Basics

· Rounds usually are at 6:30 am with the Chief Resident in the Radiology Reading room (he’ll tell the person on call if this changes)- you pre round on your assigned patients before chief rounds.  The daily patient list is printed out by the on-call resident who assigns which patient each member of the team will round on that day.  It will be on the table in the surgery resident lounge. The G2s are responsible for all ICU patients but you should know what is going on on the floor as well. The list (labeled neurosurg) is on the computer public drive just as are the general surgery lists. 

· Clinic is every Tuesday morning from 8:30 until you are done- hopefully by 1pm as this is when the plastic surgery clinic starts, and Friday at 1 pm. It is on the 5th floor in the surgery clinic next to the surgery offices (purple building)

· Fridays rounds are at 9 as the U of M neurosurgery residents have lecture at the U. There is a conference at 10am in the conference room in the Surgery offices where residents and students make presentations. Sometimes the staff will give lectures. At 11am there is Neuroradiology conference in the neurology conference room on the 5th floor (buried in the neurology clinic/office area) with Neurosurgery, Neurology and Neurorads staff. Neurology and Neurosurg present their patients for the week with interesting imaging and Neurorads staff presents the scans. Usually the neurosurgery G3 is responsible for submitting the neurosurgery radiology list, however they may ask you for help with tracking down the good cases and submitting the list.  Quantity rather than quality is the rule…you learn quickly that an hour of neurology talking about ischemic strokes is mind numbing.  

· Weekend rounds are at 8.  If you are not on-call or post-call that is your day off.

· You are responsible for the nicknames on the list. Change them frequently.

·At some point in the rotation, be sure Drs. Bergman or Rockswold go over their library of c-spine films with you. (ask about it)

Relationship with the SICU

· You are responsible for knowing all about your patients but generally you only write orders on aspects pertaining directly to neurosurgery. The SICU team will take care of all the other aspects of care and generally will get very upset if you make any non-neurosurg changes to orders without first discussing with them. The one gray zone is pressors/nipride gtts. They fall under both categories and are best if discussed with the SICU resident if they are any questions about other morbidity that may be affected by these drugs.  If your chief asks on rounds for things to be ordered, let them know you will discuss it with the SICU directly after rounds.

· The SICU team is taking care of all the day-to-day needs of your patients and hence need to be aware when patients are entering the unit. It is your responsibility to call the SICU senior (336-0666, x34245 in the SICU work room) with any admissions, either through the ED or post-op. They specifically want to know what is going on with the patient and what you plan to do for treatment: specifically BP parameters, lines,

ventilation needs, etc. If an intern is doing the operation, be sure that that the SICU team     

is called prior to pt going to SICU.

· The SICU has interdisciplinary rounds at 0900.  They appreciate our participation, but rarely we get the opportunity to participate.

· Call the SICU team, surgery treatment teams before withdrawing care on any patient.

Call

· Call is 7am to 7am every day (even weekends and holidays)

· The call room is on the 7th floor down the hall from MICU 2 and 3 – it’s on the left side of the hall in the midst of the medicine offices – the only door labeled “call room”.

· In addition to the usual consults and admissions you will get calls from clinic for requests for pain meds or if the pt should come in – you can give a verbal order for most meds. For Percocet you have to send a script down. If you write the attendings full name on the script any outside Pharmacy will fill it. You can have patients come in to the clinic and go there to see them during clinic hours or you can have them directed to the ER.

· You are also on call for the doctor’s answering service so the operator will occasionally call and connect you with the patients directly.

· You will also get calls from doctors from outside hospitals on just about anything neurosurgically related – they often do not know that you are not an actual neurosurgeon or neurosurg resident.  If you accept any transfer of a patient you need to call one of the staff in the ED, usually TCA (x33138). Make sure you get the patients name, DOB, other pertinent injuries, meds given, studies already done-always ask for a CD or hard copies to be sent.  If you are in doubt of bed availability make sure to call the house supervisor to confirm there is room for the transfer-especially if there is a shortage of ICU beds.  You can always call the referring physician back to accept the transfer.

· When in any doubt- CALL YOUR CHIEF. You will probably do this for almost every patient at first but after a while you will figure out what you do and don’t need to call for.

Ventriculostomies

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

Your chief will do this with your help – or may help you do it. What you need is in the ventriculostomy cart in the back room of SICU1.

· 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

· The Monroe Kelly doctrine tells us that the skull is hard, does not give therefore when the pressure inside goes up things (ie brain) gets pushed out (herniation – very bad). The skull contains 3 things: brain, blood and CSF.

· 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.

How to get ICPs down

Simple things:

1. Head of bed at 30 degrees or more if able (if trauma patient and spines aren’t yet clear do reverse trendelenburg to 30 degrees). Make sure ventric is draining.

2. Pain control – Opiates can decrease your BP and therefore your CPP but usually not as much as your ICP.  The nurses will usually five bumps of morphine/fentanyl before they call you but make sure.

