Hi guys - giving a lecture next month on stroke and ICH. As we don't have a nsg program at my hospital, was hoping to poll the audience here.
Re: craniectomy for ICH, it seems there is strong evidence for posterior fossa hemorrhage, easy peasy. I'm curious what y'all are doing for supratentorial hemorrhage though. I see there's one study that if its within 1cm of the cortex that might be beneficial but does not seem to improve functional outcomes, is that how you guys practice? What about blood in the ventricles, mass effect? just an EVD? That's our practice pattern here, but idk if thats actually because taking off the skull isnt beneficial or because the PAs can come in to do the drain without an attending.
What about blood pressure? We're sticking with <160 here, seems the data on <140 is not great. Is that mostly what y'all do?
Any other pearls you'd like your EM colleagues to know?
Do what your neurosurgery colleagues tell you to do; as an EM doc, you don't get to have an opinion on when craniotomies happen.
Don't come on to anonymous online forums to ask questions you can google or read about from primary sources.
Don't suggest that practice at your institution may be substandard because attendings don't want to come in to do procedures on a topic you admittedly know nothing about.
ABCs. Abcs. Abcs
I do <140 on all patients with ich. Easy titratable stuff like nicardipine. Can do labetalol or hydralazine while waiting on pharmacy. Call nsg
(07-23-2019, 01:30 PM)Guest Wrote: Do what your neurosurgery colleagues tell you to do; as an EM doc, you don't get to have an opinion on when craniotomies happen.
Don't come on to anonymous online forums to ask questions you can google or read about from primary sources.
Don't suggest that practice at your institution may be substandard because attendings don't want to come in to do procedures on a topic you admittedly know nothing about.
this
(07-23-2019, 02:13 PM)Guest Wrote: (07-23-2019, 01:30 PM)Guest Wrote: Do what your neurosurgery colleagues tell you to do; as an EM doc, you don't get to have an opinion on when craniotomies happen.
Don't come on to anonymous online forums to ask questions you can google or read about from primary sources.
Don't suggest that practice at your institution may be substandard because attendings don't want to come in to do procedures on a topic you admittedly know nothing about.
this
Wow. Ok, I suppose I shouldn't have jabbed at our neurosurgeons. Sorry.
I'm giving a lecture, it was assigned to me. I tried to review primary literature.
Let me try again. It's 3am - other than large posterior fossa bleeds or signs of herniation or obvious progressive deterioration, are there indications for calling you RIGHT NOW vs. 530am? Of course if I don't know, I'll call. But most of our graduates go on to community practice, I'm just trying to provide a general overview for understanding what needs a surgeon, what needs a transfer to a center with a neurosurgeon, and what can hang out in a medical ICU.
I understand surgical management can be difficult to break down to a simple algorithm. Just looking for some general info. What are the things you want to know if remote access at the hospital is down and you can't see the film?
(07-25-2019, 03:43 PM)Guest Wrote: (07-23-2019, 02:13 PM)Guest Wrote: (07-23-2019, 01:30 PM)Guest Wrote: Do what your neurosurgery colleagues tell you to do; as an EM doc, you don't get to have an opinion on when craniotomies happen.
Don't come on to anonymous online forums to ask questions you can google or read about from primary sources.
Don't suggest that practice at your institution may be substandard because attendings don't want to come in to do procedures on a topic you admittedly know nothing about.
this
Wow. Ok, I suppose I shouldn't have jabbed at our neurosurgeons. Sorry.
I'm giving a lecture, it was assigned to me. I tried to review primary literature.
Let me try again. It's 3am - other than large posterior fossa bleeds or signs of herniation or obvious progressive deterioration, are there indications for calling you RIGHT NOW vs. 530am? Of course if I don't know, I'll call. But most of our graduates go on to community practice, I'm just trying to provide a general overview for understanding what needs a surgeon, what needs a transfer to a center with a neurosurgeon, and what can hang out in a medical ICU.
I understand surgical management can be difficult to break down to a simple algorithm. Just looking for some general info. What are the things you want to know if remote access at the hospital is down and you can't see the film?
If it is not a ditzel traumatic SAH or stable chronic SDH in a GCS 15 patient, you need to call neurosurgery consult right away no matter what the time.
(07-25-2019, 03:43 PM)Guest Wrote: (07-23-2019, 02:13 PM)Guest Wrote: (07-23-2019, 01:30 PM)Guest Wrote: Do what your neurosurgery colleagues tell you to do; as an EM doc, you don't get to have an opinion on when craniotomies happen.
Don't come on to anonymous online forums to ask questions you can google or read about from primary sources.
Don't suggest that practice at your institution may be substandard because attendings don't want to come in to do procedures on a topic you admittedly know nothing about.
this
Wow. Ok, I suppose I shouldn't have jabbed at our neurosurgeons. Sorry.
I'm giving a lecture, it was assigned to me. I tried to review primary literature.
Let me try again. It's 3am - other than large posterior fossa bleeds or signs of herniation or obvious progressive deterioration, are there indications for calling you RIGHT NOW vs. 530am? Of course if I don't know, I'll call. But most of our graduates go on to community practice, I'm just trying to provide a general overview for understanding what needs a surgeon, what needs a transfer to a center with a neurosurgeon, and what can hang out in a medical ICU.
