SIADH vs. CSWS
SIADH
- normovlemic
- oliguria
- Urine Na 50-100
- tx = fluid restriction, Na
CSWS
- hypovolemic
- polyuria
- Urine Na»_space;100
- tx = fluids, Na
Management of BP with intracranial mass
CPP MAP-ICP
BP elevated to maintain CP in the setting of inc ICP with the mass Treat the ICP - elevated head - drain CSF - mannitol or furosemide - hyperventilate
Considerations for sitting position
Contraindicated w/ intracardiac shunts VAE hypotention Airway obstruction, poor access to airway quadriplegia from neck flexion Cerebral ischemia
Better exposure
Less tissues damage, retractions, bleeding, cranial nerve damage
Tx of VAE
Call for help 100% O2 Surgeon flood field with saline Bone wax on edges Compress jugular veins Aspirate air from CVC
BP management with aneurysm clipping
Deliberate hypotension reduced trans mural pressure and reduce risk of aneurysm rupture but given chronic HTN, CAD might place at unacceptable risk of cerebral and cardiac ischemia.
Discuss temporary clip with surgeon
Management with temporary aneurysm clip
MAP higher than normal to support collateral blood flow
Propofol to reduce CRMO2
Use EEG and SSEP
Brain relaxation with CSF drainage, mannitol to reduce traction needed
Effects of mild hypothermia for brain protection
Dec CRMO2
Delayed emergence Slow metabolism Inc infection In O2 consumption Myocardial ischemia Arrhythmias Coagulation defects
ST changes during crani, what is going on? What would you do?
SAH?
Aneurysm likely bleeding —> apply clips, lower BP slightly to help with repair and give propofol for neuro protection understanding risk of end-organ ischemia
Massive hemorrhage — compress carotids, avoid hypotension and resuscitate
Or myocardial ischemia
How do you clear a c-spine?
- Absence of cervical pain or tenderness
- Absence of paraesthesia or neurological deficits
- Normal mental status
- No other distracting pain
- Age >4
If not pass above then lateral C1-T1, open mouth ondontoid and A/P
Urine SG <1.005, inc serum Na, large volume urine, Osm <200
DI
Replace urinary losses with D5 1/2 NS
If exceeds 350ml/hr —> DDAVP (replaces patients ADH)
Significant hypotension 4 days post pituitary tumor removal, what is the cause?
Adrenal insufficiency from panhypopiuitarism
What is the normal CPP and what is the ideal CPP with a TBI?
Normal 80-100mmHg
Unknown for TBI
>70 may inc risk of ARDS
50-60 –> ischemia
so ideal may be 60-70
Would you hyperventilate a patient with head trauma?
Mildly only to 25-30 if other means were not successful and the ICP was high enough to risk brainstem herniation
Dec blood flow following trauma –> at risk for ischemia
Would you use N2O in TBI?
No
If cerebral perfusion were compromised i would want 100% O2
If hyperemia were an issue, N2O can potentially inc CBF
If air were trapped in the cranium –> expand further inc ICP
Criteria for Fat embolism syndrome
1 major + 4 minor
Petechial rash, hypoxemia, CNS depression or pulmonary edema
Tachycardia, pyrexia, retinal fat emboli, fat microglobulinemia, unexplained anemia
Extubation plan following IC mass resection
If normal, awake and reassuring airway pre-op, reasonable to perform deep extubation to avoid coughing and allow neuro exam
If obtunded pre-op - risk for aspiration, CO2 retention I would delay extubation. Possible to have post-op edema or hematoma –> dec neuro status and prolonged intubation
Risk factors for peripheral nerve injury
Male LOS >14 days Intra-op hypotension Hx vascular disease, DM Smoking Very thin or very obese
When might you avoid using mannitol to lower ICP
Disrupted BBB (preeclampsia, trauma)
Intracranial hemorrhage
–> worsen cerebral edema
*Normal ICP <15mmHg
Concerns with acute C-spine injury
- Resp function - esp if C3-5
- Hypotension - loss of sympathetic tone (T1-4)
- Aspiration - paralytic ileus
- Worsening SC injury - inadequate stabilization, hypotension, hypoxia, anemia
- Difficult airway - careful fiberoptic intubation
- Thermal regulation loss of vasoconstriction and temp sensation
- Autonomic dysfunction/hyperreflexia and arrthymia
Use of steroids in SC injury
Controversial - maybe some benefit within 8 hours but weigh risks of side effects like sepsis, hyperglycemia, pneumonia
Difference b/w spina bifida occulta and cystica?
Occulta = incomplete/abnormal formatio of midline structure w/o herniation of meninges
Cystica = failed fusion of neural arch, herniation of meninges +/- neural elements
Both have have underlying thethered cord or neuro deficits
Abruption/trauma w/ difficult airway and dec FHR, what will you do?
- Optimize mothers condition and prepare for emergency C/S
- Apply O2, auscultate for PTX
- Eval EKG
- LUD
- Call for surgeon to obtain surgical airway have area prepped
- Difficult airway equipment
- Secure airway awake
- Avoid ketamine (inc ICP, inc uterine tone, dec placental perfusion)
- Get labs (ABG, H&H, coags, lytes)
What are the monitoring options for CEA?
Awake - gold standard, requires cooperation, limited access to airway
TCD - non-invasive, can continue post-op, operator dependent, placed very near surgical site
Stump Pressure - >60 ideally
EEG - non-invasive, only reflects cortical structures, requires skilled interpretation
SSEPs - useful with abnormal EEG baseline, requires skilled interpretation
Would you give mannitol to a patient with AMS with new Cushing response?
It could potentially reduce ICP BUT it may worsen cerebral edema if BBB is not intact (trauma, Pre-E)
IC bleeding –> expansion of hematoma = avoid until intracranial pathology was clearly defined.
