Diferencia entre revisiones de «Lumbar puncture»

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== Correction for bloody tap ==
== Contraindications ==


#Nl Ratio: 700 RBCs to 1 WBC
#Protein: subtract 1mg/dL per 1000 RBCs
==Contraindications ==
#Infection at LP site
#Infection at LP site
#Severe thrombocytopenia (platelets <50) or bleeding diathesis or INR >1.5
#Severe thrombocytopenia (platelets <50) or bleeding diathesis or INR >1.5
#Mass lesion suspected (do CT or MRI first)
#Mass lesion suspected (do CT or MRI first)


== CT findings that prohibit LP ==
#Midline shift
##Look for unequal pressures between the 3 cerebral compartments (left/right supretentorial compartments, posterior fossa)
##Look for intracerebral masses not causing midline shift
#Obsutrictive hydrocephalus
##Look for enlargement of ventricles prox to lesions and normal ventricles distal (especially 4th ventricle)
#Basilar cisterns compressed
##Look for lateral/3rd ventricles may be small due to diffuse cerebral edema or enlarged due to obstr. hydroceph. +/- shift
#Posterior fossa mass
##Look for displacement/compression of 4th ventricle


== CT Head before LP ==


*If any of the following:


==CT Head before LP==
*If any of the following:
#AMS
#AMS
#Focal Neurologic deficit
#Focal Neurologic deficit
Línea 33: Línea 19:
#VP shunt
#VP shunt


<br/>NORMAL WBC


Preterm: <25
== CT findings that prohibit LP ==


Term: <22
#Midline shift
##Look for unequal pressures between the 3 cerebral compartments (left/right supretentorial compartments, posterior fossa)
##Look for intracerebral masses not causing midline shift
#Obsutrictive hydrocephalus
##Look for enlargement of ventricles prox to lesions and normal ventricles distal (especially 4th ventricle)
#Basilar cisterns compressed
##Look for lateral/3rd ventricles may be small due to diffuse cerebral edema or enlarged due to obstr. hydroceph. +/- shift
#Posterior fossa mass
##Look for displacement/compression of 4th ventricle


Child: <7
== Normal Values ==


*May also order: cytology, VDRL, AFB stain/culture (often requires lab medicine approval), fungal stain (fungal cultures often require lab medicine approval), Cryptococcal antigen (CrAg), India Ink, oligoclonal bands, MBP, Lyme titers, HSV PCR.
{| border="1" cellspacing="1" cellpadding="1" style="width: 500px; "
|-
| Parameter
| Preterm Infant
| Term Neonate
| Child
|-
| Celll Count (WBC)
| 9 (0-25) >30 suggests meningitis
| 8 (0-22) >30 suggests meningitis
| 0-7, >10 in child >1mo suggests meningitis
|-
| PMN (%)
| 57
| 61
| 0
|-
| Glucose
| 52 (24-63)
| 52 (34-119)
| 40-80
|-
| Protein
| 115 (65-150)
| 90 (20-170)
| 5-40
|-
| RBC
| 0
| 0
| 0
|}


== Laboratory Results ==


=== NORMAL ===


Appearance Clear


Glucose (mg/dl) 50-75% serum
== Subarachnoid Hemorrhage vs Bloody Tap ==


Protein (mg/dl) 15-45


Cell Count WBC 0-5


Differential 100% lymph, no PMN
#Xanthrochromia: suggestive of hemorrhage
#RBC <50 suggestive of bloody tap
#50-600 = gray zone)
#>600 c/w SAH
#Incr opening pressure c/w SAH


Pressure (cm H2O) 5-20


=== Traumatic LP ===
== <span class="Apple-style-span" style="font-size: 15px; font-weight: bold; ">Meningitis</span> ==


1000 RBC for 1mg/dL protein
=== <span class="Apple-style-span" style="font-size: 15px; font-weight: bold; " />Bacterial ===


700 -1000 RBC gives 1 WBC
#Appearance Cloudy or purulent
#Glucose (mg/dl) <40 or <40% serum
#Protein (mg/dl) >100-500
#Cell Count 100-100,000 (>5)
#Differential >80% PMN
#Pressure (cm H2O) Usually Inc


Xanthrochromia tube 4; results from RBC lysis and hemoglobin breakdown.
=== FUNGAL ===


=== HEMORRHAGE ===
#Appearance Clear or cloudy
#Glucose (mg/dl) 20-40
#Protein (mg/dl) 25-500
#Cell Count 25-1000
#Differential mono & lymph
#Pressure (cm H2O) N or I
#India ink 50% sensitivity
#LA assay for crypto antigen 80%.


