Acute Neuro Care Focused Approach to Neuroemergencies Prasanna Udupi Bidkar Ponniah Vanamoorthy Editors 123 Acute Neuro Care Prasanna Udupi Bidkar Ponniah Vanamoorthy Editors Acute Neuro Care Focused Approach to Neuroemergencies Editors Prasanna Udupi Bidkar Ponniah Vanamoorthy MBBS, MD, DNB, DM MBBS, MD, DNB (Neuroanaesthesiology), MNAMS, MBA Senior consultant and Head Division of Neuroanaesthesiology Neuroanaesthesiology & Neurocritical care Department of Anaesthesiology MGM Healthcare Pvt Ltd and critical care Chennai, Tamil Nadu Jawaharlal Institute of Postgraduate Medical India Education and Research Puducherry India ISBN 978-981-15-4070-7 ISBN 978-981-15-4071-4 (eBook) https://doi.org/10.1007/978-981-15-4071-4 © The Editor(s) (if applicable) and The Author(s) 2020 This work is subject to copyright. All rights are reserved by the Publishers, whether the whole or part of the material is concerned, specifically the rights of translation, reprinting, reuse of illustrations, recitation, broadcasting, reproduction on microfilms or in any other physical way, and transmission or information storage and retrieval, electronic adaptation, computer software, or by similar or dissimilar methodology now known or hereafter developed. The use of general descriptive names, registered names, trademarks, service marks, etc. in this publication does not imply, even in the absence of a specific statement, that such names are exempt from the relevant protective laws and regulations and therefore free for general use. The publishers, the authors, and the editors are safe to assume that the advice and information in this book are believed to be true and accurate at the date of publication. Neither the publishers nor the authors or the editors give a warranty, expressed or implied, with respect to the material contained herein or for any errors or omissions that may have been made. The publishers remain neutral with regard to jurisdictional claims in published maps and institutional affiliations. Co-publishing partnership between Byword Books Private Limited and Springer Nature India Private Limited. This Springer imprint is published by the registered company Springer Nature Singapore Pte Ltd. The registered company address is: 152 Beach Road, #21-01/04 Gateway East, Singapore 189721, Singapore Foreword Neurocritical Care (NCC) is a subspecialty of Critical Care. NCC encompasses the care of patients with neurological and neurosurgical emergencies such as traumatic brain injury, subarachnoid hemorrhage, severe acute ischemic stroke, status epilepti- cus, and infectious conditions among others. The field of NCC has evolved tremen- dously in the past few decades. The advent of novel therapies and dedicated neurocritical care units have contributed to improved outcomes of neurocritically-ill patients. NCC is delivered in a more organized fashion around the globe and is now possible for neu- rointensivists to collaborate to further both clinical and research knowledge in this field. The creation of the Neurocritical Care Society (NCS) in the early 2000s has made such partnerships possible. NCS advocates for the highest quality of care for patients with critical neurological illnesses. NCS has collaborated with various organizations from all corners of the world to enhance education of neurological emergencies. An important aspect of excellent NCC is the education of neurointensivists and critical care practitioners on the intricacies of these complex disorders. Drs. Prasanna Udupi Bidkar and Ponniah Vanamoorthy have edited an excellent textbook titled “Acute Neuro Care: A Focused Approach to Neuroemergencies.” They have brought together a group of distinguished group of neuroanesthesiologists and neurointen- sivists from established academic centers in India. The chapters cover practical but important material including airway management, ultrasound techniques, neuro- pharmacology, and more in-depth look at the most common disorders. This endeavor will contribute a great deal to the enhancement of knowledge in NCC. I recommend this book for practitioners caring for patients with acute neurological emergencies, particularly those working in countries with emerging economies. Jose I. Suarez, MD, FNCS, FANA, FAAN Neurosciences Critical Care, Departments of Anesthesiology and Critical Care Medicine, Neurology, and Neurosurgery The Johns Hopkins University School of Medicine Baltimore, MD, USA Neurocritical Care Society Chicago, IL, USA v Preface Neuro-Emergencies are time-sensitive situations in which effective therapies given during critical hours greatly improve the outcomes. A collaborative interdisciplin- ary approach with practical set of protocols, decision points, and communication is the key to good patient management. Time is Brain and time lost is brain lost. Early recognition and neuroimaging are the essentials to institute time-sensitive effective treatment strategies in Neuro- Emergencies. With advances in medical sciences and upgradation of concepts, there is a pressing need to unwind a new outcome-centric approach in place of the tradi- tional approach. Acute Neuro Care (ANC) explores the possibility of this approach and tries to simplify neuro-emergency care in a practical set of protocols. The learn- ers will have the opportunity to absorb and implement these protocols in their day- to-day practice for improving patient outcomes. Establishing systems of