“BUT I’M NOT A NEUROSURGEON

“BUT I’M NOT A

NEUROSURGEON …”

CARING FOR PATIENTS WITH

NEUROSURGICAL EMERGENCIES IN A

COMMUNITY HOSPITAL

DR. KIRSTEN JEWELL

HDMH GRAND ROUNDS MARCH 9, 2016

Conflict of Interest Declaration:

Nothing to Disclose

Presenter: Dr. Kirsten Jewell

Title of Presentation: “But I’m not a neurosurgeon” … Caring for patients with neurosurgical emergencies in a community hospital

I have no financial or personal relationships to disclose

DISCLAIMER: (I’M NOT A NEUROSURGEON)

OBJECTIVES

1. Identify cases that qualify for urgent neurosurgical

consultation and guidelines for transfer

i.e. Try not to get so frustrated when neurosurgery won’t do

what we want

2. Understand what constitutes standard of care for disease

specific management and ongoing monitoring of neurologic

emergencies in a community setting

• Cranial cases

• Spine cases

i.e. Care for our patients as best we can

#1 AVOIDING FRUSTRATION

Why won’t neurosurgery take my patient??

CRITICALL

GUIDELINES

FOR

TRANSFER

LIFE OR LIMB?

• Patient is life or limb threatened

AND

• Therapeutic options exist

• Needed within 4 hours of consultation

• Consulting physicians are expected to respond to pages designated ‘life or limb’ within 10 minutes (even if operating, with another critical case, etc)

*our CT films should be pushed by the rad tech to the ENITS system so Neurosurgery can review. Criticall should check these are available.

CASE 1:

79 M “Stroke Protocol” via EMS

• Last seen normal at 11:00h by wife

• 11:30h found on driveway, confused

• Vomited x 2

• Left sided weakness/hemiparesis

• PMH: T2DM

• Meds: ASA, Lisinopril, Simvastatin, Insulin, Terazosin

• Code status: R1

CASE 1:

In ED @ 2pm:

• Vitals: T 36.7 (O) P 68 BP 188/84 R 20 SpO2 98% r/a

• GCS 11-12 (E4V2M5-6)

• Speaks only Croatian …

• PEARL, facial musculature symmetric

• Left arm weakness – held in flexion

• Moving right arm spontaneously, intermittently clutching R side of forehead and moaning

• ?Left leg weakness

• No clonus

• Babinskis downgoing bilat

• Slight abrasion posterior occiput, no other sign of trauma

STAT CT HEAD

HELLO NEUROSURGERY?

• 1st: discuss with radiologist

• Traumatic vs. spontaneous?

• Criticall: … life or limb?

• Neurosurgeon reviewed images

• Thought to be likely spontaneous

• Recommended nonsurgical management given no midline

shift … no transfer.

• Repeat CT in 6 hours and call back if rapid expansion

• Otherwise neurology follow up

• MRI/MRA in 6 weeks to rule out underlying structural

cause

NO SUCH

LUCK

• Epidural Hematoma

• Acute Subdural Hematoma with AMS

• Acute spontaneous SAH

• Hydrocephalus with clinical signs of increased ICP

• Contusion: Temporal lobe or multiples

• ICH if: structural, in posterior fossa, or traumatic

• Brain Tumour with life-threatening presentation

EMERGENT

TRANSFERS

• Chronic/Subacute SDH

• Small acute SDH* • Admit ICU; Repeat CT @ 12h and f/u NeuroSx

as outpt

• Traumatic SAH • Admit ICU; Repeat CT @ 12h and f/u NeuroSx

as outpt

• Isolated Traumatic Cerebral Contusions

• Admit ICU; Repeat CT @ 12h

• Spontaneous non-structural ICH**

• Brain Tumour (stable)

• MRI + Gadolinium then refer as outpatient

• Linear nondisplaced skull fractures

• Admit to floor; repeat CT @ 12h

SDH: CT CRITERIA FOR

NEUROSURGICAL INTERVENTION

Evans JA, et al. A simple tool to identify

elderly patients with a surgically

important acute subdural haematoma.

Injury. 2015 Jan;46(91):76-9.

