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Tuen Mun Hospital Neurosurgical Department



Guideline for the management of common neurological conditions

A. Head injury
B. Principles of treatment of raise ICP
C. Intracerebral haematoma (haemorrhagic stroke)
D. Intraventricular haemorrhage
E. Subarachnoid haemorrhage
F. Brain abscess
G. Acute hydrocephalus
H. Brain tumour
I. Status epilepticus
J. Management of EVD / ICP monitoring catheter
K. Perioperative managment
L. Pre op antibiotics
M. Post op conditions
N. Commonly used drugs
O. Ventilator support


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Inadequate or unreliable history or suspicious of child abuse

P Management
Anticonvulsant (e.g. Dilantin loading 15mg/kg slow iv in
20mins)
Preoperative antibiotic (e.g. Rocephin 2gm IV on induction,
Paediatric 50mg/kg IV)
Mannitol if required (e.g. 0.5gm/kg IV bolus / 2.5ml 20% per kg
IV)
Consider repeat CT brain 6 hours after the first CT to follow up
progress of lesion

& Skull Fracture
P Higher risk of intracranial injury
P Compound linear fracture
Early surgical toilet and suturing in clean ward setting / OT
Consider antibiotics if heavily contaminated wound
P Depressed fracture
Formal debridement craniectomy in OT
a) Depression > thickness of skull
b) Deficit related to underlying brain
c) CSF leakage
d) Compound depressed fracture
Elevation unless close to venous sinuses and no indicat ion to
surgery
& Spinal Injury
P Acute trauma life support
Airway and Breathing: if intubation required, immobilize cervical
spine during the procedure
Circulation: Treat spinal shock with adequate hydration and
vasopressor
P Immobilization of spine
P Assessment of concomitant injury
P Assessment of neurological condition
P Arrange CT spine / MRI spine
P Catheter insertion
Nasogastric tube for paralytic ileus
Foley catheter for fluid and perfusion status monitoring and
possible urinary retention
P Treat hypothermia if present due to vasomotor paralysis
P Methylprednisolone therapy:
Should be given < 8hrs after injury
Dilute 16gm in water for injection to 256ml (62.5mg/ml)
Initial bolus: 30mg/kg over 15 minutes
Then 45 minutes pause
Then 5.4mg/kg/hr continuous infusion for 23 hrs
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C. Intracerebral Haemorrhage (Haemorrhagic Stroke)
& Urgent CT scan is indicated for all patients suspected to have haemorrhage
stroke
& AED colleague may initiate Stroke Call! when a patient with suspected
haemorrhagic stroke is admitted. We should go down to AED to assess the
patient and to determine whether urgent neurosurgical intervention is
required
& Calculation of clot volume by CT
- Modified ellipsoid volume = (AxBxC)/2
(where A,B,C are the diameters of the clot in each of the 3 dimensions.)
& Initial management
P Control excessive hypertension, avoid over treatment or large
fluctuation of BP. If SBP > 200mmHg or DBP >120mmHg, start
antihypertensive therapy
BP Treatment
SBP > 230mmHg or
DBP > 120mmHg
Sodium nitroprusside (0.5-10ug/kg/min)
Or nitroglycerine drip (at 10-20ug/min)
SBP > 180mmHg or
DBP >105mmHg
10mg labetalol IV push. May repeat or
double dose every 10-20 min to max of
300mg (or labetalol as bolus then start
drip at 2-8mg/min)
P Check and correct platelet and coagulation profile, reversal of
anticoagulation
P Anticonvulsant: Dilantin 4-7mg/kg/day IV Q8H (average 100mg IV
Q8H in adult)
P Intubate and hyperventilate if stupor or comatose to protect airway and
prevent hypercapnia
P Mannitol or Lasix can be used in the preparation of surgery, foley
catheter should be inserted for urine output monitoring
P Check and correct electrolytes disturbance (look out for SIADH)
P Angiogram is recommended when there is suspicious of
non-hypertensive causes
& Favorable factors for surgical intervention
P Lesions with marked mass effect, edema or midline shift for potential
herniation
P Lesion with symptoms appear to be due to increased ICP or to mass
effect from the clot or surrounding edema
P Moderate volume of blood clot (i.e. 10 # 30ml according to CT
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P Flush with 5-10ml of NS for the dead-space
P The clamp is released after 60 minutes allowing free drainage
P Instillation is repeated every 12 hours
P CT brain is performed for following up the progress



