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“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.