Potassium

• Goal: K+ > 4.0
• For every 10 mEq of K+ given, the serum K+ will rise about 0.1 mEq/L
• Typically use KCl for repletion (1 mEq of KCL = 1 mEq K+)
• Can also use KPO4 for repletion (3 mmols KPO4 = 4.4 mEq K+)
• Maximum infusion rate via peripheral line is 10 mEq/hour
• Maximum infusion rate via central line is 20 mEq/hour

Magnesium

• Goal: Mg > 2.0
• For every 1 g of MgSO4, the serum Mg will rise about 0.1-0.2 mg/dL
• Usually given as MgSO4 2 g IV over 1 hr
• If Mg > 1.5 given one 2 g dose, if <1.5 give 2 doses of 2 g each

Phosphorous

• Goal: Phos > 3.5
• Replacement must be ordered in mmol of phosphorus
• Can use KPhos or NaPhos depending on other lytes
• Maximum infusion rate of KPhos is 10 mmol/hr
• If Phos is >2, give 15 mmol of IV Phos over 4 hr
• If Phos is <2, give 21 mmol of IV Phos over 4 hr
• If Phos is <1, give 30 mmol of IV Phos over 4 hr

Glasgow Coma Scale for TBI

• Eyes
  1. Eyes open spontaneously
  2. Opens to voice
  3. Opens to pain
  4. Does not open eyes
• Voice
  1. Oriented
  2. Confused
  3. Inappropriate words
  4. Incoherent sounds
  5. No response
• Motor
  1. Follows commands
  2. Localize
  3. Withdraw from pain
  4. Flexion posturing (decorticate, tripleflex*)
  5. Extensor posturing (decerebrate)
  6. No movement

Use “1T” to indicate trach’d and unable to talk, but can use higher numbers if able to communicate despite trach.

*Withdraw is sustained while stimulus is present; tripleflex is a brief reflex despite continued painful stimulus.

Range: 3-15

Hunt & Hess for SAH

0. Normal
1. Asymptomatic, mild headache, slight nuchal rigidity
2. Moderate to severe headache, nuchal rigidity, no neurologic deficit other than cranial nerve palsy
3. Drowsiness, confusion, mild focal neurologic deficit
4. Stupor, moderate-severe hemiparesis
5. Coma, decerebrate posturing

Range: 0-5

ICH

• +1 for age > 80
• +2 for GCS 3-4
• +1 for GCS 5-12
• +0 for GCS 13-15
• +1 if intraventricular blood
• +1 if volume >30cc
• +1 if infratentorial

Range: 0-6

Spetzler-Martin for AVMs

• +1 if deep venous drainage
• +1 if eloquent cortex (language, vision, brainstem, i.e. high price real-estate)
• +3 if any dimension >6cm
• +2 if any dimension 3-6cm
• +1 if all dimensions <3cm

Range: 1-5

House-Brackmann for facial nerve palsy

• Grade I - Normal
  • Normal facial function in all areas
• Grade II - Slight Dysfunction
  • Gross: slight weakness noticeable on close inspection; may have very slight synkinesis
  • At rest: normal symmetry and tone
  • Motion: forehead - moderate to good function; eye - complete closure with minimum effort; mouth - slight asymmetry.
• Grade III - Moderate Dysfunction
  • Gross: obvious but not disfiguring difference between two sides; noticeable but not severe synkinesis, contracture, and/or hemi-facial spasm.
  • At rest: normal symmetry and tone
  • Motion: forehead - slight to moderate movement; eye - complete closure with effort; mouth - slightly weak with maximum effort.
• Grade IV - Moderate Severe Dysfunction
  • Gross: obvious weakness and/or disfiguring asymmetry
  • At rest: normal symmetry and tone
  • Motion: forehead - none; eye - incomplete closure; mouth - asymmetric with maximum effort.
• Grade V - Severe Dysfunction
  • Gross: only barely perceptible motion
  • At rest: asymmetry
  • Motion: forehead - none; eye - incomplete closure; mouth - slight movement
• Grade VI - Total Paralysis
  • No movement

