> She is about to
> be scanned, when she suddenly develops a sinus bradycardia.
> Scan reveals a massive hyperacute
> extradural which fills all the temporal region on the
> left and extends right up to the vertex.
> There is marked midline shift, and the right lateral
> ventricle has been obliterated. Neurosurgery is in
> another hospital 30 miles away.
>
> What is happening?
>
> How do you manage her now?
>
>
>
> She is herniating and will need an emergent burr hole prior
> to transfer to Neurosurgery, otherwise I fear she won't
> survive the trip.
>
Call your neurosurgeon first on this one. Burr holes great in subdurals.
Extradurals often have clots present (so you can sink a lot of burr holes
before you drain them). Then when you get in the bleeding doesn't stop. If
you're doing burrholes, do you want to do a craniotomy?
Bradycardia may mean she's coning but doesn't always- bit of a problem if
you've got a patient who would survive with appropriate surgery, went
bradycardic because of stomach full of beer and died because you did an
operation where you were out of your depth. Your chances of being able to do
anything useful with something as simple as a burr hole are pretty low. Not
many surgeons around these days up to date with neurosurgery. Certainly with
an extradural I'd be happier with an OK from a neurosurgeon to go ahead
before I put drill to bone; and one on the other end of the phone during the
operation. From memory, your 30 miles is mainly on fast roads (depending on
time of day) and there is scope for aero evac so you might be able to shift
her fast.
> Things are happening too fast to look
> in pupils and so on, and she has to be scanned and sorted
> later.
In these circumstances I might have considered the bradycardia a reason to
hurry up and get on with the scan- if a patient deteriorates, try to
diagnose and sort out treatable causes rather than pharmacologically
temporarily altering physical parameters in the hope that they'll get
better.
Consider diuretics, hypertonic saline and mannitol (depending on flavour of
the month with the neurosurgeons). Hyperventilate to CO2 of 4. Don't mess
around with anything fancy- get neurosurgical advice, get her operated on.
You did say PT was normal, didn't you? But, in case I've not made my point
clear, don't sink burr holes without neurosurgical advice- they may buy you
less time than mannitol (down to opinion rather than evidence) and have
higher risks attached.
Matt Dunn
Warwick
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