Transcript Neurosurgical Emergencies - Mithoefer Center for Rural Surgery

Neurosurgical Emergencies
Craig Goldberg, MD
Chief, Division of Neurosurgery
Bassett Healthcare
Overview
• Defining “rural”
• Evidence-based guidelines for TBI
treatment
• Brain surgery for the general surgeon
• Head CT basics
• A few words on spine (if there is time)
Defining Rural
China
Utah Las Vegas
Chicago
Jersey
March 29, 1976 by Saul Steinberg
Defining Rural
“I know it when I see it.”
Potter Stewart, Associate Justice of the United States Supreme Court
Wikipedia.com
Defining Rural
The author has no financial arrangements with this souvenir stand to report
Guidelines for the Management of Severe
Traumatic Brain Injury
May 2007 Journal of Neurotrauma
www.braintrauma.org
• With supplementation from additional literature
Why focus on this study?
Latest installment in this series (1995 and 2000)
significant strides in improving outcomes by minimizing secondary
injury
mortality (50% down to 25% in 30 years)
functional outcome
length of hospital stay
cost
Evidence-based
advantages
limitations
available data – some options are really standards of care
sometimes impossible to study a treatment or device
Almost all of these can be followed in a “rural” setting
Airway, Breathing, and
Circulation
Hyperventilation
• Level II - prophylactic hyperventilation
NOT recommended
• IS recommended as a temporizing measure
for the reduction of high ICP, but should be
avoided in the first 24 hours after injury and
should have SjO2 or PbrO2 monitors
BP and O2
Level II:
avoid SBP <90mmHg
Level III: avoid O2 < 90%, PaO2 < 60mmHg
unlikely ever to be a randomized controlled study
CPP Thresholds
• Level II: > 70mmHg can lead to CHF,
ARDS
• Level III: 50-70mmHg is target
Infection Prophylaxis
• Level II:
– Antibiotics for intubation
– Early tracheostomy and extubation
• Level III:
– Early extubation
– Abx and ventriculostomy rotation NOT
recommended
Hyperosmolar therapy
Level II: mannitol 0.25 to 1gm/kg is effective in high
ICP(avoid SBP < 90mmHG)
Level III: before ICP monitoring, use only for transtentorial
herniation (blown pupil) or progressive neuro deterioration
without extracranial cause
RCT needed for 3% saline
DVT Prophylaxis
• Level III:
– use SCDs
– use SQ heparin but
• no data on dose or timing
• does increase hematoma
Additional Treatments
Steroids
• Level I: In patients with moderate or severe
traumatic brain injury (TBI), high-dose
methylprednisolone is associated with
increased mortality and is
CONTRAINDICATED
• This is the ONLY standard in these
recommendations.
Seizure Prophylaxis
• Level II:
– For EARLY (first week) seizure prevention
– Not good for late
Hypothermia
Level III:
prophylactic hypothermia doesn't decrease
mortality (may work if used > 24hrs)
May lead to higher GOS
“only given to patients in a randomised (sic) controlled trial”
Cochrane Library Vol(1) 2009
Nutrition
• Level II:
– Full caloric intake by day 7
“Patients who were not fed within 5 and 7 days after TBI
had a 2- and 4-fold increased likelihood of death, respectively.”
Journal of Neurosurgery Jul 2008, Vol. 109, No. 1, Pages 50-56: 50-56.
Chemical Coma
• Level II - prophylactic barbiturates NOT
recommended
• but barbiturates ARE recommended to
control refractory ICP
• Propofol can control ICP but has not shown
improvement in mortatlity or 6 month
outcome
Indications for ICP monitoring
• Level II: Salvageable with GCS 3-8 and
abnormal CT (start to treat @ ICP 20)
• Level III: normal CT with GCS 3-8 and 2 of
the following
–
–
–
–
age >40
SBP < 90
posturing
(start to treat clinically)
Not a first choice
•
The issue of non-neurosurgeons doing emergency craniotomies and burr holes
was brought up. The consensus of the Committee is that neurosurgeons
themselves should be the ones doing these operations. We do all acknowledge,
however, that there are extreme circumstances in rural America where general
surgeons that are properly trained might be able to perform a lifesaving cranial
procedure when other alternatives are not available. The Committee, therefore,
is not totally opposed to such a concept.