E. Subarachnoid Haemorrhage
& Nearly 80% of spontaneous SAH is caused by intracranial aneurysms. Treat
spontaneous SAH unless proven otherwise by angiogram
& Trauma is the most common cause of all SAH
& Aneurysmal SAH
P 10% died before reaching hospital
P Rebleeding and vasospasm are the major cause of mortality and
morbidity for those survived the initial bleeding
P Overall, about 50% patient die within the first month of first bleeding
P ~ 66% of those who have successful aneurysm clipping never return to
the same quality of life as before the SAH
& Investigations
P CT Brain
95%of cases can be detected if done within 48 hours
High density within subarachnoid spaces
Also assesses hydrocephalus, other haematoma, infarction and
amount of blood in subarachnoid space
P Lumbar puncture
Most sensitive test for SAH
N Caution: lowering of CSF pressure may precipitate rebleeding
Elevated opening pressure with non-clotting blood-stained fluid
that does not clear with sequential tubes
P Cerebral Angiogram
Demonstrates source of bleeding in 80-85% of cases
Study the vessel of highest suspicion first. If time allowed,
complete 4 vessel angiogram should be done to rule out additional
aneurysm and assess collateral circulation
& Grading of SAH
P Hunt and Hess Grading
Grade Description
1 Asymptomatic, or mild headache and slight nuchal rigidity
2 Cranial nerve palsy (e.g. III, VI), moderate to severe headache,
nuchal rigidity
3 Mild focal deficit, lethargy or confusion
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P Consult Orthopaedics for stability
B. Raised ICP
& Indication of ICP monitoring
P Moderate to severe head injury (GCS <=8)
P Potential deterioration foreseen in CT
P When GCS monitoring impossible and patient is suspicious of raised
ICP (e.g. sedated head injury patient with ventilatory support)
& Treatment aim: maintain ICP below 20-25mmHg and keep CPP > 70mmHg
& Measures controlling ICP
P Positioning
Elevate head by 30-45 degrees if BP stable
Keep jugular vein patent by proper position of head
P Avoid hyperglycaemia
P Aggressive control of fever e.g. hypothermic bed, tepid sponging, rectal
aspirin 1 tab PR Q6H
P Sedation e.g. Dormicum 1-3mg/hr IV infusion (~30mcg/kg/hr) for a
50kg patient with supplementary Morphine / Valium
P Neuromuscular blocker e.g. Nimbex (Cisatracurium) 1-3mcg/kg/min
P Hyperventilation: keep pCO2 3.5 - 4.0 kPa (avoid hypercapnia)
P Osmotic therapy
Mannitol 0.5-1gm/kg bolus
Lasix 10-20mg Q6H (1mg/kg maximum 6mg in Paediatric
patients)
P CT to look for SOL e.g. Haematoma and consider surgical removal
P CSF drainage i.e. EVD
P Craniectomy $ Lobectomy
& Other treatment
P Close monitoring of BP and fluid status, arterial line $ Swan-Ganz
catheter if required
P Support BP to maintain CPP with inotropes and vasopressors
P Adequate hydration preferably with CVP guidance
P H2 antagonist e.g. Zantac 50mg IV Q8H







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A. Head Injury
& Primary injury: Damage to brain during the impact
& Secondary injury:
P Hypoxia
P Hypercapnia
P Intracrainal secondary bleeding
P Extracrainal bleeding causing hypotension

& Aim of management: Prevent secondary injury
P ABC
Intubation by anaesthetist with mechanical ventilation if patient
not in full consciousness state with clinical risk of upper airway
obstruction or aspiration
Stop external bleeding
Maintain Cerebral Perfusion Pressure (CPP) 70mmHg by
keeping arterial BP
Replace intravascular by crystalloid, colloids or blood products

P Assessment of concomitant injuries
Cardiothoracic and abdominal injuries always take priority
Always look for spinal injury

P Assessment of neurological condition
GCS score
Pupils size, gaze deviation
Limbs weakness
Tendon jerk reflexes
Sphincter function (in case of spinal injury)

P Investigation (after stabilization and preliminary assessment)
Indications of CT brain: (aim is to look for intracranial pathology or
skull fracture)
Depressed level of consciousness after injury
Focal neurological deficit
Progressive headache
Alcohol or drug intoxication
Post-traumatic seizure
Post-traumatic amnesia
Repeated vomiting
Multiple trauma
Serious facial injury
Signs of skull base fracture
Significant subgaleal swelling
Possible penetrating skull injury or depressed skull fracture
Age < 2 (unless trivial injury)
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4 Stupor, moderate to severe hemiparesis, early decerebrate reigidity
5 Deep coma, decerebrate rigidity, moribund appearance
Modified classification adds the followings:
0 Unruptured aneurysm
1a No acute meningeal/brain reaction, but with fixed neurological deficit


WFNS Grading
WFNS grade GCS score Major focal deficit
0
1 15 -
2 13-14 -
3 13-14 +
4 7-12 + or -
5 3-6 + or -

& Initial management

P NPO (if prepared for surgery or unconscious)
P Vital sign, neuro-observation Q1H
P Bed rest, pop-up 30 in bed
P Strict I/O
P IVF NS + 20mmol KCl/L Q4H
P Oxygen supplement (try to maintain normocarbia in intubated patients)
P Blood for CBP, R/LFT, Clotting profile, ABG, Cross-match
P CXR
P Foley if required
P Prophylactic anticonvulsant e.g. Epilim 400mg IV Q8H
P Nimotop 0.5mg-2mg per hour IV infusion. Omit if SBP 110mmHg
P Analgesic e.g. Tramadol 50mg IM Q6H prn
P H2 blocker e.g. Zantac 50mg IV Q8H
P Antiemetic e.g. Stemetil
P Beware of DVT with appropiate prophylaxis

& Vasospasm
P Delayed ischemic neurological deficit
P Usually onset on D4 to D12 post bleeding
P Clinically characterized by confusion or decreased level of
consciousness with focal neurological deficit
P Look for other causes of deterioration in case suspecting vasospasm
Hydrocephalus
Cerebral edema
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findings)
P Persistent raised ICP
P Rapid deterioration
P Favorable lesion location
Lobar, Cerebellar, External capsule, Non-dominant hemisphere
P Young patient (esp. Age < 50)
P Early intervention following haemorrhage (i.e. < 24hours)
& Favorable factors for medical treatment
P Minimally symptomatic lesions
P Poor chance of good outcome
Massive haemorrahge with significant neuronal destruction
Large haemorrhage in dominant hemisphere
Poor neurological condition i.e. GCS 5 or loss of brainstem
reflexes
P Severe coagulopathy or other significant underlying medical disorders
P Very elderly patients (Age > 75)
P Deep haemorrhage e.g. putaminal or thalamic
& Cerebellar haemorrhage
P GCS 13 and haematoma 4cm diameter: surgical intervention
P Absence of brainstem reflexes and flaccid quadriplegia: not indicated
for intensive therapy


