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Handbook of Neurosurgery, Neurology, and Spinal Medicine for Nurses and Advanced Practice Health
Professionals
This practical handbook allows nurses, physician assistants, and allied health professionals practicing in the elds of neurosurgery, neurology, and spinal care to quickly review essentials while in the work environment. It emphasizes procedural steps and critical elements in patient management, including intensive care, the neurological examination, di erential diagnoses, and pain management. Written by a multidisciplinary team of experts, this handbook is expected to become a well-worn companion and essential aid to the busy practitioner.
Handbook of Neurosurgery, Neurology, and Spinal Medicine for Nurses and Advanced Practice Health Professionals
Edited by Michael Y. Wang, Andrea L. Strayer, Odette A. Harris, Cathy M. Rosenberg, Praveen V. Mummaneni
Thank you to Roberto Suazo, Graphic Design Project Manager for the Department of Neurological Surgery, University of Miami Miller School of Medicine, who drew the majority of the figures.
First published 2018 by Routledge 711 Third Avenue, New York, NY 10017 and by Routledge
2 Park Square, Milton Park, Abingdon, Oxon, OX14 4RN
Routledge is an imprint of the Taylor & Francis Group, an informa business
International Standard Book Number-13: 978-1-1385-5695-9 (Hardback)
The right of Michael Y. Wang, Andrea L. Strayer, Odette A. Harris, Cathy M. Rosenberg and Praveen V. Mummaneni to be identified as the author of the editorial material, and of the authors for their individual chapters, has been asserted in accordance with sections 77 and 78 of the Copyright, Designs and Patents Act 1988.
All rights reserved. No part of this book may be reprinted or reproduced or utilised in any form or by any electronic, mechanic al, or other means, now known or hereafter invented, including photocopying and recording, or in any information storage or retrieval system, without permission in writing from the publishers.
Trademark notice: Product or corporate names may be trademarks or registered trademarks, and are used only for identification and explanation without intent to infringe.
Library of Congress Cataloging-in-Publication Data
Names: Wang, Michael Y., 1971- editor. | Strayer, Andrea, editor. | Harris, Odette A., editor. | Rosenberg, Cathy, 1963- editor. | Mummaneni, Praveen V., editor. Title: Handbook of neurosurgery, neurology, and spinal medicine for nurses and advanced practice health professionals / edited by Michael Wang, Andrea Strayer, Odette Harris, Cathy Rosenberg, Praveen Mummaneni.
Description: Abingdon, Oxon ; New York, NY : Routledge, 2018. | Includes bibliographical references and index.
Identifiers: LCCN 2017028274| ISBN 9781138556959 (hardback) | ISBN 9781498719421 (pbk.) | ISBN 9781315382760 (ebook)
Classification: LCC RC350.5 | NLM WL 140 | DDC 616.8/04231–dc23 LC record available at https://lccn.loc.gov/2017028274
Visit the Taylor & Francis Web site at http://www.taylorandfrancis.com and the CRC Press Web site at http://www.crcpress.com
CONTRIBUTORS
Aminul I. Ahmed, MD, PhD
Miami Project to Cure Paralysis
Miller School of Medicine University of Miami
Coral Gables, Florida
Junyoung Ahn, BS Department of Orthopedic Surgery
Rush University Medical Center Chicago, Illinois
Vincent J. Alentado, BS Department of Neurological Surgery
Cleveland Clinic Center for Spine Health and Case Western Reserve University School of Medicine Cleveland, Ohio
Khalid Al-Rayess, MD Department of Neurosurgery University of California San Francisco San Francisco, California
Arun Paul Amar, MD Department of Neurosurgery
Keck School of Medicine
University of Southern California and LAC+USC Medical Center
Los Angeles, California
Jimmi Amick, RN, BSN
Children’s of Alabama Section of Pediatric Neurosurgery
University of Alabama School of Medicine
Birmingham, Alabama
Jaclyn Baloga, MPAS, PA-C University of Miami Hospital and Clinics Miami, Florida
Gregory Basil, MD Department of Neurological Surgery
Miller School of Medicine University of Miami Miami, Florida
Mustafa Baskaya, MD Department of Neurological Surgery
University of Wisconsin Medical School Madison, Wisconsin
J.J. Baumann, MS, RN, CNS-BC, CNRN, SCRN Department of Neurosurgery
Stanford Stroke Center
Stanford University School of Medicine
Stanford, California
Marianne J. Beare, RN, MSN, ANP-BC Department of Neurosciences
Inova Medical Group—Neurosurgery
Fairfax,Virginia
Contributors
Bianca Belcher, MPH, PA-C
