Other Neurologic Causes of Acute Respiratory Failure

Một phần của tài liệu 2012 FCCS 5th edition (Trang 172 - 177)

Patients with conditions causing global weakness, such as myasthenia gravis and the Guillain-Barré syndrome, may have problems maintaining upper airway patency and clearing secretions in addition to respiratory muscle weakness. In such patients, endotracheal intubation may be needed for airway protection before being mandated by the falling tidal volume. Measurement of vital capacity and negative inspiratory pressure is important. Patients with <20 mL/kg vital capacity should be moved to

an ICU and will likely need intubation soon. One should intubate based on tachypnea and discomfort without waiting for an elevation of PaCO2. Hypoxia due to atelectasis in patients with adequate

airway protection may be treated with continuous positive airway pressure. Consultation with a neurologist should be obtained when the diagnosis is suspected, as treatment with intravenous immunoglobulin or plasma exchange may slow or halt disease progression and speed recovery.

Autonomic dysfunction is common in the Guillain-Barré syndrome, and may lead to large and rapid swings in blood pressure and heart rate requiring intravenous therapy.

I. Brain-Death Criteria and Organ Donation

Despite the best efforts of medical and surgical teams, massive injury, cerebral infarction, or

hemorrhage may result in a loss of all cerebral and brainstem functions. Evaluation of brain death and the guidelines for organ donation are variable, depending on the country, state, and facility.

Criteria for brain death vary from state to state and from country to country. For more information about brain death and organ donation, see Appendix 9.

Key Points

Neurologic Support

Brain injury occurs as a consequence of a primary insult and secondary injury. The prevention of secondary brain injury is a critical goal for the initial care team.

The most significant mechanisms for secondary injury in brain-injured patients are hypotension and hypoxia.

Optimizing oxygen delivery while controlling oxygen consumption is a general treatment principle for all types of brain injury.

Important principles/guidelines for initial treatment apply to all types of primary brain injury and help prevent harmful secondary sequelae.

Blood pressure management is dependent on the initial brain injury. However, excessive lowering of blood pressure in any acute brain injury may induce secondary ischemia.

Avoid prophylactic or routine hyperventilation in patients with brain injuries. Mannitol should

be given and hyperventilation initiated for signs of herniation or if neurologic deterioration occurs that is not attributable to other factors.

Ensure euvolemia using normal saline as the primary maintenance fluid.

Seizure activity after acute brain injury should be terminated with an intravenous dose of a benzodiazepine, followed by an intravenous loading dose of phenytoin or fosphenytoin.

Suggested Readings

1. Adams HP Jr., del Zoppo G, Alberts MJ, et al. Guidelines for the early management of adults with ischemic stroke. Stroke. 2007;38:1655-1711.

2. Anderson CS. Medical management of acute intracerebral hemorrhage. Curr Opin Crit Care.

2009;15:93-98.

3. Bederson JB, Connolly ES Jr., Batjer HH, et al. Guidelines for the management of aneurismal subarchnoid hemorrhage: A statement for healthcare professionals from a special writing group of the stroke council, American Heart Association. Stroke. 2009;40:994-1025.

4. Brain Trauma Foundation, American Association of Neurological Surgeons, Congress of Neurological Surgeons, AANS/CNS Joint Section on Neurotrauma and Critical Care.

Guidelines for the management of severe traumatic brain injury. 3rd ed. J Neurotrauma. 2007;

24(suppl 1):S1-S106.

5. Brisman JL, Song JK, Newell DW. Cerebral aneurysms. N Engl J Med. 2006;355:928-939.

6. Chiles BW, Cooper PR. Acute spinal injury. N Engl J Med. 1996;334:514-520.

7. Guidelines for the Management of Acute Cervical Spine and Spine Cord Injuries. Neurosurgery.

2002;50(suppl 3).

8. Kamel H, Navi BB, Nakagawa K, et al. Hypertonic saline versus mannitol for the treatment of elevated intracranial pressure: A meta-analysis of randomized clinical trials. Crit Care Med.

2011;39:554-559.

9. Legriel S, Azoulay E, Resche-Rigon M, et al. Functional outcome after convulsive status

epilepticus. Crit Care Med. 2010;38:2295-2303.

10. Marik PE, Varon J. The management of status epilepticus. Chest. 2004;126:582-591.

11. McDonald JW, Sadowsky C. Spinal-cord injury. Lancet. 2002;359:417-425.

12. Morgenstern LB, Hemphill JC 3rd, Anderson C, et al. Guidelines for the management of spontaneous intracerebral hemorrhage: A guideline for healthcare professionals from the American Heart Association/American Stroke Association. Stroke. 2010; 41:2108-2129.

13. Naidech AM. Intracranial hemorrhage. Am J Respir Crit Care Med. 2011;184:998-1106.

14. Nolan JP, Morley PT, Vanden Hoek TL, et al. Therapeutic hypothermia after cardiac arrest: an advisory statement by the Advanced Life Support Task Force of the International Liaison Committee on Resuscitation. Circulation. 2003;108:118-121.

15. Prasad K, Al-Roomi K, Krishnan PR, et al. Anticonvulsant therapy for status epilepticus (review). Cochrane Database Syst Rev. 2005;(4):CD003723.

16. Royal College of Physicians. National Clinical Guidelines for Stroke, 3rd ed. Prepared by the Intercollegiate Stroke Working Party. London, Royal College of Physicians, 2008.

17. Suarez JI, Tarr RW, Selman WR. Aneurysmal subarachnoid hemorrhage. N Engl J Med.

2006;354:387-396.

18. Vale FL, Burns J, Jackson AB, et al. Combined medical and surgical treatment after acute spinal cord injury: Results of a prospective pilot study to assess the merits of aggressive medical resuscitation and blood pressure management. J Neurosurg. 1997;87:239-246.

Web Sites

1. Brain Trauma Foundation. http://www.braintrauma.org. In addition to guidelines for management of traumatic brain injury, this site offers Internet-based continuing education programs, including recorded presentations, live Web-based lectures, and interactive learning modules based on the latest scientific evidence. It also offers professional and academic resources for those interested in learning more about traumatic brain injury and quality improvement in healthcare.

2. Brain Attack Coalition. http://www.stroke-site.org. This Web site contains such practical information as guidelines for the diagnosis of strokes, order sets and checklists from a variety of institutions, and pathways — step-by-step approaches to the management of stroke. It also provides information and resources for stroke patients, families, and caregivers.

Chapter 9

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