D. Intraventricular Haemorrhage
& Initial management
P Control excessive hypertension, avoid over treatment or large
fluctuation of BP. Try maintain SBP ~ 180mmHg and DBP ~
105mmHg (or MAP to premorbid level if known)
P Check and correct platelet and coagulation profile, reversal of
anticoagulation
P Anticonvulsant: Dilantin 4-7mg/kg/day IV Q8H (average 100mg IV
Q8H in adult)
P Intubate and hyperventilate if stupor or comatose to protect airway and
prevent hypercapnia
P Consider EVD thrombolysis in selected patient
& Thrombolytic therapy through EVD
P Strict aseptic technique
P Clamp EVD before instillation
P Urokinase 20,000 units is instilled into ventricle through the EVD
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Seizure
Hyponatriaemia
Hypoxia
Sepsis
P Prevention
Adequate post-SAH hydration (at least 2.5-3L/day)
Prevent anaemia


P Treatment
Nimotop: not counteracting vasospasm but may provide
neuroprotective effect
Hyperdynamic therapy:
Monitoring urine output with Foley catheter, BP with arterial
line
Volume expansion aiming at CVP around 8-12cmH2O
Transfuse blood if Hct < 40%
BP support with pressors e.g. dobutamine, dopamine or
phenylephrine, aiming SBP to be 15% increments
Proceed to CT when there is no improvement
Angiographic treatment (No improvement of neurological
condition by hyperdynamic therapy and after CT brain)
Balloon angioplasty
Intra-arterial papaverine


F. Brain Abscess
& Vectors
P Haematogenous spread e.g. lung abscess, congenital cyanotic heart
disease, bacterial endocarditis, dental abscess
P Contiguous spread e.g. purulent sinusitis, middle ear and mastoid air
cells infection
P Penetrating cranial trauma or neurosurgical procedure (required
surgical debridement to remove foreign matter, simple aspiration not
able to treat)
& Pathogens
P Sterile up to 25%
P Streptococcus is the most frequent pathogen
& Presentation
P Non-specific, fever might or might not appears (around 50% of cases)
P Symptoms of increase ICP e.g. headache, nausea, vomiting, lethargy
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Flagyl (adult 30mg/kg/d in divided doses q12h/q6h, not to exceed 4g/d. Paed
15mg/kg q8h)
P change Penicillin G to Vancomycin if MRSA suspected (adult 1g iv
q12h. Paed 15mg/kg q8hr)
P iv antibiotics for 6-8weeks +/- oral antibiotics after iv course
P Anticonvulsant
P Steroid for edema/marked mass effect under adequate antibiotic cover
(steroid reduce penetration of antibiotics into abscess, but can reduce fibrous
encapsulation of abscess)
P Investigation for primary source



G. Acute Hydrocephalus
! A surgical emergency
& Deterioration can be very rapid (in hours). Timely surgical intervention is
important.
& Clinical symptoms and signs
P Headache, nausea and vomiting, diplopia
P Neck pain
P Deterioration in conscious level
P Pupil dilatation (late sign)
P Decorticate / decerebrate posture (late sign)
& CT findings #
size of both temporal horns is >/=2mm in width
Largest width of the frontal horns is more then 50% of the internal
diameter (= distance between inner tables of the skull at the same
coronal plane of the largest width of the frontal horn)
the sylvian and interhemispheric fissures and cerebral sulci becomes
visible
ballooning of frontal horns of lateral ventricles (Mickey Mouse!
ventricle) and 3
rd
ventricle
periventricular low density on CT

& High index of suspicion in at-risk group
P Shunted patients
P Meningitis patients (TB meningitis may or may not be diagnosed to
have tuberculosis in other part of the body)
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Consider D50 50ml IV infusion
Thiamine 100mg IV preceding glucose bolus
Treat acidosis if severe with bicarbonate
P Anticonvulsants:
Ativan 4mg IV, repeated in 5 minutes interval, max. up to 9mg,
OR
Valium 10mg IV, repeated in 5 minutes interval, max. up to 4 dose
Simultaneous Phenytoin (dilantin) loading
1
st
time on phenytoin: 20mg/kg in adult, 15mg/kg in elderly
max rate at 50mg/min IV
Previously on phenytoin but level not known: give 500mg IV
then keep maintenance dose
Beware of cardio-respiratory depression, hypotension and
arrhythmias
If seizure persists:
Phenobarbital up to 20mg/kg IV, beware of hypotension (a
cardiac depressant), if so, treat with hydration and inotropes
Consider institute general anesthesia with a goal of burst
suppression on EEG by Pentobarbital loading 15mg/kg IV at
25mg/min then 2.5mg/kg/hr IV maintenance dose
P Invest igat ions:
Blood for CBP, R/LFT, Ca
2+
, Mg
2+
, random glucose, ABG,
anticonvulsant level (if previously on anticonvulsant)
CT brain for any intracranial lesion
LP if CNS infection suspected
EEG
P Drug maintenance
Continue anticonvulsant if appropiate
For new patient, provide maintenance dose of phenytoin at 100mg
iv Q8H