Department of Neurosurgery
Brigham and Women’s Hospital Boston, Massachusetts
Teresa Bell-Stephens, RN, BSN, CNRN
Department of Neurosurgery
Stanford Stroke Center
Stanford University School of Medicine Stanford, California
David Benglis, MD
Atlanta Brain and Spine Care Atlanta, Georgia
Nicole Bennett, MS, RN, ACNS-BC, APNP, CNRN, SCRN
Comprehensive Stroke Program University of Wisconsin Hospital and Clinics Madison, Wisconsin
Karen Bond, PA-C Center for Spine Health Cleveland Clinic Cleveland, Ohio
Christine Boone, BS, MD, PhD Department of Neurological Surgery
Johns Hopkins University School of Medicine Baltimore, Maryland
Nadine Bradley, RN, BSN
Children’s of Alabama Section of Pediatric Neurosurgery University of Alabama School of Medicine Birmingham, Alabama
M. Ross Bullock, MD, PhD
Miami Project to Cure Paralysis
Miller School of Medicine
University of Miami Coral Gables, Florida
Stephen S. Burks, MD Department of Neurological Surgery
Miller School of Medicine
Lois Pope LIFE Center University of Miami Miami, Florida
S. Shelby Burks, MD Department of Neurological Surgery
Miller School of Medicine
Lois Pope LIFE Center University of Miami Miami, Florida
Simon Buttrick, MD Department of Neurosurgery School of Medicine
University of Miami Miami, Florida
Adriana L. Castano, APN-C, RNFA Atlantic Neurosurgical Specialists
Morristown, New Jersey
Yi-Ren Chen, MD Department of Neurosurgery
Stanford University School of Medicine
Stanford Health Center Stanford, California
Cheng-Hsin Cheng, MD
University of California San Francisco San Francisco, California
LeAnn DeRungs, BSN, MSN, APNP School of Medicine and Public Health Division of Geriatrics and Adult Development University of Wisconsin Madison, Wisconsin
Sanjay Dhall, MD Department of Neurological Surgery
University of California
San Francisco, California
Marine Dididze, MD, PhD
Miami Project to Cure Paralysis
Miller School of Medicine
University of Miami Miami, Florida
Gabriel Duhancioglu, MS
Chicago Medical School North Chicago, Illinois
Yoshua Esquenazi, MD
Department of Neurological Surgery University of Texas Health Houston, Texas
Colleen M. Foley, MS, RN, ACNS-BC, AGPCNP-BC, APNP
UW Health
University of Wisconsin Madison Madison, Wisconsin
Erika Freiberg, PA-C
Boulder Neurosurgical and Spine Associates Boulder, Colorado
Tristan Fried, BS
Thomas Je erson University Philadelphia, Pennsylvania
Bruno V. Gallo, MD Department of Neurology University of Miami Miami, Florida
Jamshid Ghajar, MD, PhD Department of Neurosurgery
Stanford University School of Medicine
Stanford Health Center Stanford, California
George M. Ghobrial, MD
Department of Neurological Surgery
Miller School of Medicine
Lois Pope LIFE Center University of Miami Miami, Florida
C. Rory Goodwin, MD
Department of Neurological Surgery
Johns Hopkins Baltimore, Maryland
Odette A. Harris, MD, MPH
Associate Professor, Neurosurgery
Brain Injury
Stanford University School of Medicine and Rehabilitation
(Polytrauma, SCI/D, BRS, PM&R)
Defense Veterans Brain Injury Center
VA Palo Alto HCS Palo Alto, California
James S. Harrop, MD, FACS
Department of Neurological Surgery
Thomas Je erson University Hospital Philadelphia, Pennsylvania
Rachel Hart, DNP, AGACNP-BC
UW Health
University of Wisconsin Hospital Madison, Wisconsin
Roger Härtl
Department of Neurological Surgery
Weill Cornell Brain and Spine Center
Weill Cornell Medical College
New York, New York
Luke R. Hattenhauer, DNP, CRNA
Department of Anesthesiology
University of Wisconsin School of Medicine and Public Health
Madison, Wisconsin
Alisabeth C. Hearron, DNP, ARNP-C
Miami Neurological Institute Miami, Florida
Jeffrey Hernandez, BSN, RN, MSCN
Multiple Sclerosis Center of Excellence
Miller School of Medicine
University of Miami Miami, Florida
Daniel J. Hoh, MD
Department of Neurological Surgery
University of Florida
Gainesville, Florida
Contributors
Honglian Huang, MD, PhD
Physical Medicine and Rehabilitation
Cleveland Clinic Foundation Cleveland, Ohio
Christina Hughes, MMS, PA-C
Department of Neurological Surgery
Johns Hopkins Baltimore, Maryland
Danielle Hulsebus, ACNP-BC Department of Neurosurgery University of Michigan Ann Arbor, Michigan
Tricia Jette-Gonthier, APRN
Bone and Joint Center Southern New Hampshire Medical Center Nashua, New Hampshire
Eli Johnson, BS Department of Neurosurgery
Stanford School of Medicine
Stanford Health Center Stanford, California
Sara Kadlec, PA-C
Boulder Neurosurgical and Spine Associates Boulder, Colorado
Rahul Kamath, MS Chicago Medical School North Chicago, Illinois
