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Neurosurgical Emergencies - FINAL

Neurosurgical Emergencies - FINAL - Neurologic and...

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Neurologic and Neurosurgical Neurologic and Neurosurgical Emergencies in the ICU Emergencies in the ICU Thomas P. Bleck, MD, FCCM Thomas P. Bleck, MD, FCCM Louise Nerancy Eminent Scholar in Neurology Professor of Neurology, Neurological Surgery, and Internal Medicine Director, Neuroscience Intensive Care Unit The University of Virginia
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Overview Overview Altered consciousness and coma Increased intracranial pressure Neurogenic respiratory failure Status epilepticus Acute stroke intervention Intracerebral hemorrhage Subarachnoid hemorrhage Head trauma Spinal cord injury
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Altered Consciousness and Coma Altered Consciousness and Coma Consciousness requires arousal (coming from the brainstem reticular formation) and content (the cerebral hemispheres) Alterations in consciousness stem from: Disorders affecting the reticular formation Disorders affecting both cerebral hemispheres Disorders affecting the connections between the brainstem and the hemispheres
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Altered Consciousness and Coma Altered Consciousness and Coma Definitions Delirium: classically, altered awareness with motor and sympathetic hyperactivity, often with sleeplessness, hallucinations, and delusions - More recently used to describe any acute change in consciousness short of coma, as a synonym for encephalopathy Obtundation: the patient appears to sleep much of the day but has some spontaneous arousals
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Altered Consciousness and Coma Altered Consciousness and Coma Stupor: the patient lies motionless unless aroused but will awaken with stimulation; localizes or withdraws from noxious stimuli Coma: the patient makes no understandable response to stimulation but may display abnormal flexor (decorticate) or extensor (decerebrate) posturing
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Altered Consciousness and Coma Altered Consciousness and Coma Examining the patient with altered consciousness: ABCs - insure adequate oxygenation and blood pressure before proceeding Be certain that the blood glucose is at least normal If there is any reason to suspect thiamine deficiency, administer 100 mg thiamine IV
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Altered Consciousness and Coma Altered Consciousness and Coma The purpose of the coma examination is to determine whether the upper brainstem is functioning. Brainstem dysfunction means immediate imaging. Bilateral hemispheral dysfunction leads initially to metabolic or toxic diagnoses. Four domains to examine: Pupillary responses Extraocular movements Respiratory pattern Motor responses
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Parasympathetic control of pupil size
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Sympathetic control of pupil size
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III III VI VI VIII VIII MLF Neck stretch receptors - + Control of Horizontal Eye Movements Control of Horizontal Eye Movements
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Assessing Eye Movements Assessing Eye Movements Spontaneous horizontal conjugate eye movements prove that the brainstem centers for eye movement are intact.
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