The resident's electronic handbook ...
BRAIN
02/16/96 kaufmannm@ubaclu.unibas.ch
old new Conversion SI - old
CBF 50 ml/100g/min 0.5 ml/g/min x 100
delta pCO2 1 mmHg = CBF 1 - 2 ml/100g/min
cer.av-O2-Diff 6.7 ml/100 ml 3.0 mol/ml x 2.24
cer.av-Glc.-Diff. 9.0 mg/100ml 0.5 mol/ml x 18
cer.av-Lactat-Diff. 0.45 mg/100ml 0.05 mol/ml x 9
cer.O2-V. CMRO2 3.36 ml/100g/min 1.5 mol/g/min x 2.24
Liquor pH 7.30 - 7.32
Quantity 140 - 200 ml (2 ml/kg)
Specific Gravity 1,004 - 1,007 (4°C)
Pressure 0 - 150 mmHg (lateral position)
400 - 500 mmHg (sitting)
Na : 150 mmol/l
Potassium : 2.9 mmol/l Cl - 120 mmol/l
Ca2+ : 2 - 2.28 mmol/l Mg 2.3 mmol/l
Protein : 25 mg/dl
Glucose : 3 mmol/l Ventricle
2 mmol/l Lumbar
Osmolality : 289 mosmol/l
02/16/96 kaufmannm@ubaclu.unibas.ch
Beta Transfer Determination
- 1 normal cotton swab should be soaked in suspect fluid, then placed
in a sealed, dry container for transport.
- in addition, take a test tube of blood for determination of reference values
- send both to the chemistry laboratory for testing
02/16/96 kaufmannm@ubaclu.unibas.ch
Epanutin - Rapid Saturation
Epanutin must be injected direct into an iv-line, if possible via a central catheter
at a maximum rate of 50 mg (= 1 ml) per minute. Attention: Phlebitis and Cutaneous
Gangrene. After every injection slowly rinse with NaCl.
Dosage : 5 mg/kg iv
3 x in 2-hourly intervals (central)
Maintenance Dose: Start after 16 hours, then
2 x 175 mg/d (< 70 kg) iv
2 x 200 mg/d (> 70 kg) iv
Epanutin Level : on 5th day of Therapy ( Take blood before morning dose)
Target level : 15 mg/l (90% of patients between 10 - 20 mg/l)
2nd level control after 10 - 14 days
By Feeding Tube : Carbamazepine (Tegretol syrup) or orally (Capsule) if
Phenytoin allergic
Saturation dose : 5 mg/kg once
Maintenance dose : 3 x 100 mg/day for 3 days, then
from 4th day 3 x 200 mg/day
Serum level 5 - 7 days after first dose, with
3 x 200 mg (Take before morning dose) at least
1 h before or 2 h after Nagasonda, otherwise no
therapy level.
Attention : Do not give Epanutin orally with Antacids, as therapy level
will then not be attained.
50 - 55 kg 250 mg 70 - 75 kg 350 mg
55 - 60 kg 275 mg 75 - 80 kg 375 mg
60 - 65 kg 300 mg 80 - 85 kg 400 mg
65 - 70 kg 325 mg 85 - 90 kg 425 mg
02/16/96 kaufmannm@ubaclu.unibas.ch
Indications/Prognosis :
- ICP over 25-30 mmHg for longer than 20 minutes, if not responding to
therapy, use such methods as positioning, hyperventilation, osmotherapy.
- arterial hypotonia checked and treatable (MAP should be held at
> 90 mmHg)
- i.d.R. not over 65 years
- Grand-Mal Status not responding to therapy (see also)
Administration :
- Nembutal® (Pentobarbital) is incompatible with all medicines
and must be administered in a separate central line.
Control boluses can be injected into peripheral lines.
Side Effects :
- Fall in Blood Pressure
- Hypothermia
- Reduced bowel movements
- Toxic liver (Lab. checks)
- Increased danger of decubitus
Dosage :
- Adult bolus dose 5 mg/kg, maximum 3 boluses
- Child bolus dose 5-20 mg/kg, maximum 6 boluses
- Between each bolus wait 20 Minutes and closely document/monitor
ICP and MAP
- Maintenance 1-3 mg/kg/h
the maintenance dose should not be increased,
instead given as boluses direct using a perfusor syringe.