Megan Keiser, RN, DNP, CNRN,ACNS-BC, NP-C Department of Nursing University of Michigan–Flint Flint, Michigan
John Kenneally, MSW, LCSW University of Wisconsin Hospital Madison, Wisconsin
Daniel Kim, MD Department of Neurological Surgery University of Texas–Houston Houston, Texas
Alison Kirkpatrick, OTR Department of Neurological Surgery
Miller School of Medicine
Lois Pope LIFE Center University of Miami Miami, Florida
Ricardo Komotar, MD Department of Neurological Surgery Miller School of Medicine
Lois Pope LIFE Center University of Miami Miami, Florida
Wendell B. Lake, MD Department of Neurosurgery
University of Wisconsin School of Medicine and Public Health Madison, Wisconsin
John Lee, MD
Physical Medicine and Rehabilitation Cleveland Clinic Foundation Cleveland, Ohio
Elizabeth Lee, RN, GNP, FNP, AANP Department of Neurosurgery Stanford Healthcare Palo Alto, California
Allan D. Levi, MD, PhD Miller School of Medicine University of Miami Miami, Florida
Yiping Li, MD Department of Neurological Surgery University of Wisconsin Medical School Madison, Wisconsin
Dennis T. Lockney, MD Department of Neurological Surgery University of Florida Gainesville, Florida
Karthik Madhavan, MD Department of Neurological Surgery Miller School of Medicine
Lois Pope LIFE Center University of Miami Miami, Florida
Janice Y. Maldonado, MD
Multiple Sclerosis Center of Excellence
Miller School of Medicine University of Miami Miami, Florida
Martha Mangum, ACNP-BC Department of Neurosurgery University of Michigan Ann Arbor, Michigan
Álvaro Martín Gallego Department of Neurosurgery HRU de Málaga Málaga, Spain
Eric Mayer, MD Center for Spine Health Cleveland Clinic Cleveland, Ohio
Cristina Matthews, MSN, FNP-BC Department of Neurosurgery Massachusetts General Hospital Boston, Massachusetts
Chelsie McCarthy Department of Neurological Surgery
Weill Cornell Brain and Spine Center
Weill Cornell Medical College New York, New York
Scott A. Meyer, MD
Atlantic Neuroscience Institute Morristown Medical Center and
Atlantic Neurosurgical Specialists Morristown, New Jersey
Jacques Morcos, MD Department of Neurological Surgery University of Miami Coral Gables, Florida
Praveen V. Mummaneni, MD Department of Neurological Surgery University of California San Francisco San Francisco, California
Contributors
Valli Mummaneni, MD Department of Anesthesiology
University of California San Francisco San Francisco, California
Junichi Ohya, MD Department of Neurological Surgery University of California San Francisco San Francisco, California
Solomon Ondoma, MD
Department of Neurological Surgery University of Wisconsin Medical School Madison, Wisconsin
Christine Orlina Macasieb, ACNP-BC Department of Neurological Surgery University of California San Francisco San Francisco, California
Candice Osuga Lin, RN MSN ACNP-BC Department of Neurosurgery
Stanford Healthcare Stanford, California
Nelson M. Oyesiku Neurosurgery
Emory University Atlanta, Georgia
Paul Park, MD Department of Neurosurgery University of Michigan Ann Arbor, Michigan
Sherri Patchen, ARNP University of Miami Miami, Florida
Nirav Patel, MD, MA Department of Neurosurgery
Brigham and Women’s Hospital Boston, Massachusetts
Valentina Pennacchietti, MD Dipartimento di Neuroscienze Università degli Studi di Torino Torino, Italia
Contributors
Ruth Perez, ARAP
University of Miami Miami, Florida
Laura Ellen Prado, MSN, NP
Atlanta Brain and Spine Care
Atlanta, Georgia
Sharad Rajpal, MD
Boulder Neurosurgical and Spine Associates Boulder, Colorado
Daniel K. Resnick, MD
Department of Neurological Surgery University of Wisconsin School of Medicine and Public Health Madison, Wisconsin
Angela Richardson, MD
Department of Neurological Surgery University of Miami Miami, Florida
Brandon G. Rocque, MD, MS Department of Neurosurgery University of Alabama School of Medicine Birmingham, Alabama
Cathy M. Rosenberg, ARNP Department of Neurological Surgery University of Miami Coral Gables, Florida
Michael Safaee, MD University of California San Francisco, California
Carolina Sandoval-Garcia, MD
Department of Neurological Surgery
University of Wisconsin School of Medicine and Public Health Madison, Wisconsin
Christina Sayama, MD, MPH
Department of Neurological Surgery
Oregon Health and Science University Portland, Oregon
Gregory D. Schroeder, MD
The Rothman Institute
Thomas Je erson University Philadelphia, Pennsylvania
Danial M. Sciubba, MD
Johns Hopkins University School of Medicine Baltimore, Maryland
Katie Shpanskaya, BS
Department of Neurosurgery
Stanford School of Medicine