In patients greater than age 65 years,

if the patient did NOT have on CT:

1. > 1 millimeter of midline shift AND

2. the maximal area of thickness of

the bleed was not > 10 millimeters

they were able to predict with 100%

sensitivity which patients would

need any type of surgical

intervention

IF NONSURGICAL

MANAGEMENT…

Always ask:

• “what do I do if the patient gets worse”

• “when would you recommend repeat imaging”

• “when would the patient be considered for

surgery/transfer?”

Monitoring:

• Q1h neurovitals for 12hours (window for badness)

MANAGEMENT PEARLS

• ABC’s

• Intubation considerations

• Oxygenation

• BP targets?

• Q1h neurovitals (ICU); Accuchecks

• Dilantin – only to TREAT seizure (20mg/kg over 30min)

• Downfall: hypotension

• Mannitol 1.5g/kg or 3% NS 250cc over 15-30 minutes

• Only if acute change in ICP

• Generally run this by NeuroSx

• Steroids not indicated

BP TARGETS IN ICH

2010 AHA/ASA Guidelines

BP TARGETS IN ICH

Neurology 2014 Oct 21; 83(17): 1523-1529

MANAGEMENT PEARLS

• ABC’s

• Intubation considerations

• Oxygenation

• BP targets?

• Q1h neurovitals (ICU); Accuchecks

• Dilantin – only to TREAT seizure (20mg/kg over 30min)

• Downfall: hypotension

• Mannitol 1.5g/kg or 3% NS 250cc over 15-30 minutes

• Only if acute change in ICP

• Generally run this by NeuroSx

• Steroids not indicated

MANAGEMENT PEARLS

• Reversal of Anticoagulation

(INR ≤1.4)

• Coumadin Octaplex

• Observation time?

• NOACS ?Octaplex

• Plavix/ASA ?platelets

?DDAVP

• Basal Skull Fracture?

• No antibiotic prophylaxis

• Consult ENT if persistent

CSF leak after 2-3d bedrest

BACK TO THE CASE

• Admitted to ICU

• Q1h neurovitals

• BP management

• Repeat CT: significant expansion

• GCS deteriorates to 7-8

• Neurosurgery recommends palliation

CASE 2:

29 F

• Injury to low back 3 weeks ago – strain mechanism

• MRI 3 weeks prior showed disc herniation L4-S1

• CT 1 week prior showed central disc bulge at L5-S1 without evidence of nerve compression

• Has been attending physio, on pain meds (NSAIDS)

Day of presentation:

• Increasing L4/L5/S1 myotomal weakness (R)

• Bilateral paresthesias L4/L5/S1

• NEW urinary frequency/urgency & incontinence x 1

• NEW sacral paresthesias & ‘intravaginal tingling’

• Physio had confirmed worsening myotomal symptoms and asked for MD reassessment

R/O CAUDA EQUINA

Physical Exam:

• Motor exam: Confirms bilat weakness R>L

• Sensory exam: Decreased (subjective) sensation to light touch R leg L4-S1 dermatomes below the knee; otherwise normal

• DRE: Normal tone • Abnormal perianal sensation endorsed by patient

• Bedside U/S: Small amount of post-void residual

NEXT STEPS?

• Imaging?

• Criticall:

• Spoke with Neurosurgery

• Told we needed an MRI to confirm a surgical lesion

• Transfer for MRI and assessment NOT accepted

• Next steps?

• How to get an Urgent MRI …. Call Radiology on call in

Orillia and fax req

ASIA - AMERICAN SPINAL INJURY ASSOCIATION MOTOR SCORING SYSTEM

BACK TO THE CASE

Urgent outpatient MRI was arranged for the next day …

Which was NORMAL, again.

No surgical intervention

Symptoms continue ….

CASE 3: C-SPINE #

83 F

• MVC: un-belted driver of single vehicle collision - veered

off the road at 60kph. Extricated by EMS.

• Complaining of neck pain; lac to R hand; lower extremity

bruising

• GCS 15; Neurologically intact

• PMH: T2DM, Afib, Angina, Hypertension, Hypothyroid

• Meds: include coumadin

XRAY VS CT?

