Neurologic


Burr Hole

Rapid Review

  • Background
    • Also known as “trepanning”. Involves drilling or scraping a hole into the skull to provide drainage for expanding intracranial hematoma
  • Indications
    • Epidural or subdural hematoma w/ midline shift on imaging.
  • Contraindications
    • Lack of imaging, reasonable access to neurosurgery, GCS > 8
  • Complications
    • Damage to brain parenchyma, infection, bleeding.

Pearls

  • The optimal location for this procedure will be based on the location of the hemorrhage on CT scan. When in doubt though, utilize the temporal site. 
  • If a trephination tool is not available, there are case studies supporting the use of a 25-mm EZ-IO needle with an electric driver.
Video Credit: EM:RAP


HINTS Exam

Rapid Review

  • Background
    • Physical exam technique utilized as a screening tool to distinguish central causes of vertigo (ex. Posterior stroke) from peripheral causes (ex. Vestibular neuritis)
  • Indications
    • Patients with acute onset, continuous vertigo. 
  • Contraindications
    • Chronic or episodic vertigo, C-spine injury
  • Complications
    • Cervical injury from head impulse test.

Pearls

  • The patient’s neck must be fully relaxed in order to perform the test correctly. Avoid being too gentle withe the head impulse, as this may cause a false negative. 
  • Any positive finding from one of the 3 components (Head Impulse, Nystagmus, or Test of Skew) warrants further diagnostic imaging for posterior circulation stroke.
Video Credit: Peter Johns


Lumbar Puncture

Rapid Review

  • Background
    • Insertion of a needle into the lumbar subarachnoid space for the purposes of measuring CSF pressure, administering therapeutic agents, or collecting CSF for laboratory testing
  • Indications
    • Suspected subarachnoid hemorrhage, meningitis, or GBS. May also provide relief for pseudotumor cerebri.
  • Contraindications
    • Trauma or overlying skin infection at insertion site. Suspected spinal epidural abscess. 
  • Complications
    • Post-lumbar puncture headache, spinal epidural hematoma

Pearls

  • Ultrasound can be useful for identifying the intervetebral spaces, especially in obese patients.
  • There are no differences in complications or success rates between the sitting position and the lateral decubitus, so do whatever works best for you!
Video Credit: EM:RAP


Ventricular Shunt Aspiration

Rapid Review

  • Background
    • Aspirating fluid from a ventriculoperitoneal (VP) shunt may be diagnostic (evaluate for infection or blockage), as well as therapeutic (alleviates symptoms of blocked shunt). 
  • Indications
    • Suspected VP shunt infection, meningitis, or blockage
  • Contraindications
    • Infection over entry site. Relative contraindications include coagulopathy, lack of shunt imaging/information.
  • Complications
    • Infection (low risk), bleeding, CSF leak, ventricular collapse, or misplaced tap.

Pearls

  • It is always best to consult neurosurgery prior to attempting any ventricular shunt taps.
  • No fluid return or abrupt stop in flow = proximal obstruction. Opening pressure > 20 = distal obstruction
Video Credit: Larry Mellick

Brandon Simpson, PA-C
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  • Blog - 25 Feb 2021