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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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ù Inadequate or unreliable history or suspicious of child abuse

P Management ù Anticonvulsant (e.g. Dilantin loading 15mg/kg slow iv in

20mins) ù Preoperative antibiotic (e.g. Rocephin 2gm IV on induction,

Paediatric 50mg/kg IV) ù Mannitol if required (e.g. 0.5gm/kg IV bolus / 2.5ml 20% per kg

IV) ù 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 ù Early surgical toilet and suturing in clean ward setting / OT ù Consider antibiotics if heavily contaminated wound

P Depressed fracture ù Formal debridement ± craniectomy in OT

a) Depression > thickness of skull b) Deficit related to underlying brain c) CSF leakage d) Compound depressed fracture

ù Elevation unless close to venous sinuses and no indication to surgery

& Spinal Injury P Acute trauma life support ù Airway and Breathing: if intubation required, immobilize cervical

spine during the procedure ù 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 ù Nasogastric tube for paralytic ileus ù Foley catheter for fluid and perfusion status monitoring and

possible urinary retention P Treat hypothermia if present due to vasomotor paralysis P Methylprednisolone therapy: ù Should be given < 8hrs after injury ù Dilute 16gm in water for injection to 256ml (62.5mg/ml) ù Initial bolus: 30mg/kg over 15 minutes ù Then 45 minutes pause ù 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 ù ≥ 95%of cases can be detected if done within 48 hours ù High density within subarachnoid spaces ù Also assesses hydrocephalus, other haematoma, infarction and

amount of blood in subarachnoid space P Lumbar puncture

ù Most sensitive test for SAH N Caution: lowering of CSF pressure may precipitate rebleeding ù Elevated opening pressure with non-clotting blood-stained fluid

that does not clear with sequential tubes P Cerebral Angiogram

ù Demonstrates source of bleeding in 80-85% of cases ù 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 ù Elevate head by 30-45 degrees if BP stable ù 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

ù Mannitol 0.5-1gm/kg bolus ù 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

ù Intubation by anaesthetist with mechanical ventilation if patient not in full consciousness state with clinical risk of upper airway obstruction or aspiration

ù Stop external bleeding ù Maintain Cerebral Perfusion Pressure (CPP) ≥ 70mmHg by

keeping arterial BP ù Replace intravascular by crystalloid, colloids or blood products

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

P Assessment of neurological condition ù GCS score ù Pupils size, gaze deviation ù Limbs weakness ù Tendon jerk reflexes ù 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) ù Depressed level of consciousness after injury ù Focal neurological deficit ù Progressive headache ù Alcohol or drug intoxication ù Post-traumatic seizure ù Post-traumatic amnesia ù Repeated vomiting ù Multiple trauma ù Serious facial injury ù Signs of skull base fracture ù Significant subgaleal swelling ù Possible penetrating skull injury or depressed skull fracture ù 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

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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

ù Hydrocephalus ù Cerebral edema

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findings) P Persistent raised ICP P Rapid deterioration P Favorable lesion location

ù 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

ù Massive haemorrahge with significant neuronal destruction ù Large haemorrhage in dominant hemisphere ù 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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ù Seizure ù Hyponatriaemia ù Hypoxia ù Sepsis

P Prevention ù Adequate post-SAH hydration (at least 2.5-3L/day) ù Prevent anaemia

P Treatment ù Nimotop: not counteracting vasospasm but may provide

neuroprotective effect ù 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

ù 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 3rd 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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ù Consider D50 50ml IV infusion ù Thiamine 100mg IV preceding glucose bolus ù Treat acidosis if severe with bicarbonate

P Anticonvulsants: ù Ativan 4mg IV, repeated in 5 minutes interval, max. up to 9mg,

OR ù Valium 10mg IV, repeated in 5 minutes interval, max. up to 4 dose ù Simultaneous Phenytoin (dilantin) loading

− 1st 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

ù 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 Investigations: ù Blood for CBP, R/LFT, Ca2+, Mg2+, random glucose, ABG,

anticonvulsant level (if previously on anticonvulsant) ù CT brain for any intracranial lesion ù LP if CNS infection suspected ù EEG

P Drug maintenance ù Continue anticonvulsant if appropiate ù 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 ù Perimetry ù Nasal swab for culture ù Lateral skull XR ù Electrolytes ù 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

ù Monitor electrolytes and sugar, daily intake / output balance ù Check post-operative visual acuity ù Steroid cover ù 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) + 3rd 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 × 109/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 × 109/L pre-operatively including LP P Maintain platelet count ≥ 80 × 109/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

Suxamethonium

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

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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)

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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

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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(methyldopa, 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 Methylprednisolone

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

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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

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Child 0.15-0.2mg/kg im in Combination with ketamine

Hormonal Drugs Parlodel (bromocriptine)

Parkinsonism 1st wk 1-1.25mg nocte, 2nd wk 2-2.5mg nocte, 3rd wk 2.5mg bd, 4th 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 50µg/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

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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. IMV (intermittent mandatory ventilation) – A preset mandatory rate is set but patients are free to breathe spontaneously between set ventilator breaths SIMV – (simultaneous – intermittent mandatory ventilation) – mandatory breaths are synchronized with a patient’s spontaneous efforts thus avoiding ‘stacking’ of breaths. Pressure support (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

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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

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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 μg (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)