1. Neurosurgical Emergencies
Craig Goldberg, MD
Chief, Division of Neurosurgery
Bassett Healthcare
I’d like to thank Dr. Borgstrom for including me in this symposium

2. 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)

3. Defining Rural March 29, 1976 by Saul Steinberg
China
Las Vegas
Utah
Chicago
Jersey
Any definition of rural is highly dependent on your perspective.
March 29, 1976 by Saul Steinberg

4. Defining Rural “I know it when I see it.”
Justice Stewart wasn’t exactly talking about rural surgery, but I find his definition functional.
Potter Stewart, Associate Justice of the United States Supreme Court
Wikipedia.com

5. Defining Rural
With a nod to comedian Jeff Foxworthy, if you pass a tepee on your way to work, you might be a rural surgeon.
The author has no financial arrangements with this souvenir stand to report

6. Guidelines for the Management of Severe Traumatic Brain Injury
Guidelines for the Management of Severe Traumatic Brain Injury May 2007 Journal of Neurotrauma
With supplementation from additional literature

7. Why focus on this study?

8. Airway, Breathing, and Circulation

9. 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

10. BP and O2

11. CPP Thresholds Level II: > 70mmHg can lead to CHF, ARDS
Level III: 50-70mmHg is target

12. Infection Prophylaxis
Level II:
Antibiotics for intubation
Early tracheostomy and extubation
Level III:
Early extubation
Abx and ventriculostomy rotation NOT recommended

13. Hyperosmolar therapy

14. DVT Prophylaxis Level III: use SCDs use SQ heparin but
no data on dose or timing
does increase hematoma

15. Additional Treatments

16. 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.

17. Seizure Prophylaxis Level II:
For EARLY (first week) seizure prevention
Not good for late

18. Hypothermia
“only given to patients in a randomised (sic) controlled trial”
Cochrane Library Vol(1) 2009

19. 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:

20. 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

21. Indications for ICP monitoring
Level II: Salvageable with GCS 3-8 and abnormal CT (start to ICP 20)
Level III: normal CT with GCS 3-8 and 2 of the following
age >40
SBP < 90
posturing
(start to treat clinically)

22. 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

23. Intracranial Pressure Monitoring
Devices
Ventriculostomy
Still “gold standard”
Ventricles sometimes hard to cannulate
Can get obstructed with debris
Costs less
Can be recalibrated
Fiber optic monitors
Diagnostic, not therapeutic
Readings can drift
Doesn’t go through the brain
Easier to insert

24. Anatomy The skull is approx 1cm thick
The ventricles are approx 6cm deep to the outer surface of the skull

25. Anatomy The most common entry point is The most common target 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)

26. 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

27. 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

28. Procedure 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)

29. 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

30. CSF Dynamics Normal CSF volume:
50cc in ventricles, 150cc total
CSF volume is replenished 3 times per day (approx cc per day)
Typical drainage volumes are 5-20cc/hr
There will usually be an initial high-pressure gush. ICP can be measured

31. 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

32. Head CT Basics

33. Classification Morphology Intracranial lesions Focal Diffuse
Epidural hematomas
Subdural hematomas
Intracerebral hematomas
Diffuse
Concussion - usually non-structural
Diffuse axonal injury (DAI)

34. Epidural Hematoma on CT
Lentiform
Arterial
Associated with
Skull fx
“Lucid interval”
Usually younger
Outcome good
If treated in time

35. Subdural Hematoma on CT
Crescentic
(moon-shaped)
Usually venous
3-4 times more
common than EDH
High morbidity &
mortality (50%)
Usually assoc with
brain injury

36. 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

37. 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

38. Spine

39. 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

40. 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

41. Spine
Hypothermia
unproven and experimental

42. 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

43. 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

44. Questions?