Terminate :
- if 3 boluses for an adult, resp. 6 boluses for a child
(< 16 years) produce no response (CPP < 60 mmHg)
- if MAP and ICP continue to sink even as boluses given (= Patient
does not respond verbally)
Discontinue :
- if during a 36-hour period, ICP remains < 20 and CPP remains > 60 mmHg
- if MAP after exclusion of other causes cannot be maintained
- if there is a drop in CPP despite level > 50 mg/l for adults
(> 70 mg/l children)
- stop immediately, no gradual reduction
- always stop the different therapies one at a time (first barbiturates, then
hyperventilation, etc.)
Level Control :
- quantitative i.d.R. daily (Tel. 4231 to arrange)
- on weekends a different machine is used in the laboratory
so results can vary slightly
02/16/96 kaufmannm@ubaclu.unibas.ch
Epileptic Attack / Epileptic status / Anti-epileptic
drugs
Priority Medicine Dosage iv Ther. Plasma- Remarks
Adults concentration
1. Diazepam 5-30mg
(Valium®) 0.1-0.3mg/kg
1. Clonazepam 0.5-2mg 0.08-0.24ymol/l
(Rivotril®)
2. Diphenylhydantoin 20-80ymol/l ECG-Control
(Epanutin®) 5 mg/kg centr. Cath..
2. Phenobarbital 200-400mg 45-170ymol/l daily Dosage
(Luminal®) 5 mg/kg 1-5mg/kg
2. Thiopental 1-2mg/kg
Primidone according to 20-70ymol/l
(Mysoline®) level
Carbamazepine according to 13-50ymol/l
(Tegretol®) level
Valproic Acid 1-3g po. 180-700ymol/l
(Depakine®)
Ethosuximide 20-40mg/kg/d po. 280-700ymol/l
(Suxinutin/Zarontin®)
If suspicion of alcohol deprivation epilepsy : Vitamin B1 100 mg iv (Benerva)
Therapy Protocol for Grand Mal Status :
Laboratory : ABGA, Electrolyte, Blood sugar, Anti-epileptic-level
Therapy :
1. Valium® upto 20 mg iv
2. Phenytoin (Epanutin® or Phenhydan®) 5 mg/kg iv
Quick saturation (see there)
Attack inhibited ?
Yes : Phenytoin Maintenance Dose 5 mg/kg/d po
No : 2 Possibilities:
a) Phenobarbital 5 mg/kg iv
b) Valium®-Infusion 8mg/h (=100mg in 500ml Glc.5%, 40ml/h)
Attack inhibited ?
Yes : Phenytoin Maintenance Dose 5 mg/kg/d po
No : Pentobarbital (Nembutal®)5 mg/kg max. 3 boluses, then
1-3 mg/kg/h
Attack inhibited ?
Yes : Phenytoin Maintenance Dose 5 mg/kg/Tag po
No : Increase Pentobarbital (until burst-suppression in
EEG, for example Neuro-track)
02/16/96 kaufmannm@ubaclu.unibas.ch
Glasgow Coma Scale
- Eye Opening (E)
Opens eyes spontaneously.......4
Opens eyes to voice................3
Opens eyes to pain..................2
No eye opening ......................1
- Best verbal response (V)
Appropriate and oriented........5
Confused conversation............4
Inappropriate sounds..............3
Incomprehensible sounds........2
No sounds.............................1
- Best motor response (M)
Obeys commands..................6
Localises to pain................... 5
Withdraws to pain.................4
Abnormal flexor response......3
Abnormal extensor response..2
No movement........................1
02/16/96 kaufmannm@ubaclu.unibas.ch
1 = Brain Death
2 = Coma or vegetative state
3 = Severe overall disability: conscious, dependent on
others for daily support
4 = Moderate cerebral disability: performs independent
activities of daily life, but is disable for competitive work
5 = Good overall performance: healthy, alert and capable
of normal life. Might have mild neurologic or psychologic deficit.
02/16/96 kaufmannm@ubaclu.unibas.ch
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