Stanford Health Center Stanford, California
Kristina Shultz, MSN, NP-C Department of Neurosurgery
Massachusetts General Hospital Boston, Massachusetts
Krishana Sichinga, MHS, PA-C Department of Neurosurgery
Penn State Milton S. Hershey Medical Center Hershey, Pennsylvania
Lauren N. Simpson, MD, MPH Department of Neurological Surgery
Oregon Health and Science University Portland, Oregon
VA Palo Alto Health Care System Palo Alto, California
Christie Stawicki, BS
Thomas Je erson University Philadelphia, Pennsylvania
Jasmin Stefani, FNP-C
Division of Neurological Surgery
Barrow Neurological Institute
St. Joseph’s Hospital and Medical Center Phoenix, Arizona
Gary K. Steinberg, MD, PhD
Department of Neurosurgery
Stanford Stroke Center
Stanford University School of Medicine Stanford, California
Michael P. Steinmetz, MD
Chairman, Department of Neurosurgery
Cleveland Clinic Lerner College of Medicine Cleveland, Ohio
Andrea L. Strayer, MS, AGPCNP-BC, CNRN
Department of Neurological Surgery
University of Wisconsin School of Medicine and Public Health Madison, Wisconsin
Kyle Swanson, MD
Department of Neurosurgery
University of Wisconsin School of Medicine and Public Health Madison, Wisconsin
Laura Sweeney, RN, CRNP Department of Neurological Surgery
Thomas Je erson University Hospital Philadelphia, Pennsylvania
Khoi Than, MD
Department of Neurological Surgery
Oregon Health and Science University Portland, Oregon
Nancy Thomas, PhD, NP Department of Neurosurgery
University of Michigan Ann Arbor, Michigan
Leticia Tornes, MD
Multiple Sclerosis Center of Excellence
Miller School of Medicine
University of Miami Miami, Florida
Gregory R. Trost, MD, FAANS
Department of Neurological Surgery
University of Wisconsin School of Medicine and Public Health Madison, Wisconsin
Luis M. Tumialán, MD
Barrow Neurological Institute
St. Joseph’s Hospital and Medical Center Phoenix, Arizona
Tammy L. Tyree, ACNP
Division of Neurological Surgery
Barrow Neurological Institute
St. Joseph’s Hospital and Medical Center Phoenix, Arizona
Timur M. Urakov, MD
Department of Neurological Surgery
Miller School of Medicine
University of Miami Miami, Florida
Temple University Philadelphia, Pennsylvania Contributors
Alexander R. Vaccaro, MD, PhD
The Rothman Institute
Thomas Je erson University Philadelphia, Pennsylvania
Joli Vavao, MSN, ACNP, CNRN Department of Neurosurgery
Stanford Stroke Center
Stanford University School of Medicine Stanford, California
Nancy E. Villanueva, PhD, CRNP, BC, CNRN Department of Neurosurgery
Jennifer A. Viner, NP
University of California San Francisco, California
Michael Virk, MD, PhD Department of Neurosurgery
Cornell University
New York, New York
Nilesh A. Vyas, MD, FAANS
Inova Medical Group Neurosurgery
Inova Health System Fairfax,Virginia
Kelly Walters, MSN, CRRN, CNP
Cleveland Clinic Foundation
Physical Medicine and Rehabilitation Cleveland, Ohio
Amy Wang, OTR
Department of Neurological Surgery Miller School of Medicine
Lois Pope LIFE Center University of Miami Miami, Florida
Michael Y. Wang, MD Department of Neurological Surgery Miller School of Medicine
Lois Pope LIFE Center University of Miami Miami, Florida
Patrick Wang Department of Neurological Surgery Miller School of Medicine
Lois Pope LIFE Center University of Miami Miami, Florida
Angela Wolfe, ARNP Department of Neurological Surgery University of Florida Gainesville, Florida
PART I Introduction
1
THE IMPORTANCE OF NEUROLOGICAL ILLNESSES, EMERGENCIES, AND TREATMENTS
S. Shelby Burks and Michael Y. Wang
Many neurological illnesses are debilitating, but within the discipline of neurosurgery there is a broad range of pathology. In a large majority of instances patients under the care of the neurology or neurosurgical service are going through one of the most impactful events in their lives. Families and patients will depend on vigilant providers to walk them through this complex landscape. The “high stakes” conditions that come with neurosurgical diseases stem from the unforgiving nature of the nervous system and its crucial role in human function. Understanding the nuances of such critical situations will make an enormous di erence to patients seen in the emergency room, intensive care unit, hospital oor, and even outpatient setting. Currently, the largest expansion of providers in this area has been advanced practitioners, primarily nurse practitioners and physician assistants. For this reason, the practitioner treating these patients may need to be especially knowledgeable, vigilant, and compassionate.