ASIA impairment scale for spine

• A = Complete: No sensory or motor function is preserved in sacral segments S4-S5
• B = Incomplete: Sensory, but not motor, function is preserved below the neurologic level and extends through sacral segments S4-S5
• C = Incomplete: Motor function is preserved below the neurologic level, and most key muscles below the neurologic level have a muscle grade of less than 3
• D = Incomplete: Motor function is preserved below the neurologic level, and most key muscles below the neurologic level have a muscle grade that is greater than or equal to 3
• E = Normal: Sensory and motor functions are normal

Fentanyl Citrate

• Indications: sedation, analgesia
• IV Bolus dose: 1-2 mcg/kg IV
• Maintenance drip: Initiate at 1 mcg/kg/hr, titrate to effect, usual range 0.5-4 mcg/kg/hr

Lorazepam (Ativan)

• Indications: sedation, anxiolysis, status epilepticus, alcohol withdrawal
• IV Bolus dose: 1-4 mg IV push
• Maintenance drip: Initiate at 1mg/hr, titrate to effect

Midazolam (Versed)

• Indications: sedation, anxiolysis, status epilepticus
• IV Bolus dose: 1-4 mg over 5-30 seconds
• Maintenance drip: Initiate at 2 mg/hr, titrate to effect

Propofol

• Indications: sedation, general anesthesia, (off label use for status epilepticus)
• IV Bolus: not recommended (hypotension)
• Maintenance drip: Initiate at 5-10 mcg/kg/min increasing by 5-10 mcg/kg/min as needed

Head Trauma

History:

• Time of injury
• Mechanism of injury
• Medications given en route
• Seizure, LOC
• Anticoagulant/antiplatelet

Exam:

• GCS
• Pupils, cranial nerves (esp 3, 6, 7, 12)
• Strength, sensation, mental status
• Raccoon eyes, battle sign, hemotympanum, CSF rhinorrhea/otorrhea
• Scalp lacerations

Imaging: Head and C-spine CT

• Always check entire head CT for epidural, subdural, subarachnoid, parenchymal blood
• Midline shift, hydrocephalus, basal cisterns/subarachnoid spaces patent, gray/white differentiation
• Bone windows: Skull fractures? Fractures near carotids/temporal bone? Posterior frontal sinus? Orbits?
• Alignment of cervical spine/fractures. Facet dislocations? Teardrop fractures? Fishmouthing of disc spaces or spinous processes?

Labs:

• Full set of labs, +/- tox screen/EtoH if older

Plan:

• ABC’s
• Does the patient need to go to the OR (?epidural hematoma +/-shift, subdural blood +/-mass effect, open/depressed skull fracture)
• Obtain CTA if fracture through carotid canal or foramen transversarium
• usually will have spine precautions until final CT review by attending radiologist (if no fracture)
• admit to ICU for 24 hours. Floor for neuro-intact non-displaced skull fractures.
• If GCS less than 8, consider invasive ICP monitoring. Goal CPP>60, ICP<25 (CPP=MAP-ICP). See below for indications for invasive ICP monitoring
• HOB at 30 degrees (reverse Trendelenberg if spine not cleared)
• Use normal saline as primary fluid, avoid hypotonic solutions
• Maintain glycemic control
• pCO2 goal 30-35 mmHg
• pO2 >100 mmHg
• cooling blanket for fever (minimize metabolic demand)
• q1 hour neuro checks
• Na >135
• Normalize PT, PTT and platelets > 80,000
• Anticonvulsant x 1 week if depressed skull fracture, immediate post-traumatic seizure, penetrating brain injury, or intracranial blood (Keppra 500 mg BID or 10 mg/kg BID)
• Page neurosurgery for change in neuro exam or elevated ICP
• Avoid jugular vein compression
• Sedation if needed (minimize metabolic demand, ICP)
• If signs of herniation, mannitol / hypertonic saline
• steroids contraindicated

Head Injury

ABCs

GCS

• Mild (GCS 14-15)
• Moderate (GCS 9-13)
• Severe (GCS <8)

TBI Guidelines:

• No steroids
• Goal SBP >90
• Goal O2 sat>90% or PaO2 >60
• Goal ICP <20-25 (Goal CPP 50-70)
• Goal SjO2 >50%, PbrO2>15 (ischemia at 8-12)
• Goal Normothermia
• Goal PaCO2 35. Hyperventilate only as temporizing measure.
• Mannitol 0.25-1 g/kg. Contraindic in hypotension, renal failure.
• Hypertonic saline. Caution in heart failure/pulmonary edema. 250-500cc 3% NaCl or 30cc 23.4% NaCl, prefer via central line.
• Prefer propofol 20-75 mcg/kg/min (caution hypotension) and fentanyl 2-5 mcg/kg/h (caution hypotension, increased ICP)
• Thiopental coma: Load 10mg/kg over 30 min then 5mg/kg q1h x 3 doses. Titrate to burst suppression (1-2 mg/kg/h maintenance).
• +/- Keppra x 7 days, dec early seizures but seizures do not affect outcomes
• Feeds at goal by day 7, glycemic control.
• SCDs. SQH or Lovenox OK 24h after injury if bleeding stable.

