Discharge Summary Dictation
House Staff Directory
|Cytotoxic||Cellular swelling due to ischemic or toxic injury||Trauma||Minutes to hours||Resistant to treatment|
|Vasogenic||Extracellular edema due to capillary disruption / breakdown of BBB||Trauma, tumors, abscess||Hours to days|
Mortazavi, Martin M, Andrew K Romeo, Aman Deep, Christoph J Griessenauer, Mohammadali M Shoja, R Shane Tubbs, and Winfield Fisher. 2012. ‘Hypertonic Saline For Treating Raised Intracranial Pressure: Literature Review With Meta-Analysis: A Review’. Journal Of Neurosurgery 116 (1): 210–221.
Phenytoin has significant protein binding, so hypoalbuminemia will lead to increased free phenytoin.
Adjust for hypoalbuminemia using the following formula = Total Phenytoin Level / [(0.2*albumin)+0.1]
*0.2 is a correction factor
In renal failure, aside from hypoalbuminia leading to increased free phenytoin, phenytoin binding is further reduced, and this formula will tend to underestimate the free phenytoin levels. To correct for this, use 0.1 as correction factor if GFR is <10 ml/min.
Drug monitoring: (http://emedicine.medscape.com/article/2090306-overview#a2)
How to measure hematoma volume (ABC/2 method) where:
A = greatest diameter of the largest hemorrhage slice
B = diameter perpendicular to A
C = approx # of axial slices with hemorrhage multiplied by the slice thickness
HOW TO CALCULATE VOLUME OF ICH
Measure largest hemorrhage diameter = A
Perpendicular to this line, measure the largest hemorrhage diameter on the same image. = B
Multiply total number of CT slices with hemorrhage by slice thickness = C
*If hematoma area on a slice is ~25-75% of hematoma area on reference slice, then consider half a hemorrhage
**If hematoma area on a slice is <25% of reference slice, then not considered hemorrhage slice.
VOLUME = AxBxC/2
– measure largest diameter – superior to inferior – from the coronal or Sagittarius images = C
Then use formula as above.
1. Mode of ventilation – start with A/C mode, SIMV if tachypneic
2. Tidal Volume – use 8ml/Kg of predicted BW then reduce to 6ml/Kg over next 2 hours
**Monitor peak alveolar pressure (goal </=30cmH20)
**Inspiratory Flow Rate – set at 60mL/min; higher (>/=80mL/min) if respiratory distress or high MV (>/=10L/min)
**I:E ratio – normally >/=1:2, if <1:2 then inc IFR or dec TV or dec RR
3. Respiratory Rate – set at patient’s MV prior to intubation, not to exceed 35 /min; check PCO2 after 30 minutes
4. PEEP – initial PEEP at 5 cmH20
**If with occult PEEP, then increase I:E ratio or ad extrinsic PEEP
Radiology, 2005 Nov;237(2):395-400.
Heavy smoker: [>1/2 PPD]
21mg/day x 6 weeks, then 14mg/day x 2 weeks then 7mg/day x 2 weeks
Light smoker: [<1/2 PPD]
14mg/day x 2 weeks then 7mg/day x 2 weeks
Procedure: Lumbar puncture, bedside
Exam Date: <today’s date>
Fellow: <Dr. _____>, Fellow in Neurocritical Care
Supervising Physician: <Dr. _____>
[Urgent] suspected CNS infection (not brain abscess or parameningeal process) – Patient presents with fever, AMS, headache, meningeal signs
[Urgent] suspected subarachnoid hemorrhage in patient with negative CT scan
[Nonurgent] Idiopathic intracranial HTN (pseudotumor cerebri)
[Nonurgent] Carcinomatous meningitis
[Nonurgent] tuberculous meningitis
[Nonurgent] normal pressure HCP
[Nonurgent] CNS syphilis
[Nonurgent] CNS vasculitis
[Others] MS, GBS, paraneoplastic
[therapeutic or diagnostic] spinal anesthesia, intrathecal chemo, intrathecal Abx, myelography or cisternography
CONSENT: Patient is alert and oriented to person, place and time and he/she appeared to understand the indications, risks and benefits of the procedure. Patient is able to give both verbal and written consent.
PROCEDURE: The patient was placed in a [right/left] sidelying osition. The skin overlying the L3-L4 interveertebral space was identified using the iliac crests as landmarks. This area was prepped and draped in sterile fashion. Skin and soft tissue anesthesia was achieved with 1% lidocaine, 5 mL. A [20/22]-gauge 3.5 inch spinal needle was introduced and advanced in a single puncture into the subarachnoid space. The stylet was removed with appropriate return of [clear] fluid. 40 mL of clear CSF was obtained and placed in 4 vials. These vials were identified with the patient’s name and medical record number. Needle was removed after adequate fluid collected. Blood loss was minimal.
The tubes were sent for the following tests:
Opening Pressure: obtained while patient in lateral decubitus position is ____ cm H2O
Fluid appearance: clear / bloody
The patient tolerated the procedure well, without any complaints. The procedure was completed without any complications.
Procedure – Lumbar Puncture
Indication – [insert here]
Anesthesia – local 1% lidocaine w/ epi
Informed consent was obtained from the patient. The area was prepped and draped in the usual sterile fashion. Using landmarks, a 22 guage spinal needle was inserted in the L4-L5 innerspace. The stylet was removed and the opening pressure was measured at 18 cm of water. 4cc of clear fluid was collected and sent for routine studies. CSF was also sent for [other studies].
The patient tolerated the procedure well. There was no blood loss or hematoma.