Emergency Crani

[IceDoc]

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I was innocently walking down the hall and got grabbed for an emergency crani for ICH. The surgeons were going to get the patient, and fortunately our halls are long and winding and we the had the time to find out this on the computer: EF 12% one year ago, idiopathic cardiomyopathy, on heart txplant list, pulm htn.
CXR shows Intubated, AICD present, plenty of white junk in the lungs. Labs: who cares. The story was that he flicked a clot from his heart to his brain, he got heparinized, and then bled. Neuro exam upon arrival to OR was...bad.

Since there's no real mystery here, I just say what we did; and I'm wondering if anybody has any thoughts on major differences they would do.



1. Make sure EP turned off the AICD;
2. Placed defib pads
3. Scalp Block
4. O2, cracked sevo (maybe 0.3MAC)
5. Vec
6. Fentanyl (got in about 40mcg)
7. Oh yes, arrived on dopamine; kept it running.
8. Hyperventilation, mannitol

 

[adleyinga]

I was innocently walking down the hall and got grabbed for an emergency crani for ICH. The surgeons were going to get the patient, and fortunately our halls are long and winding and we the had the time to find out this on the computer: EF 12% one year ago, idiopathic cardiomyopathy, on heart txplant list, pulm htn.
CXR shows Intubated, AICD present, plenty of white junk in the lungs. Labs: who cares. The story was that he flicked a clot from his heart to his brain, he got heparinized, and then bled. Neuro exam upon arrival to OR was...bad.

Since there's no real mystery here, I just say what we did; and I'm wondering if anybody has any thoughts on major differences they would do.



1. Make sure EP turned off the AICD;
2. Placed defib pads
3. Scalp Block
4. O2, cracked sevo (maybe 0.3MAC)
5. Vec
6. Fentanyl (got in about 40mcg)
7. Oh yes, arrived on dopamine; kept it running.
8. Hyperventilation, mannitol

This guy ain't gonna walk out of the hospital in all likely hood.
I would have used pentothal if he tolerated it. Only agent with any track record- but has to be before events
Maybe fentanyl

In truth probaly makes little difference given the poor starting point

 

[Gator05]

Neuro newbie here, so I'll bite...

1. Why sevo and not iso?
2. Why fentanyl, not some more titratable like remi (I assume you're going easy re: hemodynamics)?
3. How much hyperventilation? ETCO2 20's? 30's?
4. Did they pin the head? If so, esmolol/stp?
5. How much PEEP? If concerned about increased ICP's vs terrible lungs, how well did you oxygenate?
6. Hyperventilation in a damaged brain during low cardiac output states...what's the end-product for CBF? Does it matter?

Like I said, newbie questions 🙂

 

[jetproppilot]

I was innocently walking down the hall and got grabbed for an emergency crani for ICH. The surgeons were going to get the patient, and fortunately our halls are long and winding and we the had the time to find out this on the computer: EF 12% one year ago, idiopathic cardiomyopathy, on heart txplant list, pulm htn.
CXR shows Intubated, AICD present, plenty of white junk in the lungs. Labs: who cares. The story was that he flicked a clot from his heart to his brain, he got heparinized, and then bled. Neuro exam upon arrival to OR was...bad.

Since there's no real mystery here, I just say what we did; and I'm wondering if anybody has any thoughts on major differences they would do.



1. Make sure EP turned off the AICD;
2. Placed defib pads
3. Scalp Block
4. O2, cracked sevo (maybe 0.3MAC)
5. Vec
6. Fentanyl (got in about 40mcg)
7. Oh yes, arrived on dopamine; kept it running.
8. Hyperventilation, mannitol

Never done a scalp block for a crani.

You know the whole hyperventilation argument.

Other than that I wouldda done it very similar. Probably a little midazolam since your gas is low.

 

[IceDoc]

Neuro newbie here, so I'll bite...

1. Why sevo and not iso?
2. Why fentanyl, not some more titratable like remi (I assume you're going easy re: hemodynamics)?
3. How much hyperventilation? ETCO2 20's? 30's?
4. Did they pin the head? If so, esmolol/stp?
5. How much PEEP? If concerned about increased ICP's vs terrible lungs, how well did you oxygenate?
6. Hyperventilation in a damaged brain during low cardiac output states...what's the end-product for CBF? Does it matter?

Like I said, newbie questions 🙂

I had this nice long reply that then got zapped into cybernowhere. So here's the brief because we've got a party tonight.
1. Sevo becuase it's a little more CV stable than iso.
2. Didn't really think of remi. Nice thought. I just slowly titrated fent in. (had it drawn up in peds dosing for earlier cancelled case)
3. ET mid20's until skull removed. THen slowly brought back to normal. This was the perfect case for hyperventilation because there was a definitive time for it. Once the confining skull was removed, there was no need for it. Very different from the surgeon asking you to keep it in the 20's for 5 hours on a tumor resection.
4. No pinning.
5. No PEEP for the increase in ICP. He was actually oxygenating just fine; lungs looked worse on cxr.
6. Don't know what his CO was. Hope for the best.
7. Don't forget to have EP turn the AICD on!