ICP monitoring

• GCS <8 and abn CT OR
• GCS <8 and normal CT and 2 or more:
  • Age >40
  • SBP<90
  • Posturing

Ventriculostomy

• Kocher’s point:
  • 10.5 cm from glabella, 2.5 cm from midline (roughly midpupillary line).
  • Aim toward intersection of medial canthus and tragus (perpendicular to skull).
  • Advance to 5-7 cm.
• Occipito-parietal site:
  • Frazier burr hole: 3.5cm from midline, 6.5 cm above inion.
  • Also intersection of midpupillary line with horizontal line from top of pinna
  • Aim for middle of forehead or ipsilateral medial canthus
  • Use stylet for 6cm to avoid getting into temporal horn. Then advance to 10-12 cm. For infants only 7-8cm.

Epidural hematoma

• Does not cross sutures, can cross midline. Swirl sign = active bleeding
• Usually associated with skull fractures (70-95%)
  • Middle meningeal artery or vein, also diploic veins and venous sinuses.
• Decompression if:
  • >30 cm3 regardless of GCS
  • Neurologic deficit (operate within 70 min of pupillary dilatation!)
  • >15mm thickness or >5mm midline shift
  • Brainstem distortion, low threshold for surgery in temporal location
• Consider conservative mgmt. if <30 cm3 AND <15mm thick AND <5mm shift with no focal deficit and GCS >8
  • Q1h neuro checks
  • Serial CT q 6-8h
• Mortality 10% for all operative EDH cases

Subdural hematoma

• Can cross sutures, does not cross midline
• Acute if within 14 days of head injury
• Decompression if:
  • >1 cm thickness or >5mm midline shift
  • Neurologic deficit
  • Decline in GCS of 2+ points between time of injury and hospital admission
  • Decompress within 2-4 hours for better outcome.
• Consider hemicraniectomy if associated parenchymal injury
• Mortality 40-60% for all operative acute SDH cases. Worse outcome if age >70 and GCS <9

Cerebral contusion

• Surgical decompression:
  • Any lesion >50 cm3
  • Frontal or temporal lesion >20 cm3 with >5mm midline shift or cisternal compression.
  • Consider decompression for neurologic decline or intractable ICP.
• Medically refractory cerebral edema
  • Bifrontal craniectomy within 48 hours for diffuse injury
  • Subtemporal decompression, temporal lobectomy
  • Decompressive hemicraniectomy for hemispheric lesion

Posterior fossa hematomas

• Early, aggressive approach. Can decompensate quickliy.
• Surgical decompression:
  • Distortion/obliteration of 4th ventricle, loss of basal cisterns or obstructive hydrocephalus
  • Neurologic deficit
• Consider conservative management if no significant mass effect and no neurologic dysfunction
  • Neuro checks q1h and serial CTs

Traumatic SAH

• Consider Keppra 7 days
• Q1h neuro checks
• Correct coagulopathy (see Coagulopathy in Neurocritical care)
• Repeat head CT in 6-8 hours. Lovenox OK if CT stable.

Penetrating brain injury

• Prophylactic antibiotics recommended
• Antiseizure prophylaxis recommended x 1 week
• Early ICP monitoring recommended if unable to follow exam
• Surgical correction of persistent CSF leaks, hematomas with mass effect. Avoid entry/exit site in incision. Debridement of nonviable scalp/bone/dura. Watertight repair of nasal sinus injuries.
• Conservative debridement of missile tract without retrieval of remote fragments (remove if fragment movement, abscess formation, vascular compression, obstructive hydrocephalus, heavy metals in CSF).
• CTA or angio for vascular inury (consider angio for penetration injury through pterion, or bit or posterior fossa; penetrating fragment with ICH; pseudoaneurysm during surgical exploration; GCS<8 with penetrating injury; TCDs/CTA suggestive of vasospasm)

