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Background:Intracranial hypertension, defined as an intracranial pressure (ICP) >20 mmHg for a period of more than 5 min, worsens neurologic outcome in traumatic brain injury (TBI). While several mechanisms contribute to poor outcome, impaired cerebral perfusion appears to be a highly significant common denominator. Management guidelines from the Brain Trauma Foundation recommend measuring ICP to guide therapy. In particular, hyperosmolar therapy, which includes mannitol or hypertonic saline (HTS), is frequently administered to reduce ICP. Currently, mannitol (20%) is considered the gold standard hyperosmolar agent. However, HTS is increasingly used in this setting. This review sought to compare the efficacy of mannitol to HTS in severe TBI.Methods:The PubMed database was used to systematically search for articles comparing mannitol to HTS in severe TBI. The following medical subject headings were used: HTS, sodium lactate, mannitol, ICP, intracranial hypertension, and TBI. We included both prospective and retrospective randomized controlled studies of adult patients with intracranial hypertension as a result of severe TBI who received hyperosmolar therapy.Results:Out of 45 articles, seven articles were included in our review: 5 were prospective, randomized trials; one was a prospective, nonrandomized trial; and one was a retrospective, cohort study.Conclusions:While all seven studies found that both mannitol and HTS were effective in reducing ICP, there was heterogeneity with regard to which agent was most efficacious.

Transthoracic echocardiography and lung ultrasound are noninferior to chest x-ray for screening of pneumothorax and accurate central venous catheter positioning. Thus, the point of care use of ultrasound can reduce central venous catheter insertion to use time, exposure to radiation, and improve patient safety.

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Objective Portable ultrasound is now used routinely in many intensive care units (ICUs) for various clinical applications. Echocardiography performed by non-cardiologists, both transesophageal (TEE) and transthoracic (TTE), has evolved to broad applications in diagnosis, monitoring, and management of critically ill patients. This review provides a current update on Focused Critical Care Echocardiography (FCCE) for the management of critically ill patients. Method Source data were obtained from a PubMed search of the medical literature, including the PubMed “related articles” search methodology. Summary and Conclusions While studies demonstrating improved clinical outcomes for critically ill patients managed by FCCE are generally lacking, there is evidence to suggest that some intermediate outcomes are improved. Furthermore, non-cardiologists can learn FCCE and adequately interpret the information obtained. Non-cardiologists can also successfully incorporate FCCE into advanced cardiopulmonary life support (ACLS). Formal training and proctoring are important for safe application of FCCE in clinical practice. Further outcomes-based research is urgently needed to evaluate the efficacy of FCCE

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Conflicts of Interest: CDB, HBM, EEM, and MBY have patents pending related to both coagulation/fibrinolysis diagnostics and therapeutic fibrinolytics, and are passive co-founders and holds stock options in Thrombo Therapeutics, Inc. HBM and EEM have received grant support from Haemonetics and Instrumentation Laboratories. MBY has previously received a gift of Alteplase (tPA) from Genentech, and owns stock options as a co-founder of Merrimack Pharmaceuticals. All other authors have nothing to disclose.