 

[Noyac]

I'm just curious why we do these cases at all. It is my opinion that we only prolong the suffering of these patients. My bet is that this guy circles the drain for a while and then goes, after racking up enormous bills for the family to deal with. I really hate to see these cases come through the door.

To the credit of one of my surgeons, we had a ruptured AAA come in on Easter and we talked to the pt and family giving them the options and risks and they chose to make her comfortable. She was in a state that has a poor outcome (supra renal rupture, 88yo. poor heart, obese, etc). None of us pushed the family one way or another. But in my past gigs the surgeons would have rushed her to the OR without discussing these issues.

 

[militarymd]

I'm just curious why we do these cases at all. It is my opinion that we only prolong the suffering of these patients. My bet is that this guy circles the drain for a while and then goes, after racking up enormous bills for the family to deal with. I really hate to see these cases come through the door.

To the credit of one of my surgeons, we had a ruptured AAA come in on Easter and we talked to the pt and family giving them the options and risks and they chose to make her comfortable. She was in a state that has a poor outcome (supra renal rupture, 88yo. poor heart, obese, etc). None of us pushed the family one way or another. But in my past gigs the surgeons would have rushed her to the OR without discussing these issues.

I am totaly with you on this one.

In the UK, they probably would not do things like this.

 

[s204367]

gotta be a little realistic here.....however, i use remi for all crani's and carotids. in terms of the AICD....the neuro guys almost exclusively use bo-polar on the head...you may want to keep the defibrillator on, it will work much better then external pads...and, you allow for the pacing activity of the AICD to work should it be needed after any cardioversion to treat brady arrythmias....ALL AICDs have back up pacing capabilities......Certainly you may not want to waste the time it would take to get the EP guys to actually turn it off( the process itself is only 30 sec). and def throw pads on....

that is./..if you can not talk some sense into the neuro boys..

 

[jetproppilot]

I'm just curious why we do these cases at all. It is my opinion that we only prolong the suffering of these patients. My bet is that this guy circles the drain for a while and then goes, after racking up enormous bills for the family to deal with. I really hate to see these cases come through the door.

To the credit of one of my surgeons, we had a ruptured AAA come in on Easter and we talked to the pt and family giving them the options and risks and they chose to make her comfortable. She was in a state that has a poor outcome (supra renal rupture, 88yo. poor heart, obese, etc). None of us pushed the family one way or another. But in my past gigs the surgeons would have rushed her to the OR without discussing these issues.

HA!!

NOY!!

I NEED YOU AT MY FACILITY!!!

My last night week, on my last night (Friday), ruptured AAA.

Dude is pushed up to the OR by ER nurses before OR is ready. 😱

Pressure 50.

We do our thing, and 31 units PRBCs later (along with all the other FFP/platelets/Ca++ crap.....we're in the ICU.

Only problem in my book is the sun is coming up.

And on the way home, since New Orleans is still f u kked up from the storm, I drive up to the MacDonalds driveup on the way home....its 0640....

SORRY CHUMP

McDonalds doesnt open 'til 7am....

😡 😡 😡

Thanks, post-Katrina Ronald MacDonald.

I've been up all f u kking night trying to save some dude's life and I can't even get an Egg McMuffin and a cuppa coffee on the way home.

Now thats some s hit. 😡

BTW, dude died the next day.

 

[meddog1]

No barbituate to decrease CMRO2? 😕

 

[VentdependenT]

Barbs are a last ditch effort for refractory ICP to head elevation, mannitol, lasix. By then a bolt should be on the way.

Most important things for avoiding cerebral sequelae, at least in brain trauma: Avoid hypoxia (Sp02 > 95), keep the glucose control tight (<200 fer sure), avoid hypotension (map >80), severe hypertension (cpp = map - icp), keep that hb 10 or greater.

Hypothermia for CMRO2? Sure. If they are cold keep em that way. If not I believe pt temperature around 35-35 centigrade is the way to go.

As fer your cpp: Noggin up after the surgery/prior to, mannitol, lasix.

Droppen CMRO2 with your inhalation agen and possibly slight hypothermia is the way to go.

Well, off to the Kentucky Derby yall!!! Got the box seats you ask? HELLLLLZZZ YEAAHHHSAAHAHAHAH! See you suckas in a weeeeeeeekekahhaha!

CO2: normal.

 

[The_Sensei]

Barbs are a last ditch effort for refractory ICP to head elevation, mannitol, lasix. By then a bolt should be on the way.

Most important things for avoiding cerebral sequelae, at least in brain trauma: Avoid hypoxia (Sp02 > 95), keep the glucose control tight (<200 fer sure), avoid hypotension (map >80), severe hypertension (cpp = map - icp), keep that hb 10 or greater.

Hypothermia for CMRO2? Sure. If they are cold keep em that way. If not I believe pt temperature around 35-35 centigrade is the way to go.

As fer your cpp: Noggin up after the surgery/prior to, mannitol, lasix.

Droppen CMRO2 with your inhalation agen and possibly slight hypothermia is the way to go.

Well, off to the Kentucky Derby yall!!! Got the box seats you ask? HELLLLLZZZ YEAAHHHSAAHAHAHAH! See you suckas in a weeeeeeeekekahhaha!

CO2: normal.

I see Mary Sturaitis has taught you well.....