Eligibility of out-of-hospital cardiac arrest patients for extracorporeal cardiopulmonary resuscitation in the United States: A geographic information system model.

Background: Recent evidence suggest that extracorporeal cardiopulmonary resuscitation (ECPR) may improve survival rates for nontraumatic out-of-hospital cardiac arrest (OHCA). Eligibility criteria for ECPR are often based on patient age, clinical variables, and facility capabilities. Expanding access to ECPR across the U.

Fragility Index Meta-Analysis of Randomized Controlled Trials Shows Highly Robust Evidential Strength for Benefit of <3 Hour Intravenous Alteplase.

Background: Cumulative fragility index (FI) analysis enables quantification of the evidential strength of intravenous alteplase's core indication-treatment of disabling acute ischemic stroke within 3 hours of onset.

Methods: Meta-analyses were performed (study level) or identified (individual participant level) for freedom-from-disability (modified Rankin Scale [mRS] score 0-1, primary efficacy), functional independence (mRS score 0-2, secondary efficacy), and mortality outcomes. Individual trial and cumulative FI analyses were serially conducted after each successive randomized controlled trial (RCT).

Impella in Transport: Physiology, Mechanics, Complications, and Transport Considerations.

Cardiogenic shock (CS) represents a spectrum of hemodynamic deficits in which the cardiac output is insufficient to provide adequate tissue perfusion. The Impella (Abiomed Inc, Danvers, MA) device, a contemporary percutaneous ventricular support, is most often indicated for classic, deteriorating, and extremis Society for Coronary Angiography and Intervention stages of CS, which describe CS that is not responsive to optimal medical management and conventional treatment measures. Impella devices are an evolving field of mechanical support that is used with increasing frequency.

NeuroEthics and End of Life Care.

The emergency department is where the patient and potential ethical challenges are first encountered. Patients with acute neurologic illness introduce a unique set of dilemmas related to the pressure for ultra-early prognosis in the wake of rapidly advancing treatments. Many with neurologic injury are unable to provide autonomous consent, further complicating the picture, potentially asking uncertain surrogates to make quick decisions that may result in significant disability.

The Present State of Neurointensivist Training in the United States: A Comparison to Other Critical Care Training Programs.

Objective: This manuscript describes the state of neurocritical care fellowship training, compares its written standards to those of other critical care fellowship programs, and discusses how programmatic oversight by the United Council for Neurological Subspecialties should evolve to meet American College of Graduate Medical Education standards. This review is a work product of the Society of Critical Care Medicine Neuroscience section and was reviewed and approved by the Council of the Society of Critical Care Medicine.

Data Sources: We evaluated the published training criteria and requirements of American College of Graduate Medical Education Critical Care subspecialty fellowships programs of Internal Medicine, Surgery, and Anesthesia and compared them with the training criteria and required competencies for neurocritical care.

Intersection of prognosis and palliation in neurocritical care.

Purpose Of Review: Difficult discussions regarding end-of-life care are common in neurocritical care. Because of a patient's neurological impairment, decisions regarding continuing or limiting aggressive care must often be made by patients' families in conjunction with medical providers. This review provides perspective on three major aspects of this circumstance: prognostication, family-physician discussions, and determination of death (specifically as it impacts on organ donation).

Factors associated with adverse outcomes in patients with traumatic intracranial hemorrhage and Glasgow Coma Scale of 15.

Patients with mild traumatic brain injury (mTBI) with associated intracranial injury, or complicated mTBI, are at risk of deterioration. Clinical management differs within and between institutions. We conducted an exploratory analysis to determine which of these patients are unlikely to have an adverse outcome and may be future targets for less resource intensive care.

The Code of Professional Conduct for the Neurocritical Care Society.

Part of the responsibility of a professional society is to establish the expectations for appropriate behavior for its members. Some codes are so essential to a society that the code itself becomes the central document defining the organization and its tenets, as we see with the Hippocratic Oath. In that tradition, we have revised the code of professional conduct for the Neurocritical Care Society into its current version, which emphasizes guidelines for personal behavior, relationships with fellow members, relationships with patients, and our interactions with society as a whole.