A review of some common neurological and neurosurgical conditions is informative:
• Patients with severe traumatic brain injuries have high rates of mortality, up to approximately 40% in some series (Rosenfeld et al., 2012). In the acute setting, a failure to recognize an intracranial hematoma can lead to a vegetative state or death (Figure 1.1).
• After trauma, plain cervical spine radiographs can miss spinal fractures in up to 15% of cases (Gri en et al., 2003). Failure to order three-dimensional imaging such as a computed tomography (CT) scan or to use a detailed clinical examination to evaluate the patient can lead to a missed diagnosis and loss of neurological function, including paralysis (Figure 1.2).
• The concept of a “Stroke Alert” or “Brain Attack” was developed to emphasize the importance of rapid action when neurological tissues are at risk. Opportunities now exist with endovascular therapy and intravenous “clot busting” thrombolytics to provide blood supply in the setting of ischemic stroke. It has been shown that for every 3.2 patients treated emergently, one will have regained functional independence as a direct result of the intervention (Campbell et al., 2015). Hemorrhagic strokes also may require emergent treatment to stop active bleeding or to relieve elevated intracranial pressure (Figure 1.3).
• New-onset seizures in the middle-aged patient with headaches (consistent with elevated intracranial pressure) are often a presenting feature in primary or metastatic brain tumors (Figure 1.4). Many of these patients will go on to require surgery and adjuvant treatments. However, all will require intensive and balanced discussions through the process of achieving a diagnosis, formulating a treatment
Figure 1.2 This 82-year-old man fell and su ered a C2 fracture of the odontoid. Failure to recognize it led to increasing instability and eventual partial quadriparesis due to compression of the spinal cord.
plan, and executing upon it. Many of these neoplasms, such as a glioblastoma, are uniformly aggressive and fatal.
• Traumatic spinal cord injuries are particularly devastating, largely because young, active males in the prime of their lives are the most commonly a ected (Figure 1.5). In cases of cervical cord injury, the chance of conversion by at least one American Spinal Injury Association (ASIA) Grade is nearly 60% but the timing of spinal cord decompression plays an important role in optimizing recovery (Fehlings et al., 2012). Neurosurgical teams must work to get the patient to the operating room quickly and safely in order to impact outcomes.
Figure 1.1 A patient undergoing an emergent craniotomy to evacuate a hematoma from head trauma.
Figure 1.3 A patient with a cerebellar hemorrhage causing obstruction of the ventricles with acute hydrocephalus requiring emergent ventricular drainage to relieve life-threatening intracranial pressure.
Figure 1.4 A 52 year old who developed seizures and personality changes was found to have this large right frontal extra-axial brain tumor with compression of the brain and surrounding edema.
These facets of neurological and neurosurgical care have led to the concentration of specialization at tertiary care centers. In fact, one of the major di erentiators in the designation of a level I trauma center versus a level II trauma center is the availability of 24-hour emergency neurosurgical care.
The formation of specialized treatment centers in the university setting has been the result of an increasing awareness of the disproportionate burden of neurological conditions on an ever aging population. Alzheimer’s disease, Parkinson’s disease, degenerative spinal arthritis, and peripheral nerve disorders all increase with age and have a disproportionate social, economic, and psychological impact on patient populations. The concentration of clinical expertise, basic research labs, and clinical trials in speci c centers a ords an economy of scale.