Skull fractures

• Linear non-displaced
  • Consider possibility of venous sinus thrombosis or arterial dissection
  • See peds section re: growing skull fracture in peds.
  • Diastatic: separation of cranial sutures
• Open skull fracture
  • Consider conservative management if:
    • No evidence dural penetration
    • No significant intracranial hematoma
    • No depression <1cm or cosmetic deformity
    • No frontal sinus involvement
    • No pneumocephalus or gross wound contamination
  • Operative mgmt for open skull fractures depressed with outer table of fragment past inner table of skull
• Depressed/Comminuted
  • Eval for underlying injury
  • Elevate for outer table of fragment past inner table of skull.
• Compound: communication with skull base, paranasal sinuses, overlying scalp.
  • Criteria for emergent operation:
    • Open contaminated wound
    • Hematoma and/or dural laceration
  • Elective repair if closed and no mass effect/neurologic compromise
• Skull base fractures:
  • Signs: Raccoon eyes, anosmia, rhinorrhea, otorrhea, hemotympanum, Battle?s sign, CN VII or VIII palsy.
    • Can test fluid for ring sign or dipstick glucose.
  • No CSF leak: observe 2-3 days
  • CSF leak:
    • Most resolve spont within 1 week.
    • May trial lumbar drainage with HOB up (watch for pneumocephalus)
    • Surgical closure for refractory CSF leak (can use intrathecal contrast to localize leak)
  • Temporal bone:
    • Longitudinal: risk to eardrum, EAC, otorrhea
    • Transverse: risk to middle ear, facial nerve.
    • Facial palsy: high dose steroids and possible surgical decompression/graft. Steroids for delayed facial palsy.
• Maxillofacial
  • Emergent intervention for aiway obstruction/aspiration or severe hemorrhage
  • Frontal and supraorbital
    • Suspect CSF leak.
    • Supraorbital fractures may require fixation for cranial nerve compression or globe compression
    • Frontal sinus:
    • Anterior wall alone: fix for cosmesis
    • Posterior wall: eval for dural integrity
    • Ant and post: may require visual inspection and repair
    • Cranialize/obliterate for damage to nasofrontal duct
    • «Inner table fx of frontal sinus. Abx?»

Carotid or vertebral artery dissection

• Fracture traversing carotid canal
• Heparin gtt
• Antiplatelet therapy
• Dennis classification

Diffuse Axonal Injury

Obtain MRI

• Grade I = only peripheral gray-white junction
• Grade II = injury to corpus callosum
• Grade III = injury to dorsolateral midbrain

Traumatic SAH

• admit to ICU for q1 neuro checks
• goal PLT > 100, INR < 1.4
• repeat CT wo at 24hrs or earlier if exam change
• keppra 500bid
  • if seizures already, then add 1g load

Spinal cord injury / spinal fracture

History

• Timing
• Mechanism
• Neuro deficit and trend
• Point tenderness and/or rectal tone on Trauma primary survey?
• Catalog of injuries
• History of spinal instrumentation?
• History of anticoagulation

Labs

• Pre-op labs
• Tox screen
• EtOH level

Imaging

• Full spine CT
• Check coronal, sagittal and axial images.
• Fractures? See below for types and management of spinal fractures.
  • Fracture near foramen transversarium: CTA for dissection
• Check:
  • OA distance (see below ?C-spine injury types?)
  • Atlanto-dentine interval (see below ?C-spine injury types?)
  • ALL, PLL, spinal laminal line
  • Fish-mouthing of disk spaces
  • Epidural hematoma.
• MR for neuro deficit with no obvious cause: eval acute disk herniation, epidural hematoma, cord signal change, ligamentous injury.

Plan

• Consider fracture type (see below). External stabilization v. internal fixation?
• If Neuro-deficit, consider stability for stat MRI versus fracture type requiring operative treatment.
• Cervical fracture: refer to SLIC scale to help guide management
• Thoracolumbar fracture: refer to TLICS to help guide management
• Ankylosing spondylitis type patients: High risk of epidural hematoma.
• Spinal cord injury
  • MAP goal 85-90 x 7 days, need arterial line. (Also see below, ?Neurogenic shock?)
  • PM&R consult
  • Currently no evidence for steroids
    • If giving steroids, must be within 8 hours of injury
    • Bolus 30mg/kg IV over 15 minutes (62.5 mg/mL solution).
    • Then 45 min pause
    • Maintenance rate 5.4 mg/kg/h
  • If started within 3 hours of injury, continue for 23 hours
  • If started between 3-8 hours of injury, continue for 47 hours
    • Study exclusions: cauda equina syndrome, gunshot wounds (worse outcome), life threatening morbidity, pregnancy, narcotic addiction, age <13 y/o, already on maintenance steroids.