Bailitz J. et al. CT Should Replace Three View Radiographs as the Initial Screening Test in Patients at High, Moderate, and Low Risk for Blunt Cervical Spine Injury: A Prospective Comparison. Journal of Trauma Injury Infection & Critical Care. 66(6):1605?9, 2009 Jun

• Prospective, blinded, study of 1,505 patients who were evaluated after blunt cervical spine trauma

• Adult patients who met NEXUS criteria for imaging

• All patients received both three view c-spine xrays as well as cervical CT scan, radiologists blinded to results

• Gold standard = CT diagnosis

• Rate of Clinically Significant Injuries (defined as those that required operative procedure, halo application and/or rigid cervical collar) = 3.3%

• Xray had sensitivity of 36% (18/50); • Sensitivity 62.5% in those with adequate films (10/16)

C2 #

CT Head = normal

C-spine: Complex

fracture of the body of C2

extending into the facet

joint on both sides.

Fracture of posterior arch

of C1 bilaterally (?old)

UNSTABLE C-SPINE #S

“Jefferson Bit Off A Hangman’s Tit”

• Jefferson fracture (burst # C1)

• Bilat facet dislocation

• Odontoid # (type II/III)

• Atlantoaxial or atlanto-occipital dissociation

• Hangman’s # (bilat C2 pedicle #, from hyperextension – see

C2 displaced anteriorly on C3)

• Teardrop # (avulsion # of anterioinferior portion of vertebral

body)

JEFFERSON FRACTURE

ODONTOID FRACTURE

ODONTOID FRACTURE

HANGMAN’S

FRACTURE

TEARDROP FRACTURE

WHAT ABOUT T/L-SPINE

FRACTURES?

• Chance fracture: flexion around anterior axis; horizontal

fracture through vertebral body & all posterior elements (3

column) UNSTABLE +++

• Translational fracture: shear forces shift whole vertebral

body, complete cord disruption UNSTABLE +++

• Wedge compression fracture: usually STABLE

• suspect burst fracture if >50% ant. body height loss;

• Burst fracture: loss of anterior & posterior height, disruption

of anterior and middle columns; unstable if :

• neurologic deficit;

• loss of 50% of vertebral body height;

• Canal narrowing (>30%)

• At T-L junction and angulation >20degrees

CHANCE FRACTURE

BACK TO THE CASE

Criticall:

• Neurosurgery recommended nonsurgical management

• Placed in semirigid collar (Aspen)

• May remove for personal hygeine

• Xrays q2 weeks

• Results forwarded to neurosurgery

• 2 week inpatient stay for physiotherapy

• Discharged home in Aspen collar, neurologically intact

TREATMENT

• Semi-rigid Collars

• Miami J

• Aspen

• Philadelphia

• Cervicothoracic orthoses

• Sterno-Occipito-Mandibular Immobilizer—SOMI

• Halo

• Surgery?

TREATMENT

• Thoraco Lumbar Bracing:

• TLSO (Jewett brace)

• Hyperextension bracing

• Useful for anterior compression #

• T7 down

MONITORING

• Can we proved reliable neurological monitoring?

• Nursing: Neurosurgical Nurse Educator Network “Guidelines for Basic Adult Neurological Observation” 2014

• 20 page handbook

• Specifically created to educate staff at non-neurosurgical centres

• Where to admit?

• ICU vs floor

• Management concerns:

• Activity restrictions

• Log-roll precautions

• Follow-up imaging & appointments

CREDITS & REFERENCES

www.criticalcareontario.ca -> Toolbox ->Education

1. Cervical Spine Injury An Evidence-Based Evaluation Of The Patient With Blunt Cervical Trauma

https://www.ebmedicine.net/topics.php?paction=showTopicSeg&topic_id=189&seg_id=3911

2. http://www.wheelessonline.com/ortho/burst_frx_of_spine

3. http://radiopaedia.org/articles/chance-fracture

4. Tintinalli's Emergency Medicine: A Comprehensive Study Guide, 7e

5. http://emergency.medicine.iu.edu/research/ebm-journal-club/c-spine-ct/

6. Brain Trauma Foundation. Guidelines for the management of severe traumatic brain injury. J Neurotrauma. 2007;24

Suppl 1:S1-106.

7. Sharma, Sunjay. Access to Neurosurgical Care for Traumatic Brain Injury in Ontario. Masters Thesis, Institute of Medical

Science, The University of Toronto, 2013.