2016 solving critical consults (core principles of acute neurology)(oxford university press)

Eelco F.M Wijdicks ~ OXFORD Solving Critical Consults Core Principles of Acute Neurology: Recognizing Brain Injury Providing Acute Care Handling Difficult Situations Communicating Prognosis Identifying Neuroemergencies Solving Critical Consults EELCO F. M WIJDICKS, M.D., PH.D., FACP, FNCS, FANA Professor of Neurology, Mayo College of Medicine Chair, Division of Critical Care Neurology Consultant, Neurosciences Intensive Care Unit Saint Marys Hospital 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 New York Auckland  Cape Town  Dar es Salaam  Hong Kong  Karachi Kuala Lumpur Madrid Melbourne Mexico City Nairobi New Delhi Shanghai Taipei Toronto With offices in Argentina Austria Brazil Chile Czech Republic France Greece Guatemala Hungary Italy Japan Poland Portugal Singapore South Korea Switzerland Thailand Turkey Ukraine Vietnam Oxford is a registered trademark 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 © 2016 by Mayo Foundation for Medical Education and Research 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 Solving critical consults / Eelco F. M Wijdicks p ; cm. — (Core principles of acute neurology) Includes bibliographical references and index ISBN 978–0–19–025109–3 (alk. paper) I.  Title.  II.  Series: Core principles of acute neurology [DNLM:  1.  Nervous System Diseases—therapy.  2.  Intensive Care—methods.  3.  Intensive Care Units.  4.  Postoperative Complications WL 140] RC86.8 616.02′8—dc23 2015004000 The science of medicine is a rapidly changing field As new research and clinical experience broaden our knowledge, changes in treatment and drug therapy occur The author and publisher of this work have checked with sources believed to be reliable in their efforts to provide information that is accurate, complete, and in accordance with the standards accepted at the time of publication However, in light of the possibility of human error or changes in the practice of medicine, neither the author, nor the publisher, nor any other party who has been involved in the preparation or publication of this work warrants that the information contained herein is in every respect accurate or complete Readers are encouraged to confirm the information contained herein with other reliable sources and are strongly advised to check the product information sheet provided by the pharmaceutical company for each drug they plan to administer 9 8 7 6 5 4 3 2 1 Printed in the United States of America on acid-free paper For Barbara, Coen, and Marilou Contents Preface   ix Introduction to the Series   xi Consulting in the Intensive Care Unit   Acute Confusion in the Critically Ill   17 Encephalopathies of Organ Dysfunction   The Postoperative Cardiac Patient   33 47 Neurologic Urgencies After Vascular Surgery   Post−Cardiac Arrest Support and the Brain   61 77 Acquired Weakness in the Intensive Care Unit   Neurology of Polytrauma   107 Neurooncology Emergencies   121 10 Troubleshooting: ICU Neurotoxicology   Index   93 137 151 vii Preface Neurologic consultations for critically ill patients are common and may take time Often, a neurologist is asked to explain changes in the patient’s responsiveness or to confirm and manage an obvious neurologic complication In some patients, one can quickly sense that the presented problem is a less straightforward situation — or worse Solving a clinical situation which is difficult to understand or put together may be part of an urgent neurology consult Intensive care unit (ICU) consults follow certain patterns, and context and substance have crystallized over the years For this volume I have chosen the most frequent queries Neurologists can expect consults for patients who not fully awaken after critical illness (identified by the all-encompassing term “mental status change”) or for assessment of muscle weakness (typically immobility and failure to liberate the patient off the ventilator) A new speech problem or some new perceived limb asymmetry or no movement at all is commonly a reason for a STAT consult Neurologic complications are major when they involve recurrent seizures, postoperative failure to awaken, or acute disabling neuromuscular disease Consults in general ICU’s are less common than consults on the ward and that leaves the question of whether neurologic complications are sufficiently recognized The evaluation and management of neurologic complications in acutely ill hospitalized patients should be part of the core principles of acute neurology, and realistically, is a field which is recognizably different Some requests for consultation include not only assessment of the neurologic state of a critically ill patient but also assistance with management at all levels Prognostication in devastating situations or when the critical illness has come under control is a common request A common misperception is that a serious neurologic complication should limit aggressive care of the very sick patient In some instances, neurologists not share this pessimism Assessment of outcome comes with difficult choices There is a core of consult topics The most urgent consults are selected in this volume, with a focus on pathophysiology, mechanisms, and management This field requires a special expertise and frequent reassessment of the spectrum of complications Practical advice is included to literally provide a neurologic helping hand to the general intensivist ix Introduction to the Series The confrontation with an acutely ill neurologic patient is quite an unsettling situation for physicians, but all will have to master how to manage the patient at presentation, how to shepherd the unstable patient to an intensive care unit, and how to take charge To that aptly, knowledge of the principles of management is needed Books on the clinical practice of acute, emergency, and critical care neurology have appeared, but none have yet treated the fundamentals in depth Core Principles of Acute Neurology is a series of short volumes that handles topics not found in sufficient detail elsewhere They focus precisely on those areas that require a good working knowledge These are the consequences of acute neurologic diseases, medical care in all its aspects and relatedness with the injured brain, and difficult decisions in complex situations Because the practice involves devastatingly injured patients, there is a separate volume on prognostication and neuropalliation Other volumes are planned in the future The series has unique features I contextualize basic science with c­ linical practice in a readable narrative with a light touch and without wielding the jargon of this field The 10 chapters in each volume clearly details how things work It is divided into a description of principles followed by its relevance to practice—keeping it to the bare essentials There are boxes inserted into the text with quick reminders (“By the Way”) and useful percentages carefully researched and vetted for accuracy (“By the Numbers”) Drawings are used to ­illustrate mechanisms and pathophysiology These books cannot cover an entire field, but brevity and economy allows a focus on one topic at a time Gone are the days of large, doorstop tomes with many words on paper but with little practical value This series is therefore characterized by simplicity—in a good sense—with acute and critical care neurology at the core, not encyclopedic but representative I hope it supplements clinical curricula or comprehensive textbooks The audience are primarily neurologists and neurointensivists, neurosurgeons, fellows, and residents Neurointensivists have increased in numbers, and many major institutions have attendings and fellowship programs However, these books cross xi xii Int r oduction to the   S e ries disciplines and should also be useful for intensivists, anesthesiologists, emergency physicians, nursing staff, and allied health care professionals in intensive care units and the emergency department In the end the intent is to write a book that provides a sound reassuring basis to practice well, and that helps with understanding and appreciating the complexities of the care of a patient with an acute neurologic condition ... Identifying Neuroemergencies Solving Critical Consults EELCO F. M WIJDICKS, M.D., PH.D., FACP, FNCS, FANA Professor of Neurology, Mayo College of Medicine Chair, Division of Critical Care Neurology... acquirer Library of Congress Cataloging-in-Publication Data Wijdicks, Eelco F. M., 1954– , author Solving critical consults / Eelco F. M Wijdicks p ; cm. — (Core principles of acute neurology).. .Solving Critical Consults Core Principles of Acute Neurology: Recognizing Brain Injury Providing Acute? ?Care Handling Difficult Situations Communicating