> Hyperventilation to PCO2 between 25-30 will decrease ICP but
> peaks at 8 minutes and is only effective in the acute phase.
> I don't know how this correlates to a "CO2"
4 kPa is about 30 mm Hg.
> So, while contacting an ambulance and the neurosurgeon and
> while ordering the mannitol I would also prepare to perform a
> burr hole on this patient. If she did not show rapid
> improvement after the mannitol I would rather her die having
> attempted a potential lifesaving procedure in my care than
> have her die without one.
>
Certainly one option. Burr hole may be life saving. On the other hand it may
delay definitive neurosurgical treatment and may be fatal in itself (how
confident are you that you can deal with a major bleed from the meningeal
vessels. A bit of a judgement call. Personally (probably like the great
majority of Emergency Physicians or whatever we're calling ourselves these
days) I lack the experience in this type of case to make that call and would
rather have the advice of a neurosurgeon (possible with someone getting the
kit ready while I'm on the phone). I'd follow the advice of the
neurosurgeon.
You're assuming that the patient is coning, presumably on the basis of
obliteration of one lateral ventricle and bradycardia. No pupillary
abnormality has been noted and there was no evidence of raised intracranial
pressure on fundoscopy. These are pointers but insufficient to make the
diagnosis in themselves (I've seen patients with obliteration of one
ventricle with little disturbance of conscious level; there are a lot of
other causes of bradycardia). Remains a bit of a judgement call. At the very
least I'd have another good look at the fundi and pupils before I got my
knife out.
>
> I am not suggesting several burr holes or a craniotomy be
> performed in the emergency department. We know where the
> blood has accumulated. The patient will need a craniotomy
> regardless of whether she receives a burr hole in the ED or
> not, IF she makes it to the neurosurgeon alive, which is our goal.
The trouble with your single burr hole approach is that as far as I can
remember from my time in neurosurgery, you can't usually evacuate (or often
significantly decompress) an extradural through a burr hole- they don't
drain much until you do the craniotomy. Subdural, not a problem, but this
has been confirmed on CT as mainly extradural.
Matt Dunn
Warwick
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