NROS Flashcards
Decrease ICP measures
NEURO - ICP
[21B05] Justify your strategies for managing severely elevated ICP.
- Avoid CBF
- normocapnia - IPPV
(30-35mmhg)
- normoxia - good O2
- normal BP - analgesia
- warm - Avoid venous pressure
- no cough/strain
- no head down
- no ETT ties - Prevent cerebral oedema
- maintain IV volume and CPP
- CPP>65
- mannitol 20% 1mg/ml
(0.25g/kg)
- NS 5% 100ml
- steroids for tumor and abscess ONLY - DO NOT GIVE for head injury - CSF
- ventricular/lumbar drain - CVP
- head up 30 deg - MAP
- pressor
Oxford
BRAIN
- steroids
-DECRA - tier 3 refrac
BLOOD
- CPP
- venous draina
VP Shunt
Indication:
1. Hydrocephalus
Options:
1. Ventriculoartial
2. Ventriculopleural
Surgical:
1. Occipital burr hole –> LV
2. Tunnel SC down to nec and trunk
3. Peritonal cavity via abdo cut
System:
1. Flushing device - keep system clear
2. Valve - prevent CSF draining too quickly
PRE:
1. assume raised ICP
2. paeds consideration
3. emerg = RSI
PERI:
M: routine +/- IAL
A:
D: IV or IT abx; trocar stimulating - relax/analgesia
E: FAW
POST:
D - ALOC –> CT excl. shunt mal or SDH
Considerations x3
- ICH risk if drained too quick
- shunt - block/infection = resite
- trocar - risk of PTX
oxford
WFNS
Prognostication!
GCS and motor deficit
Motor deficit grade 3+
GCS
15 = 1
13-14 no def = 2
13-14 def = 3
7-12 =4
3-6 = 5
secure aneurysm <48 hrs post ictus of 1-3
- coil / clip
mFS
Risk of vasospasm!
SAH IVH spasm%
0 = none = 0%
1 = thin/ none = 24%
2 = thin/yes = 33%
3 = thick/no = 33%
4 = thick/yes = 40%
Intracranial aneurysms
Location - junction
Common
1. AComm 40%
2. MCA bifur 34%
3. PCA 20%
RF
1. HTN
2. Smoke
3. FHx
4. PCKD
5. Cocaine
6. CTD
VAE
sx:
1. dec EtCO2!
- inc dead space
2. bronchoconstriction
3. hypoxia
4. arrhythmias
5. MI
6. hypotension
7. cardiac arrest
NEURO - prone.
[21B06] Discuss the perioperative strategies you would use to mitigate the risks of prolonged surgery in the prone position.
55.6%
Prolonged sx =
1. prolong emergence
2. Pressure injury risk
3. Exacerbation
4. VTE risk
Prone
1. Visual loss
2. PND
3. soft tissue damage
4. joint
5. Altered CVS/resp
6. IAP
7. Limb compartment
Strategies
PREOP
- consent
- optimise
- pre-existing
INTRAOP
- ETT SECURE
- IDC
- pad
- position
- euvolaemia
- move joint q1-2h
- leak test prior ext
- VAE
- cardiac arrest - pads
POST OP
- neuropraxia ax
- lesions - PT, pain mx, repair
(55.6%) Prolonged surgery in the prone position presents many challenges for the theatre team and risks for the patient. Candidates were expected to include the following issues in their answer:
- prolonged surgery itself is associated with increased morbidity
- the altered CVS and RS physiology in the prone position
- the risk of peripheral nerve damage
- the risk of postoperative visual loss
As well as discussing intraoperative strategies to reduce risk the role of preoperative risk assessment and postoperative follow up required discussion.
Answers that failed to demonstrate understanding of the above issues or failed to include the preoperative and postoperative components of their perioperative strategies didn’t attract sufficient marks to pass the question.
How do you manage acute life threatening intra operative haemorrhage during a neurosurgical procedures?
SS_NS 1.28
- Reverse heparin
- 1mg protamine for 100 U heparin - BP lowered to pre-bleed level
NEURO – Trans-sphenoidal pituitary surgery / diabetes insipidus
[18B06] A patient scheduled for trans-sphenoidal pituitary surgery is noticed to have greater than normal urine output.
a) How would you determine if this patient has diabetes insipidus? (30%)
b) How would you manage diabetes insipidus in the perioperative period? (70%) (also 04B07, 00A14)
NEURO – Large intracranial tumour
[17B04] A 44-year-old male is booked for debulking of a large intracranial tumour.
a) Describe the physiological aims during this case. (50%)
b) Justify your anaesthetic technique to achieve these aims. (50%) (also 04A05)
Table - 2 columns
NEURO – Innervation for scalp
[16B06] You are asked to provide local anaesthesia for awake craniotomy.
Describe the innervation of the scalp, including the landmarks for nerve blockade.
GGLASSZ
G/L occiptal
G auricular
Auric / Temporal V3
Zygo / temp V2
Supratrochlear V1
Supraorbital V1
NEURO – Primary / secondary brain injury post TBI
[16A07] Outline the pathophysiological insults that exacerbate a primary brain injury post head trauma & indicate how can they be minimised. (also 09B15, 06B08)
Dec 2o brain injury
1. ICP 2. CPP 3. RF
- Monitor
a. Standard + IAL + ICP + EEG +/- CVP - BP
a. sBP > 90
b. CPP > 60 (60-70) - O2 > 60mmHg
- ICP mx
a. ICP < 20 - Seizure proph
- pheny/val/leve - Temp
- normothermia - Glycaemic control
BSL 5-10
conventional no diff in outcome vs tight control - ## Electrolytes
NEURO – Intracranial pressure
[14B02] A 25 year old man with a history of blunt trauma to the right side of his head has a fixed and dilated right pupil.
He has been intubated and ventilated in the emergency department after an initial Glasgow Coma Score (GCS) of 15 on admission had fallen to 3.
Evaluate the pharmacological and non-pharmacological methods to manipulate this patient’s intracranial pressure?
MKD
CPP = MAP - ICP
ICP = 5-15
Pharm
1. Mannitol: 10% 1g/kg
2. NS 3%: 3-6mL/kg
TBI
BTF GL
DECRA
Osmotx
CSF drain
Vent
Sed
Steroid
Nutrition
Abx
DVT
Seizures
ICP mon*
CPP mon*
sBP target*
DECRA: early/late REFRAC ICP eleveation
Osmo: Mannitol (herniating pts)
CSF drain: continuous; GCS < 6
Vent: avoid HYPERvent
Sed: PPF; barbituate for refractory
Steroids: Level 1 and it is BAD
Nutrition: hit goals by 5-7/7
Abx: prevent VAP, not prophylais
DVT: Stable TBI = TEDS + hep/clex
Seizures: 7/7 pheny
ICP mon - 22 mmHg threshold for rx
CPP: 60-70 mmHg
sBP: 100 for 50-69, 110 for 18+ and rest
https://derangedphysiology.com/main/required-reading/trauma-intensive-care/Chapter-101/summary-brain-trauma-foundation-guidelines
