ED NEUROSURGERY CHEAT SHEET

Updated 2/1/11

Tom Dalton

Neurosugical Emergencies (let the chief know right away)

Percehed or locked facets, large epidural, large SDH, large IPH with high ICPs and poor neuro exam, cauda equina syndrome, epidural abscess, any posterior fossa stroke, ischemic or hemorraghic → there is no room for swelling and they will herniate and die unless they get a posterior decompressive crani.

Severity of head injuries

*GCS measures level of consciousness which consists of 1) level or alertness and 2) though content

* TBI injuries usually manifest chronically (aka post-concussive syndrome) in 3 areas: 1) somatic symptoms 2) psychological disturbances, and 3) cognition problems

*Headache and dizziness are common in minimal head injuries, and with no other high risk criteria (see CT criteria below) and no other interventions are needed other than symptomatic control. (probably will no see these during your rotation as they get filtered out by the primary care clinics/ED).

CT everybody if they have: subjective or objective focal defects, seizures, or are on anti-coagulation.

Severity of TBI

1) Minimal - GCS 15, No LOC, no altered behavior, no definite amnesia → no f/u needed

2) Mild (concussion) - GCS 13-15

3) Moderate - GCS 9-13

4) Severe - GCS 3-8

Getting CT’s of the head

All mode and severe TBI’s get head CT’s. For the mild TBIs there are decision rules to help limit the number of negative CT’s performed. The “Candian Head CT rules in Mild TBI” is one validated algorithm and it is 98.4% sensitive in detecting important CNS injury, that is injury requiring admission and f/u.

“Candian Head CT rules in Mild TBI”

CT all GCS 13-15 closed head injury patients >16 yo with any of: LOC < 5 min, definite amnesia, or disorientation and if they have any of:

- failure to reach GCS 15 in 2 hrs

- suspected open skull fx

- suspected basilar skull fx

- vomiting > 1x

- Age > 64 yo

- Amnesia > 30 min

- Dangerous MOI - pedestrian struck, assault by blunt object, fall >3 ft/5 stairs, moderate/high speed MVC, MVC ejection, heavy object fell on the head)

Consussions (Mild TBI) in Sports - different grading systems, amnesia is common in all of them. Basic story is all symptomatic players should not be returned to play.

Grade 1 (mild) - transient confusion, no LOC, sxs < 15 min

Grade 2 (mod) - same as above but sxs > 15 min

Grade 3 (severe) - Any LOC

- test, wait 15 min, if still wonky -->bench, is pass testing, provocate with physical exercise, re-test, if wonky, → bench, all out for 1 week minimum and until seen and cleared by a Sports Medicine physician/TBI clinic

Signs of elevated ICP (CT is not sensitive in detecting elevated ICPs)

1) Progressive deterioration with no other explanation

2) Any signs of herniation

    - unilateral or bilateral dilatation

    - decerebrate or decorticate posturing (usually contra-lateral to the lesion)

    - Asymetric pupillary reaction to light

Burr Holes

Primarly a diagnositic tool, sometime allow some decompression

- perform on IPSILATERAL SIDE TO BLOW PUPIL or contralateral side of posturing, or side of first pupil blow if both blow

General management of bleeding diasthesis

- need INR <1.4 (cannot push lower with FFP as this is the intrinsic INR of FFP)

- Plt > 100,000

- APTT within normal range

- DIC is unlikely unless there is a lot or primary brain destruction and thromboplastin is released

Subdural Hematomas

Treatment depends somewhat on size. Measure this on the head CT and look for any midline shift or effacement of ventricles

Usual Tx:

1. Non-opertive intervention iff: < 10 mm in largest diameter, < 5 mm midline shift (no herniation), and no s/s of increased ICPs or herniation (i.e. worsening neuro exam, GSC declines by 2 points, focal defects, pupil defects)

2. Control the Na (Q6 hour sodiums) with goal of 145-155, higher with poorer neuron exam → i.e more mass effect)

3. HOB up to 30degrees – if spines not clear do reverse trendelenburg

4. Q1 hour neuro checks

5. Dilantin-18mg/kg load, 5mg/kg div BID daily

6. Keep SBP <140

7. Repeat Head CT in 6 hrs or stat with any neuro decline

8. Control bleeding diasthesis as above

9. Steroids not indicated

10. DIC unlikely as there is not a lot or primary brain destruction

Non traumatic Subarachnoids (almost always aneurysmal)