Appearance Bloody or xantho
=== Aseptic/Viral<br/> ===


Glucose (mg/dl) N or D
#
=== <span class="Apple-style-span" style="font-size: 12px; font-weight: normal; ">Appearance Clear</span> ===


Protein (mg/dl) Inc but <1000
#Glucose (mg/dl) N or D
#Protein (mg/dl) 50-200
#Cell Count WBC 10-100
#Differential Inc mono & PMN early, then lymph.
#Pressure (cm H2O) N or I


Cell Count RBC (<~50 okay)
=== TB ===


(50-600 = gray zone)
#Appearance Cloudy
#Glucose (mg/dl) <40
#Protein (mg/dl) 100-2000
#Cell Count 50-500
#Differential Most lymph, some PMN
#Pressure (cm H2O) Usually I


(>600 c/w SAH)
=== HSV ===


Differential Same as blood
#Appearance Bloody or xantho
#Glucose (mg/dl) N or D
#Protein (mg/dl) 50-100
#Cell Count 20-500
#Differential Mostly lymph
#Pressure (cm H2O) N or I


Pressure (cm H2O) Usually Inc
=== Neoplasm ===


=== BACTERIAL MENINGITIS ===
#Appearance Clear or xantho
#Glucose (mg/dl) 40-80
#Protein (mg/dl) 50-1000
#Cell Count <100
#Differential Mostly lymph
#Pressure (cm H2O) Usually I


Appearance Cloudy or purulent
=== Guillain-Barre<br/> ===


Glucose (mg/dl) <40 or <40% serum
#
=== <span class="Apple-style-span" style="font-size: 12px; font-weight: normal; ">Appearance Clear or cloudy</span> ===


Protein (mg/dl) >100-500
#Glucose (mg/dl) Normal
#Protein (mg/dl) slight Inc
#Cell Count <100
#Differential Mostly lymph
#Pressure (cm H2O) Normal


Cell Count 100-100,000 (>5)
=== <span class="Apple-style-span" style="font-size: 19px; ">Source</span> ===


Differential >80% PMN
Emergency Radiology: Case Studies Schwartz


Pressure (cm H2O) Usually Inc


=== FUNGAL MENINGITIS ===


Appearance Clear or cloudy
Hasbun, R. et al, (Yale), NEJM, Dec 13, 2001. (prospective, 301 pts)
 
Glucose (mg/dl) 20-40


Protein (mg/dl) 25-500


Cell Count 25-1000
Differential mono& lymph
Pressure (cm H2O) N or I
India ink 50% sensitivity
LA assay for crypto antigen 80%.
=== ASEPTIC/VIRAL MENINGITIS ===
Appearance Clear
Glucose (mg/dl) N or D
Protein (mg/dl) 50-200
Cell Count WBC 10-100
Differential Inc mono & PMN early, then lymph.
Pressure (cm H2O) N or I
=== TB MENINGITIS ===
Appearance Cloudy
Glucose (mg/dl) <40
Protein (mg/dl) 100-2000
Cell Count 50-500
Differential Most lymph, some PMN
Pressure (cm H2O) Usually I
=== HERPES ENCEPHALITIS ===
Appearance Bloody or xantho
Glucose (mg/dl) N or D
Protein (mg/dl) 50-100
Cell Count 20-500
Differential Mostly lymph
Pressure (cm H2O) N or I
=== NEOPLASM ===
Appearance Clear or xantho
Glucose (mg/dl) 40-80
Protein (mg/dl) 50-1000
Cell Count <100
Differential Mostly lymph
Pressure (cm H2O) Usually I
=== GUILLAIN-BARR ===
Appearance Clear or cloudy
Glucose (mg/dl) Normal
Protein (mg/dl) slight Inc
Cell Count <100
Differential Mostly lymph
Pressure (cm H2O) Normal
=== NEUROSYPHILIS ===
Appearance Clear & cloudy
Glucose (mg/dl) Normal
Protein (mg/dl) 40-200
Cell Count 200-500
Differential Mostly lymph & mono
Pressure (cm H2O) N or I
== Lumbar Puncture Note ==
#Consent
#Indication
#Pressure
#Color
#Amount
#Tests
#Interspace
#Anesthesia
#Position
#Pt. tolerance
==Source==
Emergency Radiology: Case Studies Schwartz
Hasbun, R. et al, (Yale), NEJM, Dec 13, 2001. (prospective, 301 pts)