I understand surgical management can be difficult to break down to a simple algorithm. Just looking for some general info. What are the things you want to know if remote access at the hospital is down and you can't see the film?
On behalf of the more reasonable neurosurgeons out there (we do exist), let me apologize for the immaturity on display from my colleagues here. Jesus people, grow up.
The short answer is: somebody who is used to seeing ICH needs to see an ICH when it comes in, be it a neurosurgeon or a neurologist. ICH is a terrible catch-all term that describes a huge variety of diseases: hypertensive, amyloid, aneurysmal and non-aneurysmal subarachnoid hemorrhage, tumor-associated, RCVS, drug-associated, contusion, vasculitis/vasculopathy...the list goes on and on. These are all managed incredibly differently. An experienced person can often tell from just a non-contrast CT and a history what the most likely explanation is. So unfortunately, you really should call somebody to at least be a sounding board.
In terms of calling a surgeon directly - the #1 thing is the patient's exam. That's why we hate when EM docs reflexively intubate our patients or over-sedate them; a solitary image means next to nothing without an exam. Picture two patients with a 40cc right frontal ICH: an 18 year old after an all-night cocaine bender and a 75 year old sitting at home. The images are going to look awfully similar, but the younger patient's GCS is probably 5 and the older's is probably 14-15. For those reasons (among many others), the surgeon should get an immediate call about the first one. The older patient can probably be managed in a good ICU with frequent checks. There are obvious subtleties to both cases that I can't go into here. Another word of caution: know your resources. If your MICU has no experience with neuro patients (i.e., no neurosurgeons at your hospital), then that ICU is NOT the best place for any of these patients.
Finally, ICH is one of the banes of neurosurgeons' existence. We haven't figured out now to treat them well surgically, or whether they even need to be surgerized at all. Trials are ongoing. So don't expect that you'll find any good answers in the primary literature. If you do want to present something, look at the STITCH, STITCH 2, MISTIE, and ENRICH trials (the last one hasn't published results yet).
Bottom line: every ICH probably deserves a look from a neuro specialist of some kind, and when you call, spend some actual freaking time to get a basic neuro exam. If you don't know how to do a good one, grab a neuro person and have them show you. I can't tell you how many calls I've had from the ER when they haven't bothered to get a neuro exam before intubating a patient with an ICH (yeah, ABCs, I get it - but you can usually bag them) or haven't bothered to hold sedation before getting an exam on an intubated patient.
Best of luck. You're wading in shark-infested waters here.
(07-25-2019, 05:54 PM)Guest Wrote: (07-25-2019, 03:43 PM)Guest Wrote: (07-23-2019, 02:13 PM)Guest Wrote: (07-23-2019, 01:30 PM)Guest Wrote: Do what your neurosurgery colleagues tell you to do; as an EM doc, you don't get to have an opinion on when craniotomies happen.
Don't come on to anonymous online forums to ask questions you can google or read about from primary sources.
Don't suggest that practice at your institution may be substandard because attendings don't want to come in to do procedures on a topic you admittedly know nothing about.
this
Wow. Ok, I suppose I shouldn't have jabbed at our neurosurgeons. Sorry.
I'm giving a lecture, it was assigned to me. I tried to review primary literature.
Let me try again. It's 3am - other than large posterior fossa bleeds or signs of herniation or obvious progressive deterioration, are there indications for calling you RIGHT NOW vs. 530am? Of course if I don't know, I'll call. But most of our graduates go on to community practice, I'm just trying to provide a general overview for understanding what needs a surgeon, what needs a transfer to a center with a neurosurgeon, and what can hang out in a medical ICU.
I understand surgical management can be difficult to break down to a simple algorithm. Just looking for some general info. What are the things you want to know if remote access at the hospital is down and you can't see the film?
If it is not a ditzel traumatic SAH or stable chronic SDH in a GCS 15 patient, you need to call neurosurgery consult right away no matter what the time.
Agree with above. There is no simple algorithm. Whether a patient is surgical depends on a number of factors and will vary from surgeon to surgeon. It can be hard to tell if a patient is going to deteriorate. Some may initially have a small bleed that 2-3 hours later has enlarged with life threatening sequelae. A portion of these patients will ultimately die regardless of what is done. Most of the time, a spontaneous ICH is not neurointact as thalamic, basal ganglia, pons and cerebellum are the most common locations. Lobar hemorrhages in the elderly are obviously going to be symptomatic due to their mass effect. By necessity, they will require ICU care with careful monitoring, most community hospitals won't have this capability. Traumatic ICHs and contusions also have a tendency to enlarge, which is why we often get repeat scans.
If you choose not to call a neurosurgeon or step up the level of care, you are accepting medical/legal responsibility for your decision. If you are at a hospital without a neurosurgeon, is that really the best place for an ICH? The ultimate outcome will depend on a number of factors, e.g. high quality stroke care, PT/OT, etc. that are likely not present at the community hospital.
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