J. Management of EVD / ICP monitoring catheter
& Strict aseptic technique during manipulation.
& CSF leakage from exit site or connections is an surgical emergency
(requires immediate attention e.g. add stitches to exit site)
& Dressings of main and ICP catheter exit wound is changed whenever there is
soaking or loosening of dressing
& All connections are dressed at all times with Betadine cream and occlusive
dressings (Tegaderm)
& The drainage bag level is placed with reference to ear level in cm. Therefore,
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Specific conditions
& Head injury
& Aneurysm # refer Part E. SAH
& Haemorrhagic stoke
& Ventriculo-peritoneal Shunt
P For patient with pre-existing EVD, pre-op clamping of catheter
facilitates ventricular tapping
P Shunt drainage is posture related, post-operative posture might vary
from case to case

& Pituitary lesion surgery
P Pre-operative baseline investigations
Perimetry
Nasal swab for culture
Lateral skull XR
Electrolytes
Endocrinological tests
Fasting blood glucose and electrolytes
Prolactin
FSH and LH
Estradiol (in female) or testosterone (in male)
TSH and FT4
AM Cortisol (9 am)
In case of doubt of hypocortisolaemia, need to perform short
synacthen test (see appendix I)
P Post-operatively
Monitor electrolytes and sugar, daily intake / output balance
Check post-operative visual acuity
Steroid cover
Arrange post-operative hormonal tests as required:
Prolactin
FSH and LH
Estradiol (in female) or testosterone (in male)
FT4
Cortisol (see appendix I)
& Spinal Surgery
P Arrange pre-operatively baseline SSEP, sensation and motor charting
P Arrange urodynamic study as required
P Usually required XR of the regional spine with a marker indicating
thoraco-lumbar region
P Assure stability before mobilizing the patient
P Wean off foley catheter following a period of clamp and release
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P Post-operative patients

H. Brain Tumor
& Full history and complete physical examination, take note on any baseline
neurological deficit and ADL performance
& Refer physiotherapy and occupational therapist for preoperative assessment
& Trace all radiological imaging films for reference
& Pre-operative investigations including
P CBP, R/LFT, ABG, clotting profile, cross-match
P CXR
P ECG
& In case of suspicion of metastasis, look for markers of primary tumors
& For supratentorial lesion, start anticonvulsant e.g. Dilantin 100mg IV Q8H
& Start Dexamethasone 4mg po/iv Q6H in case of significant mass effect or
edema
& Start H2 antagonist e.g. Pepcidine 20mg po BD/Zantac 50mg Q8H iv
& Look out for acute deterioration due to acute hydrocephalus








I. Status Epilepticus
& 30 minutes of continuous seizure activity or multiple seizures without full
recover of consciousness between seizures
& CNS injury from repetitive electrical discharges leading irreversible cell
damage and cell death, or by the acute insult that provokes the SE
& Systemic stress from the seizure towards cardiac, respiratory, renal and
metabolic functions
& General management: Aim at stop SE with close monitoring (ICU care
preferred)
P Secure airway, consider intubation, ensure good oxygenation
P Setup IV line
P Cardiac monitoring with close vital signs monitor
P Medications:
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P Newborns: cranial enlargement, seizures, meningitis, irritability, failure
to thrive
P WCC may be normal or mildly elevated in 60-70% of cases, CRP 90%
sensitive and 77% specific, ESR may be normal

& Staging
Stage Histological characteristics
1 Early cerebritis (days 1-3): early infection and inflammation, poorly
demarcated form surrounding brain
2 Late cerebritis (days 4-9): developing necrotic center
3 Early capsule (days 10-13): Neovascularity, necrotic center with reticular
network surrounds
4 Late capsule ( days 14): Collagen capsule, necrotic center, gliosis around
capsule

& Contrast CT findings
P Cerebritis: faint rim present on pre-contrast CT with thin ring
enhancement
P Capsule: thick ring enhancement with further diffusion of contrast into
central lumen
Indication for surgical treatment Indication for medical treatment alone
Mass effect Multiple abscesses, especially if small
Increase ICP Concomitant meningitis/ependymitis
Poor neurological condition,
Neurological deterioration during
medical treatment
Poor surgical candidate
Proximity to ventricle Abscess in critical location (dominant
hemisphere/brainstem)
Traumatic abscess, Multiloculated
abscess
Hydrocephalus requiring shunt that
could become infected in surgery
& Surgical Management
P Burr hole drainage
P Excision of abscess
& Medical Management
P Obtain blood culture (although rarely useful)
P Initiate antibiotics therapy
e.g. Penicillin G (adult 5M units IV q12hr. Paed 15mg/kg q8hr) +
3
rd
generation Cephalosporin (e.g. claforan) +
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P Prone position in paediatric patients can avoid soiling of the lumbar
wound
P Inspect wound for any CSF leakage
& Interventional radiology
P Keep bed rest for at least 24 hours post-procedure
P Look for any sudden onset neurological deficit which may signifies
thrombus embolization
P Check post-procedural RFT
P Check puncture site wound and distal pulses
& Radiosurgery for vascular lesions
P Prepare patient as angiogram