There are numerous impediments to neurological and neurosurgical care, including
• The need for highly trained personnel at all levels of the medical team
• Dependency on expensive capital equipment
• Specialized training of nurses, therapists, and ancillary support personnel to recognize and respond appropriately to nonintuitive clinical symptoms and signs
• Intensive rehabilitation programs and facilities
• Dedication to this challenging but rapidly advancing arena of medicine
In the practices of neurology and neurosurgery, the impact on the lives of patients and their families quickly becomes clear. This is especially pronounced in the situations mentioned above. Caring for these patients uni es practitioners and is extremely rewarding but requires dedication and e ort.
Figure 1.5 An 18-year-old male who fell from a tree and su ered a C5 fracture and accompanying ASIA Grade A (complete quadriplegia) spinal cord injury.
Common pitfalls and medicolegal concerns
• Trusting the neurological exam by those unfamiliar with neurosurgical patients
• Finding a balance between swift and thorough care
• Recognizing secondary gain in the patient
• Advising the patient and his or her family of the risks associated with a particular procedure and con rming understanding
Relevance to the advanced practice health professional
Seamless communication between members of a neurosurgical team improves patient safety and outcomes. Understanding the importance of neurological illnesses, emergencies, and treatments allows the advanced practitioner to provide prompt attention and consider the potential disasters.
References
Campbell BC, Donnan GA, Lees KR, et al. Endovascular stent thrombectomy: the new standard of care for large vessel ischaemic stroke. Lancet Neurol. August 2015; 14(8):846–854.
Fehlings MG, Vaccaro A, Wilson JR, et al. Early versus delayed decompression for traumatic cervical spinal cord injury: results of the Surgical Timing in Acute Spinal Cord Injury Study (STASCIS). PloS One. 2012;7(2):e32037.
Gri en MM, Frykberg ER, Kerwin AJ, et al. Radiographic clearance of blunt cervical spine injury: plain radiograph or computed tomography scan? J Trauma. August 2003;55(2):222–226; discussion 226–227.
Rosenfeld JV, Maas AI, Bragge P, Morganti-Kossmann MC, Manley GT, Gruen RL. Early management of severe traumatic brain injury. Lancet. September 22, 2012; 380(9847):1088–1098.
2
NEUROLOGICAL DECOMPENSATION AND EMERGENCIES
Nirav Patel and Bianca Belcher
Decompensation and emergencies
We believe identifying and managing emergencies and neurological decline are among the most important skills for anyone taking care of neurologically injured patients; it is Neurosurgery 101, but this can take time to master. This short list of emergencies will serve you well when things go badly, and they will go badly.
We have to trust our examination, and that of our colleagues, especially in this day of hand-o s. For example, when the sign-out was “moving all fours” through the night, but the patient’s left arm is weaker on morning rounds, we must believe this is a change that needs to be pursued right away. Furthermore, we should take exam changes seriously, ruling out the worst etiologies rst, rather than attributing a change to a benign reason, such as “not sleeping well” or “maybe we should just give him time.”
It is important to stay exible in one’s mind about the diagnosis of a patient when the patient’s exam is changing. It is important to reevaluate a working diagnosis, even though it may be endorsed by others or in the chart since admission.
The emergencies listed below need swift, correct diagnosis and proper action. The exact etiology can be worked out later, since many etiologies converge in a common pathway of emergency (e.g., hematoma, brain tumor, and hydrocephalus if untreated lead to herniation). For this reason, we have listed the emergency, how it may present, and options for management, as well as provided a short explanation next to the recommendations. When called about a change, I ask myself, “What’s the worst mistake I can make here?” This way, I can rule out the life-threatening issues rst.
“Need to know neurosurgical emergencies”
Brain herniation and coma
Herniation and coma happen when a mass (blood, cerebrospinal uid [CSF], or tumor) is pushing on the brain causing dysfunction. The mass e ect may force the brain to herniate out of a dural opening since the skull is unable to expand to accommodate the mass.
Red flag physical findings
• Motor changes such as hemiparesis due to compression of internal capsule.
• Pupillary changes due to compression of the third nerve against the tentorium.
• A decline in consciousness due to brainstem compression; may be subtle early in herniation and appear as confusion, or even anxiousness.
Treatment
• Elevate the head of the bed to greater than 30°.
• Reason: By increasing venous out ow, there is a decrease in intracranial pressure (ICP).
• Osmotics: Administer mannitol 1 g/kg IV bolus (or 100 g as a rough dose) put in fast or 10–20 mL of 23.4% saline or give a bolus of 3% (250 mL) if the patient is hypotensive and mannitol is a less optimal choice.
• Reason: These agents pull water out of the brain by increasing serum osmolality (OSM), which decreases ICP.
• Intubation and hyperventilation: The herniating patient will not be able to protect his or her airway and will have irregular breathing. Taking the PCO2 to 25 is a short-term measure to decreased ICP as it constricts blood vessels.