care, collaborating with primary centers, creating public awareness, enhancing clinical pathways, and implementing patient education form the crux of a strong survival chain in Neuro-Emergencies. The main objective of this endeavor is to inculcate and disseminate outcome-centric focused approach of his- tory taking, clinical examination, and rapid imaging in everyday clinical practice among physicians and nursing personnel involved in the acute care of neurological patients. A wide spectrum of topics are covered in this book such as neurotrauma, stroke, status epilepticus, coma, neuromuscular weakness, neuroinfections, and neurophar- macology and importantly include algorithmic approaches for easy understanding. With contributions from authors across various institutions in India, this book will provide a diverse yet focused set of learning material for easy adoption into daily clinical practice. In short, Acute Neuro Care is the one-stop destination to gain prac- tical knowledge in management of Neuro-Emergencies. Puducherry, India Prasanna Udupi Bidkar Chennai, India Ponniah Vanamoorthy vii Contents 1 Airway and Breathing . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 Gyaninder Pal Singh, Surya Kumar Dube, and Devika Bharadwaj 2 Approach to a Patient with Coma . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23 S. Srinivasan and Prasanna Udupi Bidkar 3 Focused Neurological Evaluation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 35 Ajay Prasad Hrishi and Manikandan Sethuraman 4 Neuropharmacology . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 57 Swagata Tripathy and Suma Rabab Ahmad 5 Role of Ultrasound in Neuroemergencies . . . . . . . . . . . . . . . . . . . . . . . . 79 Saurabh Anand, Nitin Manohar, and Astha Palan 6 Basics of Neuroradiology . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 101 Zulfiqar Ali and Nidhi Gupta 7 Raised ICP and Brain Herniation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 117 Kiran Jangra, Hemant Bhagat, and Nidhi Panda 8 Traumatic Brain Injury . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 139 Keshav Goyal and Rahul Yadav 9 Traumatic Spine Injury . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 159 Niraj Kumar and Ashish Bindra 10 Acute Hemorrhagic Stroke . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 175 M. R. Rajani, Rajshree Deopujari, Shwetal Goraksha, and Joseph Monteiro 11 Aneurysmal Subarachnoid Hemorrhage . . . . . . . . . . . . . . . . . . . . . . . . 195 Charu Mahajan, Indu Kapoor, and Hemanshu Prabhakar 12 Acute Ischemic Stroke . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 209 Ponniah Vanamoorthy and Prasanna Udupi Bidkar 13 Management of Status Epilepticus . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 239 K. N. Gopalakrishna and M. Radhakrishnan ix x Contents 14 Acute Non-traumatic Weakness . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 253 Venkataramaiah Sudhir and Kamath Sriganesh 15 Meningitis and Encephalitis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 269 Vasudha Singhal and Prasanna Udupi Bidkar About the Editors Prasanna Udupi Bidkar is incharge of the Division of Neuroanesthesiology at Jawaharlal Institute of Postgraduate Medical Education and Research (JIPMER), Pondicherry, and was instrumental in set- ting up the DM Neuroanesthesiology course at the insti- tute. He has been working in neuroanesthesiology and neurocritical care for 15 years. He completed his DM in Neuroanesthesiology at the All India Institute of Medical Sciences (AIIMS), New Delhi. He has pub- lished more than 50 papers in reputed national and international journal and has written 12 chapters in various textbooks in the field of Neuroanaesthesiology and Neurocritical care. He is an active member and current treasurer of the Indian Society of Neuroanesthesiology and Critical Care (ISNACC). He is founding mem- ber and current treasurer of Neurocritical care society of India (NCSI). Ponniah  Vanamoorthy is Chief of Neuroanesthesiology and Neurocritical Care Services at MGM Healthcare, Chennai. He was instrumental in setting up the Department of Neurosciences at Global Hospital, Chennai. He received advanced training in neuroanesthesiology and neurocritical care at the All India Institute of Medical Sciences (AIIMS), New Delhi. He is an authority on acute stroke management in India. He is an active member and current secretary of  the Indian Society of Neuroanesthesiology and Critical Care (ISNACC). He is founding member and current secretary of Neurocritical care society of India (NCSI). xi Abbreviations ABC Airway, breathing, and circulation ACA Anterior cerebral artery AED Antiepileptic drug AFP Acute flaccid paralysis AIS Acute ischemic stroke BA Bioavailability BP Blood pressure CBC Complete blood count CBF Cerebral blood flow CMRO Cerebral metabolic rate of oxygen 2 CN Cranial nerve CNS Central nervous system CPP Cerebral perfusion pressure CSF Cerebrospinal fluid CT Computed tomography CVS Cardiovascular system DTR Deep tendon reflex ECG Electrocardiography ED Emergency Department EDH Extradural hematoma EEG Electroencephalogram EMS Emergency medical services ETT Endotracheal tube EVD External ventricular drain FFP Fresh frozen plasma GCS Glasgow coma scale HR Heart rate HTS Hypertonic saline ICA Internal carotid artery ICH Intracranial hemorrhage ICP Intracranial hemorrhage ICU Intensive care unit IVC Inferior vena cava LL Lower limb xiii