<br/>[[Category:Neuro]] <br/>[[Category:Procedures]] <br/> <br/><br/>
[[Category:Neuro]] <br/>[[Category:Procedures]] <br/><br/>

Revisión del 21:40 30 jun 2011

Contraindications

  1. Infection at LP site
  2. Severe thrombocytopenia (platelets <50) or bleeding diathesis or INR >1.5
  3. Mass lesion suspected (do CT or MRI first)


CT Head before LP

  • If any of the following:
  1. AMS
  2. Focal Neurologic deficit
  3. Papilledema
  4. Head Trauma or h/o CNS disease (recent or remote)
  5. New Onset Sz (<1 wk prior to ED visit)
  6. HIV + / AIDS or any immunocompromised (transplant pt, steroids, cancer) patient
  7. Age > 60.
  8. VP shunt


CT findings that prohibit LP

  1. Midline shift
    1. Look for unequal pressures between the 3 cerebral compartments (left/right supretentorial compartments, posterior fossa)
    2. Look for intracerebral masses not causing midline shift
  2. Obsutrictive hydrocephalus
    1. Look for enlargement of ventricles prox to lesions and normal ventricles distal (especially 4th ventricle)
  3. Basilar cisterns compressed
    1. Look for lateral/3rd ventricles may be small due to diffuse cerebral edema or enlarged due to obstr. hydroceph. +/- shift
  4. Posterior fossa mass
    1. Look for displacement/compression of 4th ventricle

Normal Values

Parameter Preterm Infant Term Neonate Child
Celll Count (WBC) 9 (0-25) >30 suggests meningitis 8 (0-22) >30 suggests meningitis 0-7, >10 in child >1mo suggests meningitis
PMN (%) 57 61 0
Glucose 52 (24-63) 52 (34-119) 40-80
Protein 115 (65-150) 90 (20-170) 5-40
RBC 0 0 0



Subarachnoid Hemorrhage vs Bloody Tap

  1. Xanthrochromia: suggestive of hemorrhage
  2. RBC <50 suggestive of bloody tap
  3. 50-600 = gray zone)
  4. >600 c/w SAH
  5. Incr opening pressure c/w SAH


Meningitis

Bacterial

  1. Appearance Cloudy or purulent
  2. Glucose (mg/dl) <40 or <40% serum
  3. Protein (mg/dl) >100-500
  4. Cell Count 100-100,000 (>5)
  5. Differential >80% PMN
  6. Pressure (cm H2O) Usually Inc

FUNGAL

  1. Appearance Clear or cloudy
  2. Glucose (mg/dl) 20-40
  3. Protein (mg/dl) 25-500
  4. Cell Count 25-1000
  5. Differential mono & lymph
  6. Pressure (cm H2O) N or I
  7. India ink 50% sensitivity
  8. LA assay for crypto antigen 80%.

Aseptic/Viral

Appearance Clear

  1. Glucose (mg/dl) N or D
  2. Protein (mg/dl) 50-200
  3. Cell Count WBC 10-100
  4. Differential Inc mono & PMN early, then lymph.
  5. Pressure (cm H2O) N or I

TB

  1. Appearance Cloudy
  2. Glucose (mg/dl) <40
  3. Protein (mg/dl) 100-2000
  4. Cell Count 50-500
  5. Differential Most lymph, some PMN
  6. Pressure (cm H2O) Usually I

HSV

  1. Appearance Bloody or xantho
  2. Glucose (mg/dl) N or D
  3. Protein (mg/dl) 50-100
  4. Cell Count 20-500
  5. Differential Mostly lymph
  6. Pressure (cm H2O) N or I

Neoplasm

  1. Appearance Clear or xantho
  2. Glucose (mg/dl) 40-80
  3. Protein (mg/dl) 50-1000
  4. Cell Count <100
  5. Differential Mostly lymph
  6. Pressure (cm H2O) Usually I

Guillain-Barre

Appearance Clear or cloudy

  1. Glucose (mg/dl) Normal
  2. Protein (mg/dl) slight Inc
  3. Cell Count <100
  4. Differential Mostly lymph
  5. Pressure (cm H2O) Normal

Source

Emergency Radiology: Case Studies Schwartz


Hasbun, R. et al, (Yale), NEJM, Dec 13, 2001. (prospective, 301 pts)


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