Recommendations for the Critical Care Management of Devastating Brain Injury: Prognostication, Psychosocial, and Ethical Management : A Position Statement for Healthcare Professionals from the Neurocritical Care Society.

Devastating brain injuries (DBIs) profoundly damage cerebral function and frequently cause death. DBI survivors admitted to critical care will suffer both intracranial and extracranial effects from their brain injury. The indicators of quality care in DBI are not completely defined, and despite best efforts many patients will not survive, although others may have better outcomes than originally anticipated.

Repeat neuroimaging of mild traumatic brain-injured patients with acute traumatic intracranial hemorrhage: clinical outcomes and radiographic features.

Objectives: Emergency department (ED) management of mild traumatic brain injury (TBI) patients with any form of traumatic intracranial hemorrhage (ICH) is variable. Since 2000, our center's standard practice has been to obtain a repeat head computed tomography (CT) at least 6 hours after initial imaging. Patients are eligible for discharge if clinical and CT findings are stable.

Airway management and out-of-hospital cardiac arrest outcome in the CARES registry.

Background: Optimal out of hospital cardiac arrest (OHCA) airway management strategies remain unclear. We compared OHCA outcomes between patients receiving endotracheal intubation (ETI) versus supraglottic airway (SGA), and between patients receiving [ETI or SGA] and those receiving no advanced airway.

Methods: We studied adult OHCA in the Cardiac Arrest Registry to Enhance Survival (CARES).

The incidence of seizures in patients undergoing therapeutic hypothermia after resuscitation from cardiac arrest.

Study Objective: Non-convulsive seizures/status epilepticus occur in approximately 20% of comatose, non-cardiac arrest intensive care unit (ICU) patients, and are associated with increased mortality. The prevalence and clinical significance of seizures in comatose survivors of cardiac arrest undergoing therapeutic hypothermia is not well described.

Methods: At this urban level I trauma center, every patient undergoing therapeutic hypothermia is monitored with continuous video encephalography (cvEEG).

Cost-effectiveness of diagnostic strategies for evaluation of suspected subarachnoid hemorrhage in the emergency department.

Objectives: Diagnosing subarachnoid hemorrhage (SAH) in emergency department (ED) patients is challenging. Potential diagnostic strategies include computed tomography (CT) only, CT followed by lumbar puncture (CT/LP), CT followed by magnetic resonance imaging and angiography (CT/MRA), and CT followed by CT angiography (CT/CTA). The objective was to determine the relative cost-effectiveness of diagnostic strategies for SAH.

Neurogenic stunned myocardium associated with acute spinal cord infarction: a case report.

Introduction. Neurogenic stunned myocardium (NSM) is a reversible cardiomyopathy resulting in transient left ventricular apical ballooning presumed to result from catecholamine surge occurring under physiologic stress. Acute spinal cord ischemia is a rare ischemic vascular lesion.

Withdrawal of antithrombotic agents and its impact on ischemic stroke occurrence.

Background And Purpose: Antithrombotic medications (anticoagulants and antiplatelets) are often withheld in the periprocedural period and after bleeding complications to limit the risk of new or recurrent bleeding. These medications are also stopped by patients for various reasons such as cost, side effects, or unwillingness to take medication.

Methods: Patient records from the population-based Greater Cincinnati/Northern Kentucky Stroke Study were reviewed to identify cases of ischemic stroke in 2005 and determine the temporal association of strokes with withdrawal of antithrombotic medication.

The degree of bandemia in septic ED patients does not predict inpatient mortality.

Background: A delay in diagnosis of sepsis and appropriate treatment increases subsequent mortality. An association with the degree of bandemia, or the presence of immature neutrophils in the white blood cell count, has not been explored in septic patients presenting to the emergency department (ED). We hypothesized that the presenting band levels would be higher in septic patients who die in hospital compared with survivors.

Inadequate provision of postintubation anxiolysis and analgesia in the ED.

Introduction: Patients intubated in the emergency department (ED) often have extended ED stays. We hypothesize that ED intubated patients receive inadequate postintubation anxiolysis and analgesia after rapid sequence induction (RSI).

Methods: This was a retrospective cohort study of every adult intubated in a tertiary-care ED (July 2003-June 2004).