Risks including re-bleeding, hydrocephalus, and vasospasm of cerebral vessels → very dangerous

Usual Tx:

1. CT angios emergently.  Discuss with neurointerventional any positive finding to determine if the patient is a candidate for coiling.  Small necks and larger bodies on the aneurysms make good candidates but there are other factors as well including location and proximity to other vessels.

2. Dilantin x 7 days

3. SBP <140

4. Control Na goal 145-155

5. Nimodipine to help prevent vasospasm – start right away 60mg po/down ft Q4 hrs x 21 days

6. Discuss ventric placement with chief – based on exam

7. Formal angio in AM, treatment of aneurysm

8. Transcranial dopplers usually done every day to eval for vasospasm after acute treatment.  If elevated, talk to the Chief and IR right away as they will likely need catheter delievered vasodilaters to the spasmed vessel. Usually get CT perfusion studies every couple of days as well.  Any change in exam warrents emergent CT perfusion or angio to eval for vasospasm-discuss with chief and neurointerventional. Treat with the triple H: Hemodilution, hypervolemia, and hypertension (pressors)

9. Keep Mag >3.0

10. Watch Na; if Na decr--->spasm

Traumatic SAH

- Treated differently because they don’t have the risks of aneurysmal SAH – this is a one time bleed

- Typically follow exam and if small no further treatment. If big/ bad neuro exam discuss with chief.

- Dilantin x 7 days.

- Make sure Na is normal but no need to drive Na up unless neuron deficits.

- Goal SBP <160, but no hard and fast rule as these do not have a mass effect you are trying to counter

Epidural Hematomas

-Treatment is almost always evacuation – if small (<10 mm) and are stable in size on repeat imaging you may sit on this but always discuss this with your chief as these are dangerous. Admit to the SICU with q1h neuro checks

- No dilantin – these do not cause seizures

- Goal Na 145-155, may drive to 165 if need be

Seizure prophlaxis in TBI

- if you had a seizure = 6 mo of AED medication

- 7 days if - acute SDH, acute EDH, or intracerebral hematoma close to the surface, open or depressed skull fx, GCS < 10, penetrating injury

IV Fluids and Medications in Intracranial Bleeding

- Always use normal saline or higher salt content. Never use fluids with Dextrose in head injured patients. Typical MIVF is NS at 75 cc/hr (don’t fluid overload head injuries, shoot for UOP 0.5-1 cc/kg/hr minimum. To adjust Na you use 2% or 3% saline- typically start with 3% at 30cc/hr and titrate up or down as you need to. If you get to 60 cc/hr of 3% change to 5% saline. 2% can be run through a PIV provided it is a big vein, 3% must be run through a central line. 2% can be run through a peripheral. You can run 2% as maintenance if you want (100-120cc/hr). They can do 3% on STN 3 or in the unit but not on the floor. 2% can be done anywhere.

- Dilantin: load 18mg/kg IV (must be on cardiac monitor) and then start 2.5mg/kg IV BID. IV and PO doses are equivalent. Oral load 400mg po then 300mg po in 2 hrs and 4hrs (adults). Check free dilantin levels Q mon and thurs

- For elevated BP:

Hydralazine 10-20mg IV q2 hrs prn

Labetalol 10-20mg IV q2 hrs prn

Nipride drip – titrate to SBP – need central line and arterial line

Esmolol drip – titrate to SBP – need central line and arterial line

- Mannitol *for blown pupils/herniation syndromes, this can cause hypovolemia, renal failure, and after a couple of doses rebound elevations in the ICP. Initial dose 1g/kg IV bolus adults, then 25-100g IV Q6. PEDs 0.5-1g/kg IV bolus, monitor sOsm, Na, Gluc, hold if Na>160 or Osm>310

NEUROSURGERY "Handheld"PEARLS

Trauma(blood in head; GCS<8)

- Dilantin

18mg/kg load Adult 5mg/kg IV/PO divided BID maint.

