The scope and purpose of this work is 2-fold: to synthesize the available evidence and to translate it into recommendations. This document provides recommendations only when there is evidence to support them. As such, they do not constitute a complete protocol for clinical use. Our intention is that these recommendations be used by others to develop treatment protocols, which necessarily need to incorporate consensus and clinical judgment in areas where current evidence is lacking or insufficient. We think it is important to have evidence-based recommendations to clarify what aspects of practice currently can and cannot be supported by evidence, to encourage use of evidence-based treatments that exist, and to encourage creativity in treatment and research in areas where evidence does not exist. The communities of neurosurgery and neuro-intensive care have been early pioneers and supporters of evidence-based medicine and plan to continue in this endeavor. The complete guideline document, which summarizes and evaluates the literature for each topic, and supplemental appendices (A-I) are available online at https://www.braintrauma.org/coma/guidelines.

Guidelines for the Management of Severe Traumatic Brain Injury, Fourth Edition

Chelsea Kidwell, Patrick D. Lyden, Lewis B. Morgenstern, Adnan I. Qureshi, Robert Brass, Anthony Furlan, Robert L. Grubb, Randall T. Higashida, Edward C. Jauch, Harold P. Adams, Jr, Gregory del Zoppo, Mark J. Alberts, Deepak L. Bhatt, Lawrence Guidelines for the Early Management of Adults With Ischemic Stroke : ISSN: 1524-4628 Copyright © 2007 American Heart Association. All rights reserved. Print ISSN: 0039-2499. Online Stroke is published by the American Heart Association. 7272 Greenville Avenue, Dallas, TX 72514 doi: 10.1161/STROKEAHA.107.181486 2007, 38:1655-1711: originally published online April 12, 2007 Stroke http://stroke.ahajournals.org/content/38/5/1655 located on the World Wide Web at: The online version of this article, along with updated information and services, is http://stroke.ahajournals.org/ http://stroke.ahajournals.org/ An erratum has been published regarding this article. Please see the attached page for:

/pdf/guidelines-for-the-early-management-of-adults-with-ischemic-3dcmwodyff.pdf

Guidelines for the early management of adults with ischemic stroke: a guideline from the American Heart Association/American Stroke Association Stroke Council, Clinical Cardiology Council, Cardiovascular Radiology and Intervention Council, and the Atherosclerotic Peripheral Vascular Disease and Quality of Care Outcomes in Research Interdisciplinary Working Groups: The American Academy of Neurology

Purpose— Our goal is to provide an overview of the current evidence about components of the evaluation and treatment of adults with acute ischemic stroke. The intended audience is physicians and other emergency healthcare providers who treat patients within the first 48 hours after stroke. In addition, information for healthcare policy makers is included. Methods— Members of the panel were appointed by the American Heart Association Stroke Council’s Scientific Statement Oversight Committee and represented different areas of expertise. The panel reviewed the relevant literature with an emphasis on reports published since 2003 and used the American Heart Association Stroke Council’s Levels of Evidence grading algorithm to rate the evidence and to make recommendations. After approval of the statement by the panel, it underwent peer review and approval by the American Heart Association Science Advisory and Coordinating Committee. It is intended that this guideline be fully updated in 3 years. Results— Managem...

/pdf/guidelines-for-the-early-management-of-adults-with-ischemic-16k5yjn0ic.pdf

Guidelines for the Early Management of Adults With Ischemic Stroke: A Guideline From the American Heart Association/ American Stroke Association Stroke Council, Clinical Cardiology Council, Cardiovascular Radiology and Intervention Council, and the Atherosclerotic Peripheral Vascular Disease and Quality of Care Outcomes in Research Interdisciplinary Working Groups: The American Academy of Neurology affirms the value of this guideline as an educational tool for neurologists

Guidelines for the management of severe traumatic brain injury. Editor's Commentary.

In 1994, a panel appointed by the Stroke Council of the American Heart Association authored guidelines for the management of patients with acute ischemic stroke.1 After the approval of the use of intravenous recombinant tissue plasminogen activator (rtPA) for treatment of acute ischemic stroke by the Food and Drug Administration, the guidelines were supplemented by a series of recommendations 2 years later.2 Several promising interventions for the treatment of acute ischemic stroke have subsequently been tested in clinical trials, and other components of acute management have been evaluated since the previous guidelines were published. These new data have prompted the present revision of the prior guideline statement.

The goal of these guidelines is to provide updated recommendations that can be used by primary care physicians, emergency medicine physicians, neurologists, and other physicians who provide acute stroke care from admission to an emergency department through the first 24 to 48 hours of hospitalization by addressing the diagnosis and emergent treatment of the acute ischemic stroke in addition to the management of its acute and subacute neurological and medical complications.

Several groups have now written statements about management of stroke.3–7 These statements also include recommendations about public educational programs, the organization of stroke resources, and other aspects of patient management. For example, the Brain Attack Coalition published recommendations for organizing stroke services in a community, and the recommendations of the American Heart Association Emergency Cardiovascular Care Committee provide an outline for emergency medical services.6 The current panel elected not to duplicate these recent efforts.