L. Preoperative Antibiotics
& Rocephin 2gm IV bring to OT (Paediatric cases: 50mg/kg)
& In case of penicillin allergy or history of MRSA: Vancomycin 1gm IV over 1
hour (children 10mg/kg) and Sulperazone 1gm IV (children 10-20mg/kg)
& In case of confirmed or suspected valvular hear disease
P Add Ampicillin 2gm IV and Gentamicin 1.5mg/kg (max 120mg) IV
within 30mins before surgery, then Ampicillin 1gm at 6hours after
surgery
P In case of penicillin allergy: Vancomycin 1gm IV over 1 hour and
Gentamicin 1.5mg/kg (max 120mg) IV within 30mins before surgery

M. Postoperative conditions
& Deep vein thrombosis and Pulmonary embolism
P Predisposing factors
Patient factors (age, previous DVT, immobility, obesity,
pregnancy, thrombophilia, OC pills)
Surgical factors (Trauma/surgery, malignancy, MI, CHF,
polycythaemia, length of operation)
Prevention
General # early post operative mobilization,
adequate hydration, avoid calf pressure, stop OC
pills 6 weeks pre-operatively
Specific # mechanical (TED stocking,
intermittent pneumatic pressure device),
pharmacological (low dose sc heparin/ LMW
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it has to be adjusted whenever the patient change in position
& Negative ICP reading is anticipated in some post-operative patients due to
low intracranial pressure created by sub-galeal drain suction
& Regular CSF sampling is required
& Recalibration required for disconnection from old model of transducer
& Always send EVD catheter tip for culture whenever the EVD is removed

K. Peri-operative Management
General conditions
&
P CBP, generally keep Hb 10g/dl, platelet count 100 10
9
/L
P RFT and normalized electrolytes accordingly
P Clotting profile
P ABG and CXR for patients with pre-existing cardiac or lung problem
or history of smoking
P ECG for all major surgery
P Cross-match and prepare blood for transfusion
& Patient on Epilim # look out for drug induced thrombocytopenia
& Thrombocytopenia
P Aim at platelet count 100 10
9
/L pre-operatively including LP
P Maintain platelet count 80 10
9
/L post-operatively or patient with
clinically stable neurological lesions e.g. chronic subdural haematoma,
AVM with no bleeding
P Platelet transfusion have limited usefulness when thrombocytopenia is
due to platelet destruction e.g. ITP
& Patient on Aspirin #
P withhold in case of acute haemorrhagic stroke.
P For elective operation/procedure, need to stop 1 week beforehand

& Coagulation
P For non-emergent neurosurgical procedures, INR should be 1.4
P For emergent neurosurgical procedures, correct coagulopathy or
reverse anticoagulation with FFP (2-4 units IV full rate) and Vitamin K
(10-20mg IV at 1mg/min) as fast as possible
P Patient on warfarin undergoing elective neurosurgical procedures need
to be admitted 4-5 days before surgery and substitute by heparin


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heparin)
Diagnosis
Doppler ultrasound
(other relevant investigations # D-dimer, FDP,
clotting profile, ECG, CXR +/- ventilation
perfusion scan
Treatment of DVT
Below knee # analgesia, TED stocking
Above knee # anticoagulation with heparin
initially (e.g. fraxiparine), then warfarin


N. Commonly Used Drug in Neurosurgery
Symptom Relieving Drugs
Panadol Adult 500mg-1gm Q4-6H (max 4gm/day) PO/PR
Paed 10-15mg/kg Q4-6H
Dologesic 1 tab Q4H (max 8 tab/day) PO
Doloxene Co 1 tab TID-QID (max 4 tab/day) PO
Stemetil 5-10mg TID PO
Maxolon Adult 10mg TID PO / IV or IM
over 1-2 mins
Paed 12mcg/kg Q6H (max
0.5mg/kg/day)
SE: extrapyramidal reaction,
tardive dyskinesia,
hyperprolactinaemia
Ondansetron 8mg slow IV then 8mg BD, up to 5 days
Nootropil Adult 800mg TID PO
Paed 30-50mg/kg/day
CI: renal insufficiency
SE: agitation, drowsiness,
insomnia
Sermion 5-10mg BD PO SE: flushing, drowsiness,
insomnia
DI: potentiate antihypertensives
Duxaril 1-2 tab BD PO CI: pregnancy
SE: Preipheral neuropathy,
agitatioin, palpitation,
drowsiness, insomnia, vertigo
DI: MAOI
Neurobion 1-2 tab TID PO
Methycobal 1 tab (500mcg) TID PO
Bisolvon Adult 8-16mg TID/QID PO/IV
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Sedative and hypnotics
Morphine Adult 10-15mg q4h sc/im SE: respiratory depression,
vomiting, constipation
Narcan Adult 0.8-2mg iv/im/sc12-3min, max 10mg
Child 10ug/kg then 100ug/kg if no response
Neonate 10ug/kg q2-3min prn
Haldol Adult 2-10mg q4-8h im
Child 50-75ug/kg/d im
Elderly max 3mg/d except psychotic
history
SE: hypertonia, orthostatic
hypotension, galactorrhoea,
cholestatic hepatitis
DI \: Lithium, methyldopa,
anticonvulsants, alcohol,
opiates, CNS depressants
Dormicum Adult 2.5mg-7.5mg iv at rate of 1mg in 30sec
Elderly 1-2mg iv
Child 7.5-15mg nocte po
flumazenil 0.2mg iv over 15s then 0.1mg q1min prn, max 1mg
Imovane Adult 7.5-15mg nocte
Elderly 3.75mg nocte
Ativan Adult 7.5mg-15mg nocte
Elderly 3.75mg nocte
Chloral
hydrate
50mg/kg for hypnosis max 1g


