prompt detection, and management of surgical complications, and other factors that put the brain or spinal cord at risk. Close monitoring is required in the first 6–12 post-operative hours as deterioration in clinical status is usually the first sign of a potentially fatal complication. The majority of patients do not require complex monitoring or management beyond the first 12 hours after elective surgery, although prolonged intensive care unit management may be required for those who develop complications, or after acute brain injury. Cardiovascular and respiratory disturbances adversely affect the injured or ‘at risk’ brain, and meticulous blood pressure control and prevention of hypoxia are key aspects of management. Hypertension is particularly common after intracranial neurosurgery and may cause complications, such as intracranial bleeding and cerebral oedema, or be a consequence of them. A moderate target for glycaemic control (7.0–10 mmol/L) is recommended, avoiding hypoglycaemia and large swings in blood glucose concentration. Pain, nausea, and vomiting occur frequently after neurosurgery, and a multimodal approach to pain management and anti-emesis is recommended. Adequate analgesia not only ensures patient comfort, but also avoids pain-related hypertension. Disturbances of sodium and water homeostasis can lead to serious complications, and a structured approach to diagnosis and management minimizes adverse outcomes. Post-operative seizures must be brought rapidly under control because of the risks of secondary cerebral damage and/or progression to status epilepticus.