In this chapter, we will cover indications and contraindications, complications, informed consent, patient preparation, lung function tests, test phases, and when to terminate a test.

Continuous EEG (cEEG) monitoring offers bedside, noninvasive, diffuse, and continuous information about brain function. These characteristics allow clinicians to assess brain function, evaluate for changes in brain function over time, and identify electrographic seizures that are often not clinically observable. These advantages have led to widespread and increasing use of cEEG in critically ill patients across the age spectrum. This chapter introduces cEEG in critically ill neonates and children including seizure epidemiology (incidence and risk factors), the relationship between electrographic seizures and outcome, available consensus statements and guidelines, and role of quantitative EEG.

Indications, procedures, complications, management

EEGs are a simple and commonly used neurological test that most trainees find hard to interpret. Summations of excitatory and inhibitory postsynaptic potentials of pyramidal neurons in the superficial layers of the cortex generate electrographic activity. These occur constantly, hence normal electrographic activity is continuous. Subcortical structures such as the thalamus and reticular activating system (RAS) modulate cortical neuronal activity, resulting in electrographic rhythms. A sizable area of cortex is required to generate enough signal on scalp recordings. Small potentials may be missed. Voltage is current times resistance (Ohm’s law). EEGs are used in a variety of clinical care settings, including clinics, wards, emergency rooms, critical care units, and operating rooms. Like every other test, the EEG has significant technical and practical limitations. EEG electrodes should have low impendences (less than 5 ohms). Electrodes are placed on the scalp using a standardized system (international 10-20 system). EEGs should be calibrated before and after each recording. Each major division is 1 second within which there are five subdivisions of 200 milliseconds each. For adult records, most readers will use a sensitivity of 7 uV/mm, low-frequency filter of 1 Hz, high-frequency filter of 70 Hz, notch filter (60 Hz), and paper speed of 30 mm per second.

By the late 1700s and early 1800s, cinchona bark was, to many, ‘the most important, and the most usual remedy that medicine possessed’. Though of limited repertoire – cinchona trees prospered only on the precipitous eastern slopes of the Andes at the time, in the Spanish American Viceroyalties of Peru and New Granada – and comparatively recent acceptance into Old World materia medica, the bark had, by the turn of the eighteenth century, woven itself into the texture of everyday medical practice in a wide range of societies within, or tied to, the Atlantic World. It was everywhere attributed ‘wonderful’, ‘singular’, even ‘divine’ medicinal virtues, the knowledge of which, so it was said, had come to mankind from its simplest, and humblest, specimens, ‘wild Indians’ close to nature and privy to its most coveted secrets. Bittersweet ‘febrifugal lemonades’ and bottled wines of the bark sat on the shelves of Lima apothecaries, the counters of Cantonese market stands and in the medicine chests of Luanda hospital orderlies. They were routinely concocted, and administered at the bedside, by Moroccan court physicians, French housewives and slave healers alike and they accompanied, tucked into their pouches, Dutch sailors to febrile environs, Peruvian soldiers to the battlefield and North American settlers westward. Scottish physicians, creole botanists and French writers alike were unanimous not only in according the bark ‘singularity’, and ‘the first place among the most effective remedies’ (die erste Stelle unter den würksamsten Arzneimitteln), but also in holding it to be ‘more generally useful to mankind than any in the materia medica’. It was commonly agreed upon that there was ‘no febrifuge of such well-known virtue in all of medicine’ (por que no se halla en la Medicina febrífugo de virtud tan conocida), and that not a single remedy ‘more estimable and precious [than the bark] had been discovered unto this day’.

Rwanda has become the paradigmatic case for a missed opportunity to prevent genocide and human suffering on the largest scale, and subsequent analyses of this case have shaped a significant part of the practical and academic thinking. The chapter contests the dominant argument that Rwanda was a straightforward case for heeding plenty, early and high-quality warnings. It argues that indications need to be distinguished from actual warnings and persuasiveness of warnings needs to be empirically studied rather than assumed. The analysis shows that most sources cited in the literature did not contain an actual warning and gave a more ambiguous picture than is claimed by proponents who argue that lack of political will, not warnings, was the problem. It is suggested that hindsight bias partly explains why the availability of warnings has been overestimated, whereas the diagnostic difficulties in this case were underestimated. Contrary to expectations, persuasive warning communication appears to be no less of a problem for preventive policy as the will and ability to respond. The findings suggest that renewed attention is needed to the challenge of making knowledge, relevance and action claims about impending mass atrocities that are clear and persuasive enough.