My Elective in Neurosurgery

So I am about to embark on my elective rotation - Neurosurgery. I can't wait. I am lucky enough to be doing my elective at a Level 1 Trauma Center in a Neurosurg Dept that does not have residents. This means that PAs get to DO a ton (first assist on surgeries, do most of the on-floor procedures, etc). In honor of my elective I wanted to post something with a neurosurgical flair...

Neuro Trauma - Notes on Initial Assessment

• Standard ABC
• -Blood pressure
• -Oxygenation
• GCS
• Pupil exam
• Motor Strength

*Pay special attention to hypOtension and hypoxia for the following reasons:

• HypOtension = doubles mortality
• Hypoxia = increases mortality
• Both = 3x increase in mortality

AGGRESSIVELY RESUSCITATE

*HypOtension is rarely attributable to head injury (I will not go into the few exceptions to this.)

Neurogenic Shock:

• Occurs in Spinal cord injuries above T1
• Due to interruption of sympathetics

o    Loss of vascular tone below the level of injury – incidence increases with injuries above T6

•       Parasympathetics are unopposed

o    Bradycardia

o    Venous pooling

o    Lower systemic vascular resistance 

Initial Survey in Neurotrauma:

• Look for injuries to head, spine, eyes, TMs, and CSF leaks

Cranium:

•        Look for basilar skull fx (NEVER insert NG tube if basilar fx is suspected!)

o    Raccoon eyes

o    Battle sign

o    CSF rhinorrhea/otorrhea

o    Pts describe salty or metallic taste

o    Collect fluid: quant glucose/beta2 transferrin (Ring sign at bedside)

•        Look for facial fx

o    Lefort fx

o    Orital rim fx

•       Periorital edema
•       Cranio-cervical auscultation

o    Auscultate over the globe of the eye: bruits my indicate traumatic C-C fistula

o    Auscultate over the carotid a.

GCS: GCS of 8 or less = coma

SERIAL ASSESSMENT NEEDED!

Source: The Society of Neurological Surgeons - "Neurological and Neurotrauma Assessment" 

http://www.youtube.com/watch?v=I_JCg8DHO2o&feature=channel&list=UL
Photo: http://www.thebarrow.org/Neurological_Services/Neurotrauma/index.htm