Drug used in Status Epilepticus (D50 50nl, dilantin, correct Ca,Mg,H+)
Thiamine 50-100mg iv preceding D50
oral 10-25mg up to 200-300mg/d
Valium Bolus 10mg iv q5min up to total 4 doses
Child 0.3mg/kg, max 3mg for <11kg , 10mg for >10kg
Infusion 100mg in 500ml D5 at 40ml/hr







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Antimigrane drugs
Cafergot 1-2 tab at onset,
max 4 tab/d and 8
tab/wk
CI: PVD, CHD, HT, sepsis, pregnancy,
lactation
Amitriptyline 25mg tds. Max
150mg/d
CI: IHD, glaucoma, on MAOI
SE: dry mouth, blurred vision, tachycardia,
arrhythmia
DI:acute alcohol, barbiturate, opiate
intoxication, anticholinergics, adrenaline,
noradrenaline, clonidine, bethanidine,
guanethidine
Clonidine 50ug bd to 75ug bd DI: potentiate antihypertensives, alcohol,
sedatives, hypnotics

Anaesthetic drugs
Propofol Adult iv 2-2.5mg/kg at a rate of 20-40mg/10s
Maintenance iv 4-12mg/kg/hr
Thiopentone Adult 100-150mg over 10-15s, max 4mg/kg
Child 2-7mg/kg
Atropine Adult 300-600ug iv
Child 10ug/kg iv, repeat when needed
Infant 30-40ug/kg, repeat when needed
Atracurium
besylate
Bolus iv 300-600ug/kg then 100-200ug/kg prn
Infusion iv 5-10ug/kg/min (300-600ug/kg/hr)
Pancuronium
bromide
Adult iv 50-100ug/kg then 10-20ug/kg prn
Child in 60-100ug/kg then 10-20ug/kg prn
Neonate 30-40ug/kg then 10- 20ug/kg prn
ICU 60ug/kg q1-1.5hr
Suxamethoni
um
Adult iv 600ug/kg, usu 20-100mg
Child 1-12yrs 1-2mg/kg
Infant<1yr 2mg/kg
Infusion iv 2-5mg/min
Dormicum Premed (30min before induction)
Adult 0.07-0.1mg/kg im
Child 0.15-0.2mg/kg im; 0.35-0.45mg/kg pr
Induction
Adult 10-15mg iv at rate of 2.5mg in 10 sec
23


Acute CVS drugs
Adrenaline 1:1000 1ug/min <60kg> (3amp 3mg in 47ml NS at 1ml/hr)
[Beta <2ug/min; B>a 2-10ug/min; alpha>10ug/min]
Levophed(noradrenaline) 1-3ug/min <60kg> (1amp 250mg in 55ml NS at 1ml/hr)
[Beta 1-20ug/kg/min]
Dobutamine 1ug/kg/min <60kg> (1amp 200mg in 50ml NS at 1ml/hr)
{delta<5ug/min; Beta15-10ug/min; alpha>10ug/min
Dopamine 1ug/kg/min <60kg> (1amp 200mg in 50ml NS at 1ml/hr)
[delta<5ug/min; beta15-10ug/min; alpha>10ug/min]
Amiodarone 10mg/hr <60kg> (4amp 600mg in 48ml D5 at 1ml/hr)
Labetalol Oral 100-400mg bd, max 2.4g,
maintenance 200-400mg bd po
Slow iv 50mg over 1 min, repeat q5min, max 200mg
Betaloc Oral 100mg/day,
maintenance 100-200mg/d in 1-2 divided doses
iv 5mg in 3-5min, repeat q5min
Nitroprusside dehydrate
sodium
0.3ug/kg/min <60kg> (1amp 50mg in 48ml NS at
1ml/hr)
Nitroglycerin 0.3ug/kg/min <60kg> (1amp 50mg in 40ml NS at
1ml/hr)
Ventolin 2ug/min <60kg> (1 amp 5mg in 37ml NS at 1ml/hr)
Aminophylline 5mg/hr <60kg>
(250mg in 40ml NS
at 1ml/hr)
DI: increase t1/2 by cimetidine,
erythromycin, ciprofloxacin,
propranolol, contraceptive
steroids; reduce t1/2 by
phenytoin, carbamazepine,
barbiturates, rifampicin

IV CPResuscitation Drugs
Adrenaline 1:10000 , 10ml (adult) 0.1ml/kg (child);
max 10ml for <11kg, 20ml for >10kg
Atropine 3mg
Lignocaine 100mg
Bretylium 5mg/kg (10mg/kg if repeat)
Procainamide 100mg
Sodium Bicarbonate 50ml (only after >10min with good ventilation)
20


Anticonvulsants
Dilantin Loading 15-20mg/kg; 300mg q4h po
or iv 1g over 1 hr (<50mg/min); max
200mg for <11kg, 1g for >10kg
Half dose if already on dilantin
Maintenance
Adult 300mg/d;
child 5-8mg/kg/d
Therapeuric level
40-80umol/L
CI: bradycardia, heart block
SE: ataxia, nystagmus,
diplopia, confusion,
headache, dizziness,
hypotension, gingival
hyperplasia, hirsutism,
stevens-johnson syndrome
DI: drug effect increase by
chloramphenicol,
sulphonamide, isoniazid,
warfarin, cimetidine,
disulfiram, reduce by
carbamazepine
Epilim Adult 600mg/day po/iv, max 2.5g/d
Child 20-30mg/kg/d, max
35mg/kg/d
Therapeutic level
376-694umol/L
SE: skin rash,
stevens-johnson syndrome
DI: drug effect reduce by
carbamazepine, phenobarb,
phenytoin, primidone;
potentiate MAOI
Tegretol Adult 100-200mg qd to bd, max
1.6g/d
Child 2mg/kg q8h, max 1.2g/d
Therapeutic level
34-51umol/L
SE: ataxia, diplopia,
dizziness, taste disturbances
DI: drug effect increase by
erythromycin, isoniazid,
cimetidine, doloxene,
verapamil
Luminal 30-60mg q6h po/iv for sedation
<20mg/kg iv (<100mg/min) for status epilepticus
child 20-30mg/kg; max 300mg for <11kg, 600mg for >10kg