3. Blood pressure – in general keep SBP less than 140 in people with head injuries but you need to take CPP into account as well. If they have a ventric you usually titrate BP to keep CPP >60--CPP should be a higher priority that SBP.

4. Make sure the c-collar is not too tight as this will definitely increase ICP

5. Temperature - a fever will increased ICP. Get the temp down with Tylenol, cooling blankets- the nurses are very good with this.

6. Keep their Na up (definitely helps) goal is usually 155-160 but you can drive them up as high as 165 if they have good renal function.

7. 23% NaCl – analgous to but works better than Mannitol. It is in EPIC as 23% sodium as a single, 30 mL dose. 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.

8. 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. DO NOT mess with vents before checking with the SICU resident.

Sedation/paralysis:

9. 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.

10. Ativan – start with a 2mg bolus – if the patient responds you can start a drip at 0.1 mg/kg/hr – 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).

11. 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:

12. 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. 

Check list of what to do before calling your chief in the middle of the night for elevated ICPs:

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.

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

The Study

Dr. Rockswold has a study going for TBI (traumatic brain injury) investigating HBO. It is his baby and very important that any possible patients for this be identified. Potential patients are anyone 16 or older with TBI and GCS less than 8.

You will get orientation on this by Archie who is the research fellow. Basically participants get randomized to control, HBO treatments for 3 days or high flow O2 for 3 days. In addition to a ventric the patients get:

1. a Camino monitor (measures ICP from the subarachniod space – usually not as accurate as the ventric),

2. a microdialysis catheter for serial measurements of glucose and lactate.

3. a brain O2 monitor and

4. a brain temperature monitor

This requires several extra catheters/bolts to be put in. Archie is on call and knows where all this stuff is and how to set it up. The study requires several blood draws per day for special labs. Archie gets consent from the family.

Spinal Cord Injury

Divided into blunt and penetrating – treated differently

· The Exam- 4 important exam points in SCI:

1. Sensation to pinprick and the level this is lost

2. Motor – strength and which muscle groups are affected

3. Proprioception – 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

· The evaluation – start with CT with Recons.

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

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 neruologic 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.

· Discuss any neuro deficit pt with chief, especially if they have a partial cord syndrome with a deteriorating exam.

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

Subdurals

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

Usual Tx:

1. discuss evacuation with chief if big

2. Control the Na (Q6 hour sodiums) with goal of 145-155, higher with poorer neuron exam

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: Consider mannitol 100 g/kg

Non traumatic Subarachnoids (almost always aneurysmal)

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

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

3. SBP <140

4. Control Na goal 145-155

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

6. Discuss ventric placement with chief – based on exam

7. Angio for eval, treatment of aneurysm

8. Transcranial dopplers usually done every day to eval for vasospasm after acute treatment.  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.

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

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

2. Usually dilantin for 7 days.

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

Epidural Hematomas

Treatment is evacuation – if small and stable you may sit on this but always discuss this with your chief as these are dangerous. Frequent neruo exams.

No dilantin – these do not cause seizures

Consider 23%/mannitol

IV Fluids

Always use normal saline or higher salt content. Never use fluids with Dextrose in head injured patients. Typical maintenance is NS at 75 cc/hr ( don’t fluid overload head injuries). 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.

- 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

NEUROSURGERY "Handheld"PEARLS

Trauma(blood in head; GCS<8)

1. Dilantin

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

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

divided BID maint.

-1mo until f/u appt

-dilantin cks HD2, QMon/Th

2. PT/INR/PTT chk Q6*4, brain

releases thromboplastin when

irritated.

3. Na chks Q6(euvolemic &hypernatremic, 150-160) for 24hrs

-NS;if decr Na, then3% NaCl

5-40 cc/o to keep up.

-also NaCl tabs(2-4 PO Q6)

4. rHCT Q6 to chk evolution

5 MIVF = NS 20KCl@75-100cc /o

6 C/T/L spine series ordered; T&L spine recons c/ C-ABDPEL CTscan

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

8. Goal Hgb >10 in all heady injury patients

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

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

SAH (nontrauma/i.e.aneurysm)

nimodipine 60mg PO/FT Q4

4 vessel angio in AM

keep SBP <120.

try to keep Mg > 3.0.

SAH, aneurysm Postop

Cont nimodipine

Vasospasm days 5-12; order

TCDs (vasospasm>200)

Triple H-HTN, Hemodilution, &

Hypervolemia; use pressors

,fluid, albumen.

Watch Na; if Na decr---spasm

Mannitol

*for blown pupils/herniation syndromes

1g/kg IV bolus adults, then

25-100g IV Q6

0.5-1g/kg IV bolus PEDS

monitor sOsm, Na, Gluc

hold if Na>155 or Osm>310

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.

True Emergencies-large epidural, SDH, large IPH with high ICPs and poor neuro exam, cauda equina syndrome, & epidural abscess.

NEURO EXAM OF THE UPPER EXTREMITIES

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