• EVD: Placing a drain into the lateral ventricles will allow you to remove CSF, which will immediately decrease force on the brain by taking volume out of the skull.
• Sedation with propofol bolus, midazolam, and/or paralytics: These reduce metabolic demand.
• Pentobarbital 500 mg IV bolus: This medication is used to help get the patient to the operating room or to the computed tomography (CT) scanner.
• Reason: It decreases metabolic demand of the brain, increasing cells’ ability to survive with less blood ow or high ICP and acts directly to stabilize the cell membrane. It also leads to burst suppression on an electroencephalogram (EEG).
• Surgical decompression: Surgery can directly address herniation by relieving the rigid skull or by removing mass from inside the skull (brain, tumor, blood, or CSF).
Brain herniation is the most urgent neurosurgical emergency. It should be treated with the same urgency as a myocardial infarction or hypotensive shock. It requires immediate action as the patient has minutes until irreversible damage or death occurs. Remember that the CT scan does not treat herniation or ICP.
Often a patient’s exam can be confounded or limited by sedating medications or paralytics, often right after being intubated. In these cases, one can rely more on pupillary ndings (very few medications will dilate pupils) and imaging. Initial aggressive treatment should be considered rather than possibly missing the chance to treat at all. This concept can also be applied to younger patients with poor exams at presentation. We favor treating them aggressively to give them the best chance of survival rather than attempting to predict prognosis at such an early stage (Figures 2.1 and 2.2).
Figure 2.1 Sagittal CTA, a 20 year old with intracerebral hemorrhage from a posterior fossa arteriovenous malformation (AVM), found in dense coma. Note how the posterior inferior cerebellar artery (PICA) around the tonsil sags well below the foramen magnum. This illustrates tonsillar herniation.
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He goes each morning to the barn and helps his good friend Pat
To catch the naughty rodents, who are called the name of RAT.
The cook she feeds him daily, and he captures all the mice,
Which love to haunt the kitchen of the cleanly Bridget Bryce.
While little Mikey loves dear Kent far more than all his toys,
And says he'd rather play with him than any girls or boys,
Because he never minds a bit to jump right in the pond
And bring to land a stick or stone or weeping willow wand.
He always acts politely to all who may come near,
And so all strangers pet him and think he is a dear.
They like his soft and silky hair, which proves he has good blood,
And never does he make folks mad by tracking floors with mud.
He's wiser than most common dogs, whose hair is rough and coarse,
His bark is always pleasant, and 'tis never loud nor hoarse;
He's swifter also than slow dogs who cannot catch a rat,
Because they always eat too much and get so very fat.
MORAL.
This story proves that good, pure blood is a fine thing to own,
But it can't help the puppies or the children all alone,
Unless these youthful puppies and the children, very small,
Learn to keep quite busy and to have a smile for all.
Too ticklish to Count His Ribs
(Written for Richard Montgomery, Erie, Pa.)
In the class of physiology the teacher asked one day, How many ribs have you, my boy, tell me, Dickie Gray?
And wiggling, giggling Dickie very promptly made reply, "Dear teacher, I must tell the truth, for I could never lie, But as for ribs I cannot say how many I possess, For I'm too awful ticklish to count them, I confess."
The Young Mail Carrier
(Written for Mr. and Mrs. W. F. Wocher, Indianapolis, Ind.)
Young Billy from his lovely home disappeared one day,
And when his mother missed her lad she thought he'd run away,
But soon the sprightly little chap came quickly running back,
Bearing on his shoulders small, a large round leather sack,
And said, "Dear mother, I have been a very good, kind boy,
Trying like the Bible says, to bring our neighbors joy.
I played I was a postman and I paid each one a call, And to the people in this block, I gave them letters, all."
MOTHER: "But where, my precious little lad, my darling, honey pet,
Where in the name of goodness these letters did you get?"
BILLY: "I found them with no trouble; they were the ones that you
Kept in your top bureau drawer, all tied with ribbons blue."
On Thanksgiving
Before you eat good turkey, rich mince and pumpkin pies
On that great feast or feast days when "tum-tums" grow in size,
The good old day THANKSGIVING, the best day in the year,
When all should be so thankful around the board of cheer, Then don't forget the poor ones, the hungry, cold and sad, Go fill their empty tables and make the whole world glad.
Living Valentines Presented By Cupid
Written February, 1909, for an entertainment at St. Paul's Episcopal Sunday School, Evansville, Ind.
CUPID: "I'm glad to see you all to-night, And it will give my heart delight
Some lovely valentines to show And make you wish you had a beau." (SHOWS BOW.)
FIRST PICTURE—A SUNBONNET BABY.