18

Paed 4mg BD (<5yr), 4mg QID (5-10yr)
Fluimucil Adult 200mg TID PO
Paed 200mg Daily (<2yr),
200mg BD (2-6yr),
200mg TID (>6yr)
Baclofen Adult 5-20mg TID (max 100mg/day) PO
Paed 0.75-2mg/kg/day (<10yr)
Max 2.5mg/kg/day (>10yr)
Kaolin pectin 10-20ml Q4H po

Drug counteracting Vasospasm
Nimotop 1-2mg/hr iv infusion until tolerate
feeding, then 60mg q4h po for total of
3 week
SE:marked hypotension,
bradycardia, headache,
flushing
DI:antihypertensives(meth
yldopa, B-blocker, Ca
antagonist, frusemide,
aminoglycosides,
cephalosporin


Drugs controlling cerebral edema
Glycerol
10% solution
500ml iv over 30 mins then 200-500ml iv over 2hrs q12h
Mannitol
20%
0.5-1g/kg iv over 30-60min
Decadron 10mg then 2-4mg q6h po/iv
thiopental 5mg/kg/hr for 24hr then 2.5mg/kg/hr
Methylpredni
solone
16g dilute with water to 256ml, 30mg/kg iv in 15min then pause 45
min then 5.4mg/kg/hr for 23hrs, given within 8hrs of spinal cord
trauma







24

8.4%
Antihypertensive drugs
Adalat 5-10mg sl prn, may repeat after 30min prn, then 10-30mg
q6-8h po
Captopril 12.5-25mg po stat, then tds po
Betaloc 50-200mg bd
Labetalol 200mg po stat, then 200mg tds po
Labetalol 20mg iv bolus over 2 min, repeat 40mg iv bolus, then
0.5-2mg/min infusion in D5 (max 300mg/d) followed by
100-400mg bd po
Nitroprusside
dehydrate sodium
0.25-10ug/kg/min iv
infusion in D5 (5-mg in
100ml D5 = 500ug/ml,
start with 10ml/hr
NB: protect solution from light
by wrapping
CI: pregnancy, >48hr because of
risk of cyanide accumulation
Hydralazine 5-10mg slow iv over 20min, repeat q30min , or iv infusion
200-300ug/min and titrate, then 10-100mg qid po
child 0.1-0.2mg/kg iv; max 2mg for <11kg, 10mg for >10mg
Phentolamine 5mg iv bolus, repeat 10-20min prn (for phaeo crisis)

Miscellaneous
Rocephin
(Ceftriaxone)
Adult 1-2g/d, max 4g/d, iv or deep im
Child>6mth 20-50mg/kg;
meningitis 75-100mg/kg/d, max 4g/d
Amphotericin B iv 0.25-1mg.kg/d or alt day
Ketoconazole Adult 200mg qd for 2wks, continue till symptoms &
cultures negative, max 400mg qd po with food
Child 3mg/kg/d
Botulium type A toxin 10ug/ml 10-30ml/muscle group im
Protamine sulphate Slow iv 1mg/100u heparin, max 50mg
Heparin iv adult loading 5000-10000u then 5000-10000u/ 4-6hr;
child 50-100ug/kg 4hr
sc <prophylaxis> 7500Axa IC u/d for 1 wk or till mobilize
Fraxiparine sc <prophylaxis> 7500Axa IC u/d for 1 wk;
<treatment> 225Axa IC u/kg/bd for 10days
Distigmine bromide <urinary retention> 5mg po om or alt day 30min before
breakfast
22

Child 0.15-0.2mg/kg im in Combination with ketamine
Hormonal Drugs
Parlodel
(bromocriptine)

Parkinsonism
1
st
wk 1-1.25mg nocte,
2
nd
wk 2-2.5mg nocte,
3
rd
wk 2.5mg bd,
4
th
wk 2.5mg tds,
then %2.5mg every 3-14 days, to usu
10-40mg/d
Acromegaly & prolactinoma 1-1.25mg
nocte, % to 5mg q6h, up to 30mg/d
SE:
Postural hypotensi
on, nausea,
vomiting, visual
disturbance
Pitressin
(vasopressin)
Infusion 25 unit in 250ml D5, starting
0.5-5 unit/hr, aim urine output 2-4ml/kg/hr
Im/sc 5-20 unit q4h
SE:
Water Intoxication
DDAVP/Minirin
(desmopressin)
Iv 2-6microgm q6-8h prn, aim urine
output <4ml/kg/hr
Intranasal adult 10-40mcg/d, child
5-20mcg/d
Im/sc adult 1-4mcg/d, child 0.4mcg/d
Oral 0.1mg tds, maintenance 0.3-0.6mg/d,
range 0.2-1.2mg/d
SE:
Water Intoxication

