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IO craniotomy?

20 Nov

back after a bit of a layoff with a bit of an interesting, if maybe not ready for primetime procedure idea, via this Austrailian resus blog:

screen-shot-2017-11-09-at-5-48-47-pm-1058x630

basically, in the setting of an expanding intracranial hematoma, evacuating the pressure to temporize (the alternative being herniation, then death).

while burr holes are preferred, if you have nothing else, interesting to see this on the horizon as a potential option.

 

References: resus blog post & photo

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blood pressure targets (strokes, bleeds, and tears)

15 Sep

 

Adapted from an old post, but a good refresher that came up again recently, with a new little table from a recent emed journal article that includes some recommendations for BP targets in stroke (ischemic or otherwise):

neuroBP

 

(and from a previous post):

IS SOMETHING BLEEDING (OR ABOUT TO)?  MINIMIZE THE DAMAGE:

ICH:

–lowering to SBP 140-160 probably safe

–theory: less/slower hematoma growth

–options: nicardipine (less cerebral vasospasm)

 

AORTIC DISSECTION:

SBP 100-120, HR <60

–theory: reduce shear forces

–options: beta blocker (labetolol push, esmolol drip), nitroprusside

 

RUPTURED AAA:

–goal SBP 80-100

–theory: permissive hypotension; bleed slower, less likely to blow out the few clots they’re making

Reference(s): emed-journal articleuptodate.com: Ruptured abdominal aortic aneurysm, management of aortic dissection, Spontaneous intracerebral hemorrhage: Prognosis and treatment, Kodama K, et al. Tight heart rate control reduces secondary adverse events in patients with type B acute aortic dissection, picture

to CT or not CT?: Canadian CT Head Rule & New Orleans Criteria

9 May

CT or NOT?

–Papa et al. study looked at both decision rules (link below)
–314 patients (73%) had a GCS of 15
–22 of the 314 (7%) had evidence of a traumatic intracranial lesion on CT
3 of 314 (1.0%) required neurosurgical intervention


NEW ORLEANS CRITERIA (if ANY of these are true, then do a CT ):
  • headache
  • vomiting
  • age > 60 years
  • drug or alcohol intoxication
  • deficits in short-term memory
  • evidence of trauma above the clavicles
  • seizure

CANADIAN CT HEAD RULES (if ANY of these are true, then do a CT):
  • GCS < 13
  • failure to reach GCS of 15 within 2 h
  • suspected open skull fracture
  • any sign of basal skull fracture
  • vomiting >2 episodes
  • age >65 years
  • amnesia before impact >30 min 
  • dangerous mechanism of injury (pedestrian struck by car, ejection from MVC, fall > 3 feet or > 5 stairs)

–NOC and CCHR both had 100% sensitivity (95% confidence interval [CI] = 82% to 100%)

CCHR was more specific (36.3% specificity) for detecting any traumatic intracranial lesion on CT vs. NOC (10.2% specificity)



decision rule for subarachnoid hemorrhage?

12 Apr

THOSE CANADIANS ARE AT IT AGAIN:
–study by Ottawa docs, Perry et al. reviewed nicely in an AAEM/Common Sense article (see reference)
–tried to identify a set of clinical characteristics to make a decision rule for those who need SAH workup

BASIC STRUCTURE:
–1,999 patients, 130 diagnosed with SAH
–SAH diagnosis defined by +CT, xanthrochromia, or >5 x 10^6/L RBCs + aneurysm/AVM on cerebral angiography

–included:

  • adults (>16 yo)
  • chief complaint = headache
  • GCS 15
  • non-traumatic
  • peak intensity of HA within 1 hr

–excluded:

  • >2 wks after symptom onset
  • prior SAH
  • previous CT and/or LP workup
  • 3 similar HA’s within past six months
  • papilledema/focal neuro symptom
  • prior hydrocephalus or cerebral neoplasm

RULES THEY CAME UP WITH:
–all have sensitivity 100%, but specificity sucked (28-39%)

the rules (each set works to help rule-out SAH):

  • age >40, neck pain/stiffness, witnessed LOC, DBP > 100mmHg
  • arrival by EMS, age>45, vomiting, DBP > 100
  • arrival by EMS, age 45-55, neck pain/stiffness, SBP > 160

BOTTOM LINE:
–nice study, helps think about why we do what we do, but isolated population
–the extra H&P details (age, BP, vomiting, neck pain/stiffness, etc.) are not very specific for SAH, but together might be sensitive (reminds me of appendicitis)
not ready for primetime just yet, but food for thought

Submitted by S. Lee.

Reference(s): AAEM/RSA review, picture

cervical radiculopathy

14 Feb

LIKELY CULPRITS:

Disc herniation accounts for 20-25% of young pt’s cervical radiculopathy

foraminal narrowing is the most common cause of elderly pt’s symptoms. 

–Risk factors are manual labor, smoking, and driving/operating vibrating equipment.

MRI IN ED? 

–As in lumbar radiculopathy, MRI is the appropriate test but should be limited to those symptomatic after 4-6 weeks of nonsurgical treatment given high frequency of abnormalities detected in asymptomatic adults.


Submitted by T. Boyd.

Reference(s): Carette et al. Cervical Radiculopathy. NEJM. 2005; 353:392-399. Malanga et al. Cervical Radiulopathy. Emedicine. picture

spinal epidural abscess: how good is our H&P?

13 Feb

Spinal epidural abscesses have variable presentations with:

  • 70-90% having back pain
  • (only) 60-70% having fever
  • 33% having point tenderness to palpation
  • 71% have an abnormal neuro exam
  • 94% of these patients have an elevated ESR

IMAGING:
–MRI spine
–CT myelogram

BOTTOM LINE:
–symptoms for epidural abscess include fever, spine tenderness, back pain
–unfortunately, less patients show up with these than you’d think (or like to think)
–MRI or CT myelogram if suspicious
–good luck

Submitted by T. Boyd.

Reference(s): Tompkins et al. Spinal Epidural Abscess. J Emerg Med. 39:3; 2010.; picture

How to tell a traumatic tap vs. SAH

18 Jan
QUICK REVIEW:
–There is no criteria for how many RBCs in the CSF are needed to diagnose SAH
–One of the best methods to distinguish traumatic tap vs SAH is by looking for xanthochromia
–Can measure xanthochromia by visual inspection (subjective, human error) OR spectrophotometry (very sensitive but not very specific, not widely available at most hospitals)
–Occurs via breakdown of Hgb -> oxyhemoglobin (pink-orange, can happen in vitro) -> bilirubin (yellow, only happens in vivo)
PEARLS:
False positive xanthochromia can occur from jaundice (usually total serum bili of at least 10-15 mg/dL), rifampin, high CSF protein concentration (>150 mg/dL), or excess carotenoid intake
–Oxyhemoglobin can be present in traumatic tap and appear faintly yellow
–Formation of bilirubin takes time, but after 12 hrs from onset of aneurysm rupture (i.e. “worst HA of my life”), CSF should show xanthochromia in patients with SAH
Elevated opening pressure (> 20 cm H2O) + bloody CSF strongly suggests SAH
–When all else fails, you may repeat the LP at a higher interspace
Submitted by F. DiFranco.