20mg/kg load Peds 5mg/kg IV/PO

divided BID maint.

- Dilantin cks HD2, QMon/Th

- PT/INR/PTT chk q6h to q12h to assess for DIC depending on how much brain tissues was damaged.

- Na chks Q6 (goal euvolemic &hypernatremic, 150-160) for 24hrs, once Na and patient stable can start salt tabs (2-4 PO Q6)

- Repeat HCT 6 hrs after the initial one to check for evolution of the bleed

- Incr HOB to 30degrees; reverse Trendi until T&L spine cleared.

- Goal Hgb >10 in all heady injury patients

- All TBI patients follow up with Dr. Sarah Rockswold in the TBI clinic one month after discharge.  No driving, work, or school until then.  Some may benefit from depakote ER for headaches.  Start 500 mg qHS, increase to 1000mg in a week if sxs continue.

- Follow up in neurosurgery clinic 4 weeks with CT, plain films for all fxs, traumatic bleeds except for tiny traumatic SAH.

Ventriculostomies

- need INR <1.4 and Plt > 100,000 prior to placing, otherwise can bleed like stink

· This is a catheter inserted through the skull into the lateral or 3rd ventricle.

· Ventrics let you drain out fluid in hydrocephalus or monitor ICPs. Generally anyone with a poor neurologic exam (withdrawing to pain or worse) will need one because it will be the only way to judge an ICP.  General rule of thumb is anybody with GCS of 8 and signs of elevated ICPs will need a ventric, GCS of 3 will need operative intervention.

· The catheter connects to a canister that collects CSF and to the pressure transducer via a 3 way stopcock. It is set to drain at a specific level – 0 to 20cm H20. This means that the ICP must go over whatever the pressure is set at to drain. The stopcock must be off to the drain to check the pressure so if you are draining you can’t check the ICP.

· The ventric should have a good waveform which is due to pressure differential with cardiac activity – if it doesn’t it probably isn’t accurate. You can flush it to see if you can improve the waveform – if you can’t it should be replaced.  The caveat to this is if the patient doesn’t have a bone flap-without an intact skull there isn’t the pressure differential with cardiac activity.  Also make sure the scale is appropriate on the monitor.  

· To flush the ventric you have to use sterile normal saline. Prep the stopcock with alcohol. Flush to the system first (as much as you want) with the stopcock off to the patient – make sure all air is flushed from the line as this will dampen the pressure. Then flush to the patient (never more than 2-3 cc) – sometimes small jerky flushes will help. After flushing to the patient open the ventric to drain to allow the patient to drain out what you have flushed in.

· Sometimes you need to send CSF from the ventric. To do this prep the stopcock with alcohol, turn it off to the system and depending on the kind of stopcock port you have connect an empty 3cc syringe (you may need a needle) and draw back CSF (no more than 3cc). Always send for cell counts, culture, glucose and protein.  In a pinch, if you cannot get the CSF to draw from the patient and have tried flushing the ventric, you can turn the stopcock off towards the patient and draw from the line, but this obviously isn’t as ideal a sample

· To do intratheal antibiotics for ventriculits/meningitis you need to order the dose every day from Pharmacy (usually Vanco – ask the chief for the dose) in a preservative free solution. To administer turn the stopcock off to the system, prep it with alcohol and slowly infuse the abx over several minutes, leave the ventric clamped (off to the system) for 1 hour, or less if the ICPs won’t tolerate it (you have to write an order for this in the chart).

Elevated ICPs (ICPs >20 for 5-10 minutes)

- The Monroe Kelly doctrine tells us the skull contains 3 things: brain, blood and CSF.

The skull is hard and does not expand therefore when the pressure inside goes up, things (ie brain) gets pushed out (herniation – very bad). - Intracranial pressure (ICP) is measured through a ventriculostomy. Normal is less than 10 cm H2O. Acceptable is less than 20. 30-40 for long periods is bad. In the 60-70 range you can herniate.

- The cerebral perfusion pressure (CPP) is MAP (mean arterial pressure) – ICP. This should be preferably >60. >70 is good, >80 is great. If CPP<60 can start pressors to keep it up.