Spinal cord injury

• ABCs
• ASIA score: Prefer to examine at 72h.
  • A = Complete. Sensory and motor all lost, no sacral signs.
  • B = Incomplete. Sensory but no motor preserved more than 3 levels below injury (sacral sensation)
  • C = Incomplete. Sensory and motor preserved, minimal motor. 0-2/5 strength in more than half of muscles below level.
  • D = Incomplete. Sensory and motor preserved, functional. 3-5/5 in more than half of muscles below level.
  • E = Normal, return of all sensory/motor function.

C-spine injury

• Airway: maintain immobilization with intubation
• Breathing: consider paralysis of intercostals/diaphragm with hypoventilation
• Circulation: Consider spinal shock with hemorrhagic/cardiogenic shock.
  • MAP goal 85-90 mmHg x 7 days
• Complete trauma eval
  • Exam: ASIA score (see above)
    • Determine most caudal sensory and motor level for both L and R. Most caudal motor with at least 3/5 strength.
    • Complete: no motor or sensory function extends to sacral segments
    • Incomplete: Any motor or sensory function including sacral segments (voluntary contraction or sensation during DRE. Bulbocavernosus reflex no voluntary).
• CT total spine. (Plain films AP/lat C spine and T/L spine if too unstable for CT and headed for emergent OR).
• NO STEROIDS
• Consider CTA/MRA eval carotids and verts.
• Cervical immobilization
  • Awake, asymptomatic patient = no imaging, no immobilization
    • No midline neck pain
    • Normal neurologic exam
    • No distracting injury
    • No pain with full ROM exam
  • Awake symptomatic patient and CT negative
    • Can d/c C collar after normal flex-ex films
    • Option to d/c C collar with normal MRI within 48h of injury
  • Obtunded/unevaluable patient and CT negative
    • Option to d/c C collar with normal MRI within 48h of injury
    • D/c C collar per Trauma protocol
• Closed reduction
  • Contraindications:
    • Extension-distraction injury (ankylosing spondylitis)
    • Local infection
    • Comminuted skull fracture
    • Hemodynamically unstable
    • Atlanto-occipital dislocations
    • Depressed LOC
  • Do not attempt in patients with additional rostral injury or unreliable neurologic exam/intoxication.
  • Halo or Gardner-Wells tongs with X-ray/fluoro guidance
    • Start with 3 lb traction per injury level.
    • Add weight every 10-15 min
    • Serial neuro exams and lateral C spine films with each weight
  • 2-4% transient neurologic complication, 1% risk permanent neurologic complication
  • If fail closed reduction get MR before open procedure

from Neurosurgery, March 2013

Cervical Spine Traction

• Frame placement
  • Call for appropriate bed, weights and pulleys (clerks or call patient equipment)
  • Call O&P
  • Inject lidocaine at anticipated pin sites
  • Anterior pins over lateral 1/3 of eyebrow (avoid supratrochlear n)
  • Posterior pins about 1cm above pinna in line with EAM
    • Posterior pin placement will provide flexion
    • Anterior pin placement will provide extension
  • Ensure frame does not touch ears
  • Tighten pins stepwise, gradually in opposing fashion to avoid torqueing
• Get X-ray/fluoro
• Add weights
  • Align traction axially along spinal column straight back.
  • Start 10 lbs
  • Usually add 5 lbs per level. Change every 20-30 minutes at 5-10 lb intervals
  • Neuro exam before and after each change in weights.
  • Confirm on X ray
  • Can give valium for musc

Central Cord Syndrome

• BUE paraesthesia, weakness; spares BLE
• CT can suggest stenosis and disc, follow with MRI wo
• consider decompression if acute disc bulge
• severe: decadron 10 + 6q6, decompression
• prognosis: most recover, some with residual spasticity/weakness
• admit to ICU for MAP goal > 85