Therapies to prevent recurrent stroke, also a component of acute management, are similar to prophylactic medical or surgical therapies used for patients with transient ischemic attacks and other high-risk patients. The reader is referred to relevant recent statements for additional information.8,9 

In developing …

https://www.pennstatehershey.org/c/document_library/get_file?folderId=115233&name=DLFE-2413.pdf

Guidelines for the Early Management of Patients With Ischemic Stroke A Scientific Statement From the Stroke Council of the American Stroke Association

Intracranial Pressure Dynamics During Head Impact

✓ The authors have analyzed the hospital course and outcome in 100 consecutive patients with severe head injuries who either on admission or within 24 to 48 hours of their hospitalization were not verbally responsive, and not able to follow commands. All were treated in a uniform manner. Operative intervention was performed immediately in patients with significant extracerebral hematomas or large superficial intracerebral hematomas. Intracranial pressure (ICP) was monitored in all, and in 55 patients treatment with a combination of dexamethasone, hyperventilation (PaCO2 of 25 to 28 mm Hg), mannitol, normothermia, and controlled systemic arterial pressure was required for intracranial hypertension (ICP > 15 mm Hg). In 25 patients whose ICP remained significantly elevated (ICP > 40 mm Hg for 15 minutes or more), high-dose pentobarbital therapy was used to lower the ICP. Forty-five patients recovered with no or minimal neurological deficit, and returned to their pre-injury occupation (good recovery). Fifteen...

The outcome with aggressive treatment in severe head injuries. Part I: the significance of intracranial pressure monitoring.

J" In a series of 100 consecutive patients with severe head injuries, uncontrolled intracranial hypertension, which was defined as occurring when intracranial pressure (ICP) exceeded 40 mm Hg for 15 minutes or more, occurred in 25 patients. This was despite high-dose dexamethasone, hyperventilation, normothermia, appropriate surgical evacuation, and cerebrospinal fluid drainage when possible. Persistently elevated ICP occurred in 19 patients with diffuse brain injury, and in six patients uncontrolled intracranial hypertension followed evacuation of a surgical mass. All of these patients received intravenous barbiturates to control the ICP. At the time of initial barbiturate administration, 11 of the 25 had bilaterally unreactive pupils and 12 were decerebrate. The initial pentobarbital loading dose (3 to 5 mg/kg) effectively reduced the ICP in 76% of the patients. Prolonged pentobarbital treatment with blood barbiturate levels from 2.5 to 3.5 mg% was associated with normalization of the ICP (ICP less than 15 mm Hg) in 13 patients. In those patients responding to barbiturates, the daily mannitol requirement was reduced from 4.5 to 0.5 gm/kg/day (p < 0.01). In six nonresponders to barbiturates, mannitol requirements increased to 5.9 gm/kg/day; five of these died and one remains vegetative. Ten of the 19 barbiturate responders have returned to a productive life, two remain moderately disabled, two are severely disabled, one is vegetative, and four are dead. The high rate of good quality survival in this series of severely brain-injured patients indicates that barbiturates are useful in the treatment of uncontrolled intracranial hypertension and that a broader investigation of the clinical application of barbiturates is indicated.

The outcome with aggressive treatment in severe head injuries: Part II: Acute and chronic barbiturate administration in the management of head injury

There is little information as to the optimal use of mannitol. To determine the dose-response relationship, the osmotic gradient required, and the time course of intracranial pressure (ICP) reduction produced by mannitol, eight patients with acute head injury were studied in whom ICP was monitored with a ventriculostomy and found to be elevated. Ventilation was controlled to a pCO2 of 25 +/- 3 mm Hg and all were paralyzed with Pavulon. None had received barbiturates. Before mannitol administration the intracranial volume-pressure response was determined. Mannitol was administered as a bolus of 0.25 gm/kg, 0.5 gm/kg, and in six patients, 1 gm/kg, separated by at least 8 hours. In all patients the ICP reduction with 0.25 gm/kg (41.3 +/- 10.2 mm Hg leads to 16.4 +/- 5.6, p less than 0.01) was equivalent to that achieved with the larger doses. Serum osmolality rises of 10 mOsm or more were associated with a reduction in ICP. Much smaller doses than those previously recommended were effective in reducing the ICP acutely, although at 5 hours there was a trend toward persistent reduction when the larger dose is used. This trend was small and indicates that smaller and more frequent doses are as effective in reducing the ICP while avoiding the risk of osmotic disequilibrium and severe dehydration.

Randall W. Smith

Papers

Intracranial Pressure Dynamics During Head Impact

The outcome with aggressive treatment in severe head injuries. Part I: the significance of intracranial pressure monitoring.

The outcome with aggressive treatment in severe head injuries: Part II: Acute and chronic barbiturate administration in the management of head injury

Mannitol dose requirements in brain-injured patients

The Outcome with Aggressive Treatment in Severe Head Injuries. Part II: Acute and Chronic Barbiturate Administration in the Management of Head Injury