How to get ICPs down

- HOB >= 30 degrees

- Sedation - start with profolol and fentynal, if they are still going up or you need to sedate for longer than 3 days, then start ativan

- Keep SBP < 140 for all intracranial bleeds (decreases enlargement of the bleed) but only if you can keep CPP >60, if CPP<60 then allow the SBP to rise as CPP is a higher priority than SBP (perfusion over enlargement of the bleed)

- Get the C-collar off if possible, remove other compression on the jugular venous system

- control fevers and cool

- Keep Na up, goal 155-160 on all people with elevated ICPs, can drive up to 165 if they have good renal function

- Can give hypertonic (23%), 30 cc is normal dose, analgous to, but works better than Mannitol. Sometimes you use Mannitol if the patient responds better to this – usually 30-50 grams. These can cause renal failure if the kidney function is not good so try not to use it more than a few times per day (4-5). Also avoid if Na is 160 or greater. Avoid mannitol if osmolarity >315. These both should start working in 15-30 minutes

- Hyperventillation   This decreases the PCO2 which decreases ICP and CPP because it causes cerebral vasoconstriction.  General goal for TBI is pCO2 of 35. In an attempt to emergently drop ICPs you can shoot for a pCO2 of 30, but only for a short time.  Don’t drop pCO2 less than 30 as you will get more vasodilation which counteracts your attempts to drop the ICPs. This only last for a short time.

- Sedation/paralysis:

- Propofol drip – up to 80 mcg/kg/min. Over 60 for long periods of time can cause pancreatitis. This will drop the patients BP and therefore their CPP. This is your first line of sedation. Use with fentynal CADD.

10. Ativan – start with a 2mg bolus – if the patient responds you can start a drip at 0.1 mg/kg/hr (start at 6-10) – you can titrate up to 22 mg/hr very quickly as needed to control ICPs. You can give 1-2 mg boluses q2-3 min for breakthrough initially. This will not decrease BP much but can last for days if you use it long term (esp in old people). Wean by initially decreasing dose in half (22-->11) and then decreasing by 0.5 mg q12hrs.

- Vecuronium – paralytic. Use only in sedated patients-usually goes along with an ativan gtt. Start with a 10mg/kg load then 1.2 mcg/kg/hr up to 2mcg/kg/hr. Definitely can help. This is titrated to the “train of 4” – the nurses do this – it is like giving 4 small shocks to stimulate muscle contraction. 1 of 4 is adequately paralyzed – if you have 0 for long periods the pt may be at risk for rhabdomyolysis from the vec.  Patients on vec/ativan will also need a BIS moniter which is a modified EEG.  BIS scores in the 30s-40s are adequate.

Last Resorts:

- Decompressive craniectomy: Taking the frontal part of the skull off to allow the brain to herniate out. Should be considered early on and only in those that had a good exam (ie talking or at least following commands) who then deteriorated.

Elevated ICP checklist:

1. Make sure sodiums are in the 160s.

2. Give 23% sodium and/or mannitol.  These should start working in a couple of minutes.  If the sodiums are low, you can repeat 23% as needed to get the sodium up. (starts working in 15 min)

3. Hyperventilate, check ABGs to goal pCO2 of 30

4. HOB up, sit bolt-upright if able.

5. Adequate sedation.  Start ativan/vec gtts and max out.

6. Make sure ventric is open, at 0, and draining.

7. Pain control

8. Repeat 23% unless Na more than 165

Spinal Cord Injury

Divided into blunt and penetrating – treated differently

The Exam - 4 important exam points in SCI: (checking the 3 spinal tracts and autonomic system)

1. Sensation to pinprick and the level this is lost (anteriorlateral system - pain, temp, gross touch)

2. Motor (corticospinal/pyramidal tracts)– strength and which muscle groups are affected

3. Proprioception (DCML along with vibration and 2 point discrimination (fine touch)) – Isolate the MTP joint of the big toe on each foot and with patients eyes closed see if they can tell which way you bend it up or down.