CUPID: "Here's a little baby fair, But you can't see her face or hair."
BABY: "I'm some one who loves you (POINTING AT AUDIENCE).
Can't you guess who?"
SECOND PICTURE—BOY WEARING A LARGE HAT AND WITH BACK TURNED TO THE AUDIENCE.
CUPID: "Here's another, called 'GUESS WHO,'
Come to say, 'How do you do.'"
BOY: "I'm for my own dear valentine.
Guess me and I'll be thine."
THIRD PICTURE—HEART'S DELIGHT
CUPID: "This is Heart's Delight, Look at her face, so beaming bright."
HEART'S DELIGHT: "If you love me, oh, my dear, This is how I will appear." (SMILES AND SINGS A SONG.)
FOURTH PICTURE—HEART'S SORROW.
CUPID: "Watch this poor aching heart of sorrow, He'll cry all day and perhaps to-morrow.
HEART'S SORROW: "If you do not love me, dear,
This is how I will appear."
FIFTH PICTURE—TWO JAPS.
CUPID: "Allow me the pleasure to show to thee
A very sweet picture from over the sea."
THE JAPS HOLD FANS IN FRONT OF FACES AND SING:
"Jap a ling a ling, Jap aling a lee,
You're my Jappie baby,
If you lovee me as I lovee you
No knife can cut our love in two."
CUPID: "I'll tell you what they said, I'm sure they mean to wed.
Cho, cho, cho, cho, nano hagi tomare
Nano haga eyay nawraw teni tomare.
Dai dai mushi, dai dai mushi
Tsuno chitto dashare
Ame kaze foku kara tsuno chitto dashare."
SIXTH PICTURE—FRENCH VALENTINE.
CUPID: "Now I'll show you a lady from far away France
Who says, 'Parlez-vous' and knows how to dance."
FRENCH VALENTINE: "Je vous aime, je vous adore
Que voulez-vous de plus encore?"
FRENCH VALENTINE DANCES.
SEVENTH PICTURE—GERMAN VALENTINE.
CUPID: "This is a lady who wants a beau, In her own language she'll tell you so."
GERMAN VALENTINE: "Ich liebe dich, lieben sie mich?"
EIGHTH PICTURE—COMIC VALENTINE.
CUPID: "This a comic, to make you smile, And keep you good humored a little while."
COMIC, HOLDING A LARGE GRAVY SPOON IN ONE HAND, YELLOW MOON IN OTHER.
"Of all earthly joys, I love best to spoon With thee, oh, my darling, 'neath the light o' the moon."
NINTH PICTURE—ANOTHER COMIC.
CUPID: "Another comic will now appear, I hope that you his plea will hear."
BOY DRESSED IN RIDICULOUS COSTUME, KNEELING AND HOLDING A CARDBOARD HEART:
BOY: "My heart is thine, my soul is thine,
Won't you be my valentine?"
TENTH PICTURE—THE OLD-FASHIONED VALENTINE.
CUPID: "The pleasure now, dear friends, is mine, To show you one more valentine. This is my dear sweet valentine, Sent to us from 'Ye olden time.'"
GIRL DRESSED IN OLD-FASHIONED COSTUME:
"I am an old-fashioned dame, But I love you just the same."
CUPID: "And I am an Esperanto valentine, For me dear friends, you all should pine.
Karulin' mi amas vin, Chu vi amas, amas min?
Kaj nun mi deziras vin
Estu mia valentin'!"
[AUTHOR AT FOUR YEARS OLD]
Universal Peace
(Written for Mr. Charles Randall, Seattle, Washington, (Mia Onklo Karlo.)
[ N EATA Y —N . M K ESPERANTO...K ]
Not long ago, Sir Wu Ting Fang, A song of peace most sweetly sang, Suggesting that the Pension Millions, Given yearly will be billions
Unless all wars be made to cease
By a Tribunal ruled by "PEACE."
But good Sir Fang he did not go Far off to Hague or else he'd know
That Peace Tribunals bring not "PEACE,"
Nor cause all bloody wars to cease; As every man from each strange land
All other men can't understand E'en when the learned GO-BETWEEN
Tries to explain and makes a scene.
Of mighty sword and mightier pen
Poets have sung time and again,
But they forgot in songs they sung
To praise the power of a COMMON TONGUE, And ne'er will banners of PEACE be unfurled 'Till ESPERANTO rules over the world.
All The World Cries
(Written for Katherine Wellman, Evansville, Ind.)
"Quack-quack-quack-quack!" cries Auntie Duck, While Mother Hen goes "Cluck-cluck-cluck!"
And Papa Dog cries, "Bowwow-wow," And Sister Cat, "Me-ow, me-ow!"
