Clinical Review ABC of intensive care

Neurological support

BMJ 1999; 319 doi: https://doi.org/10.1136/bmj.319.7202.110 (Published 10 July 1999) Cite this as: BMJ 1999;319:110
  1. Ian S Grant,
  2. Peter J D Andrews

    The neurological conditions that require management in intensive care are diverse. Indications for admission range from maintaining the airway to control of seizures and intracranial pressure. Intensive care of a patient with a neurological disease requires a partnership between the referring specialist and intensive care doctors. Despite the diversity of the neurological diseases being managed some standard principles apply.

    Standard principles for neurological intensive care

    • The airway should be protected, generally with an endotracheal tube or tracheostomy

    • Normal gas exchange should be maintained using mechanical ventilation if necessary. Especially in conditions of critical cerebral oxygen supply—for example, acute brain injury—the arterial oxygen tension (PaO2) should be kept above 12 kPa and the arterial carbon dioxide tension (PaCO2) at low normal values (4.0-4.5 kPa)

    • Maintenance of an adequate cerebral perfusion pressure is essential to maintain cerebral oxygen delivery

    • Specialised measurement techniques such as monitoring intracranial pressure assist management

    Acute brain injury and encephalopathy

    Patients with acute brain injury, regardless of the cause, all raise similar intensive care problems. Some care, including ventilation, control of intracranial and cerebral perfusion pressure, and anticonvulsant treatment, may be similar, although patients will also require specific treatment of their condition. Patients should have their pupil size and responses assessed and conscious level measured by the Glasgow coma scale. These signs should be reassessed regularly thereafter.

    Causes of acute brain injury

    • Trauma

    • Aneurysmal subarachnoid haemorrhage

    • Ischaemic or haemorrhagic stroke

    • Infection (encephalitis or meningitis)

    • Vasculitis (such as systemic lupus erythematosus)

    • Demyelination (such as acute demyelinating encephalomyelitis)

    • Tumour or peritumoral haemorrhage

    Aims of intensive care management

    The number and duration of secondary insults affect outcome. In particular, hypotension, decreased cerebral perfusion pressure, hypoxaemia, and hyperthermia are associated with a worse outcome. Intensive care management aims to avoid secondary insults and to optimise cerebral oxygenation by ensuring a normal arterial oxygen content and by maintaining cerebral perfusion pressure above 70 mm Hg. This figure may be modified depending on the jugular …

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