Clinical Review
ABC of intensive care
Neurological support
Cite this as:
BMJ
1999;319:110
- Adult intensive care
- Other anaesthesia
- Injury
- Neurological injury
- Trauma
- Trauma CNS / PNS
- Infection (neurology)
- Vascularitis
- Metabolic disorders
- Diabetes
- Stroke
- Cardiothoracic surgery
- Coma and raised intracranial pressure
- Connective tissue disease
- Drugs: musculoskeletal and joint diseases
- Drugs: psychiatry
- Epilepsy and seizures
- Immunology (including allergy)
- Mechanical ventilation
- Mechanical ventilation
- Neuromuscular disease
- Peripheral nerve disease
- Spinal cord
- Systemic lupus erythematosus
- Infectious diseases
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- Ian S Grant,
- 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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