•
From Council of State Neurosurgical Societies Neurotrauma Committee
Meeting, April 25, 2003
Intracranial Pressure Monitoring
• Devices
– Ventriculostomy
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Still “gold standard”
Ventricles sometimes hard to cannulate
Can get obstructed with debris
Costs less
Can be recalibrated
– Fiber optic monitors
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Diagnostic, not therapeutic
Readings can drift
Doesn’t go through the brain
Easier to insert
Anatomy
• The skull is approx 1cm thick
• The ventricles are approx 6cm deep to the
outer surface of the skull
Anatomy
• The most common entry point is
– 10-12cm back from the glabella
– Then lateral approx 2-3cm to the mid-pupillary
line
• The most common target point is
– The foramen of Monro (connects the lateral
ventricle to the third ventricle which is past the
choroid plexus)
Procedure
• Often done at bedside in ER or ICU
– (rarely on floor, in emergency, then immediate
transfer to ICU likely)
• Patient supine, head elevated to 30 degrees
or more
• Analgesia, sedation, paralysis (if intubated)
• Right side of head shaved
Procedure
• Cranial access kit, ventriculostomy tube and
drainage bag opened
• Local anesthetic instilled
• Small linear (A-P) incision made
• Self-retaining retractor inserted
• Burr hole drilled
• Bone dust cleared
Procedure
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Dura punctured
Tube inserted to approx 6cm depth
CSF pressure measured, specimen collected
Tube tunneled postero-laterally
Tube secured, wound closed
Tube attached to drainage bag and set to
desired level (usually 10cm above pts ear)
CSF Dynamics
• When tube attached to transducer
– Triphasic waveform, with second wave
corresponding to dicrotic notch on a-line
– Please do NOT use heparin
• Normal ICP 5-15mmHg = 7-20cm H2O
• Autoregulatory range (Monro-Kelly
doctrine)
• Small changes in volume lead to little or no
changes in pressure
CSF Dynamics
• Normal CSF volume:
– 50cc in ventricles, 150cc total
• CSF volume is replenished 3 times per day
(approx 400-500cc per day)
• Typical drainage volumes are 5-20cc/hr
• There will usually be an initial highpressure gush. ICP can be measured
Transport
• Clamp off (no drainage) for transport
– Bed to stretcher to ambulance to other hospital
if patient can tolerate
– Trying to avoid overdrainage
– Do NOT leave open and below head
– May need to be opened, either intermittently or
continuously for lengthy transport
– Pressure changes with air travel further
complicate the issue
Head CT Basics
Classification
• Morphology
– Intracranial lesions
• Focal
– Epidural hematomas
– Subdural hematomas
– Intracerebral hematomas
• Diffuse
– Concussion - usually non-structural
– Diffuse axonal injury (DAI)
Epidural Hematoma on CT
• Lentiform
• Arterial
• Associated with
– Skull fx
• “Lucid interval”
• Usually younger
• Outcome good
– If treated in time
Subdural Hematoma on CT
• Crescentic
– (moon-shaped)
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•
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Usually venous
3-4 times more
common than EDH
High morbidity &
– mortality (50%)
• Usually assoc with
– brain injury
Intracerebral Hematoma on CT
• More diffuse
• Capillaries and small
– Vessel source
• Actual injury to the
– Brain itself
• Can be remote from
– Impact site
– Coup vs contrecoup
Craniotomy 101
• Verify the correct side on imaging
– if no imaging, go with the side of the blown
pupil
– if both pupils are blown, go with the side that
blew first
– if you don’t know, go in on the left first
Spine
Spine
• Steroids
• Treatment with methylprednisolone for either 24
or 48 hours is recommended as an option in the
treatment of patients with acute spinal cord
injuries that should be undertaken only with the
knowledge that the evidence suggesting harmful
side effects is more consistent than any suggestion
of clinical benefit.
• Neurosurgery supplement to March 2002, Vol 50#3, pS63
Spine
• Solumedrol protocol
– bolus 30mg/kg IV over 15 min
– 45 min pause
– 5.4mg/kg/hr X 23 hrs if < 3hrs from injury
–
X 47 hrs if < 8hrs from injury
Spine
• Hypothermia
– unproven and experimental
Conclusions
• Rural is rural
• Don’t treat TBI with steroids
• Do keep the patient oxygenating and
perfusing
• Many treatments to try with suspected or
documented high ICP
Conclusions
• Steroids in spine are an option, hypothermia
has no proven benefit (yet?)
• If there is a possibility that you might find
yourself doing brain surgery, this lecture is
not enough
Questions?