4. Rectal tone or presence of priaprism (sacral autonomic dysfunction)

Important things to note:

1. fractures - where they are (level and part of vertebrae – lamina, pedicles, body facets), if there is intrusion on the canal

2. Locked or perched facets → will need HALO placement and traction

3. spondylolisthesis

4. Any fracture that appears to involve the transverse foramen will need a CT angio to eval for vertebral injury.  If you see the fracture while the patient is being scanned it is easy to add on the angio portion and then you have more information when rounding with the chief and staff in the morning.

If there is neurologic deficit the patient will need an MRI at the affected level – this can’t usually be done overnight

*** If the neurologic deficit is complete (eg paraplegia or quadraplegia with loss of all 4 exam points) and the pt never had neurologic function at the time of injury this will not be emergent as the prognosis for any recovery is very poor. If the pt at some point did have some level of neuro function this is more emergent as decompression can improve prognosis.

Solumedrol: Not being used any more for spinal cord injury.

C-spine perched/locked facets:

-call chief

-call Winkley even in middle of night for traction set-up- they would like to know the pts ht, wt, circ @1 in above eyebrow, chest circ @xiphoid.

-Traction equiptment on G3 ortho in the shampoo room.  Discuss with your chief about proper setup, initial weight you will need.

-Portable lat c-spines after 1 hour, add more weight as needed.

-When re-aligned, lock down HALO. There is a spare torque wrench that is in the SICU back storage room.

HALOs:

Call Winkley to order.  They’ll walk you through the whole procedure.  Will need upright films and post-ambulatory films after being locked down in the HALO.  All pts need pt/ot.  FU 1,2,3 months in clinic with AP/lat films

TLSO:

Call metro orthotics to order.  For traumatic fxs, will need 0/30/60/90 degree films.  Watch for increasing kyphosis in the films.  If you sit the patient up on the floor prior to sending to radiology you won’t have to make the trip down to the radiology department to sit the patient up for the first time.  Same follow up as HALOs.

Neuro Exam of the Upper Extremities

* There is some overlap between adjacent levels and the muscles they innervate.

Simplified Upper Extremity Motor Exam

C4 - shrug shoulders

C5 - shoulder abduction

C6 - wrist extension and elbow flexion

C7 - elbow extension

C8 - squeeze hand

T1 - abduction of the little finger

Simplified Lower Extremity Motor Exam

S1 - ankle plantar flexion

L5 - dorsiflexion of the big toe

L4 - ankle dorsiflexion/knee extension

L3 - Hip flexion/thigh adduction

L2 - Hip flexion

shoulder abduction C5

elbow flexion C5-6

elbow extension C6-7

wrist extension C6-7

wrist flexion C7-8

finger flexion C8

finger extension C8

finger abduction T1

ALL EXTENSORS OF UE ARE INERVATED BY THE RADIAL NERVE C6-8

THE 2 DISTAL FLEXORS ARE INERVATED BY THE MEDIAN NERVE C7-8.

FLEXION OF THE ELBOW IS BY THE MUSCULOCUTANEOUS NERVE C5

SHOULDER ABDUCTION BY AXILLARY NERVE C5

FINGER ABDUCTION BY ULNER NERVE T1

REFLEXES OF UPPER EXTREMITY

biceps C5-6

brachioradialis C5-6

triceps C6-7 (mainly C7)

NEURO EXAM OF THE LOWER EXTREMITIES

hip flexion L2-3

knee extension L3-4

ankle dorsiflexion L4-5

hip extension L4-5

knee flexion L5-S1

ankle plantar flexion S1-2

HIP FLEXION BY FEMORAL( Nerve to the iliopsoas) L2-3

KNEE EXTENSION BY THE FEMORAL NERVE L3-4

ANKLE DORSIFLEXION BY PERONEAL NERVE L4-5

HIP EXTENSION BY THE GLUTEAL NERVE L4-5

KNEE FLEXION BY THE SCIATIC NERVE L5-S1

ANKLE PLANTAR FLEXION BY TIBIAL NERVE S1-2

REFLEXES OF THE LOWER EXTREMITY

knee jerk L3-4 (mainly L4)

ankle jerk S1

hamsting (rare) L5