Eltroxin
(thyroxine T4)
Adult 100-200mcg/d po, % by 25-50mcg per month
Child 10mcg/kg, max 50g/d
Infant, 100mcg/d by 5 years, 100-200mcg/d by 12 years
Hydrocortisone Replacement adult 20-30mg/d,
Child 10-30 mg/d orally
Slow iv/im/ivi adult 100-500mg tds-qid,
Child <1yr 25mg, 1-5yr 50mg, 6-12yr 100mg
Cortilan
(cortisone
Acetate)
Replacement 25mg om and 12.5mg noon
Prednisolone Initially po 10-20mg/d, max 60mg/d, maintenance 2.5-15mg/d






25

Praziquantel <neurocysticercosis>
50mg/kg/d po in 3 doses for 15 days (1tab=600mg)
O. Ventilator support
Modes of ventilation
CMV (controlled mechanical ventilation) a preset no. of breaths are delivered,
either volume controlled / pressure controlled. Patient cannot initiate ventilator
breaths.
ACMV (assist controlled mechanical ventilation) # Patient can trigger ventilator
breath. A preset no. of breaths are delivered if patient&s spontaneous respiratory rate
falls below the preset level.
I MV (intermittent mandatory ventilation) # A preset mandatory rate is set but
patients are free to breathe spontaneously between set ventilator breaths
SI MV (simultaneous intermittent mandatory ventilation) # mandatory breaths
are synchronized with a patient&s spontaneous efforts thus avoiding 'stacking& of
breaths.
Pressuresupport (PS)# a preset inspiratory pressure is added during inspiration in
spontaneously breathing patients.
Tidal volume are guaranteed in CMV and ACMV.

Common initial setting for adult
FIO2 0.3-0.5
Tidal volume 7-12ml/kg
Rate 10-15/min
I:E ratio 1:2
Peak pressure <40cmH2O
PEEP 0-5cmH2O
Sensitivity -2

Poor tolerance / fighting the ventilator!
1. check patency and position of ET tube (reintubate if in doubt)
2. patient should be removed from the ventilator and
placed on manual ventilation while the problem is
resolved. (resorting to increased sedation +/- muscle
relaxation in this circumstances is dangerous until the
cause is resolved.
3.Check ET tube cuff and setting of ventilator
2. look for tension pneumothorax, ventilator circuit/ventilator problem
4. allow spontaneous respiratory efforts with IMV + PS or PS alone
5. if fail to synchronize with IMV (causing stacking of mandatory and spontaneous
breaths), increasing pressure support and reducing mandatory rate may help,
alternatively, the use of PSV may be appropriate.
6. careful adjustment of TV, RR, inspiratory flow and trigger sensitivity.
7. additional sedation +/- muscle relaxation
8. Always recheck ABG when setting of ventilator changed

27

All specimens, with time (0 min, 30 min), patient's name and ID no. clearly written on containers,
should be sent to laboratory in one request form (MR311702/TM- special chemistry request form of
Chemical Pathology, NDH / TMH).

Clinical monitoring
No specific clinical monitoring is required. Allergic reactions to synacthen (tetracosactrin) are a
possibility, but rarely occur.


Appendix II
Commonly used no.
5264 # CT
5266 # MRI
5472 # EOT
5186 , 5271 # AED
5003 resuscitation room (stroke call)
5736 # ICU
5402 # secretary Shirley
MO locker no. 4678

Trauma call 44-5003

Disaster call 991
Stand down 77
29

31

28

26

Adjustment in response to blood gas #

Low PaO2
increase FIO2, increase PEEP (may increase peak airway pressure or reduce cardiac
output), increase I:E ratio, review TV and RR
consider CMV, increased sedation +/- muscle relaxants
High PaO2
Decrease PEEP (usually to 5cmH2O before reducing FIO2), decrease FIO2, decrease
I:E ratio
High PaCO2
Increase TV, increase respiratory rate
Consider reducing dead space, CMV, increased sedation +/- muscle relaxants
Low PaCO2
Decrease respiratory rate(to 10-12/min)
Decrease TV (to<7ml/kg)


Appendix I

Short Synacthen Test

Author: Dr Tony Mak, Cons(Path)
Authorised by: Dr Tony Mak, Cons(Path)
Reviewed by: Judy Lai, SO(M) Pathology
Operative date: 1 April 2001

Principle

Synacthen or tetracosactrin is synthetic adrenocorticotrophic hormone (ACTH) analog. It
stimulates the adrenal gland to produce cortisol. Failure to response adequately indicates adrenal
insufficiency.

Indication
For patients with suspected adrenal insufficiency, primary or secondary.

Patient Preparation
The test is best done in the morning. In case of emergency, it can be performed anytime of the
day. Rest for 30 minutes before the test. Smoking is not allowed. If the patient is on
replacement hydrocortisone therapy, it should be changed to an equivalent dosage of
dexamethasone one day before the procedure and delay the morning dose of dexamethasone until
the procedure is completed. Warning: do not withdraw steroid replacement abruptly, which is
dangerous.

Procedure
1. Collect baseline serum cortisol specimen (time: 0 minute).
2. Inject 250 (g (microgram) synacthen (or tetracosactrin) intramuscularly or intravenously.
3. Take another specimen for serum cortisol 30 minutes later.
4. A 60-minute serum cortisol specimen is optional but usually does not provide additional
information. This is not recommended.

Sampling
Serum cortisol: 4 mL blood in plain blood tube (red top, non-gel)

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