-
Mannitol
- d/c ICP by drawing water into the vasculature
- *albumin for the brain
-
Diprivan (Propogol)
- sedative for anxiety
- d/c agitation
-
nimodipine
- oral CCB specific to the brain
- antispasmodic for subarachnoid hemorrhage
-
Solu-medrol
IV steroid to d/c inflammation
-
ICP
- 0-15
- i/c: space-occupying lesions, cerebral edema, CSF outflow obstruction, failure of compensatory mechanisms
-
CPP
- 60-100
- < 30 produces neuronal hypoxia, cell death
- CPP = MAP - ICP
-
Sodium
- 135-145
- i/c with DI
- d/c with SIADH
-
Serum osmolaity
- 285-300
- high: hypovolemia (DI)
- Low: hypervolemia (SIADH)
-
-
GCS: eye opening
- 4: spontaneous
- 3: to speech
- 2: to pain
- 1: none
-
GCS: verbal
- 5: oriented x3
- 4: confused
- 3: inappropriate words
- 2: incomprehensible sounds
- 1: none
-
GCS: Motor
- 6: obeys commands
- 5: localizes to pain
- 4: withdraws from pain
- 3: abnormal flexion
- 2: abnormal extension
- 1: no response
-
Oculocephalic reflex
- Dolls eyes
- Hold eyes open & turn head rapidly side to side
- Normal: eyes stay centered
- coma: eyes will move in the opposite direction
- bad: eyes move with ehad as if painted on
-
Oculovestibular
- irigate the auditory canal with iced water (20-50cc)
- Normal: eyes should slowly move toward the irrigated ear with rapid nytagmus away from the ear within 20-30 seconds
- Coma:
- Good (+): slow movement toward the ear & 2-3 minute delay to return to midline
- Bad (-): no response may indicate brain death
-
Vital signs: ususlaly late int he course of neurodysfunction
F°, BP, pulse
- F°: side variations especially if hypothalamus injured
- BP: i/c with i/c ICP
- Pulse: sinus tach w/ increasing ICP
-
Cushing's Triad
- late sign of herniation syndrome d/t pressure on the medulla in response to increasing ICP
- 1. bradycardia
- 2. systolic hypertension
- 3. widening pulse pressure
-
Cheyne-stokes respirations
most common respiratory pattern with unconsicous patients
-
Causes of subarachnoid hemorrhage
- -Aneurysm: localized dilation of aterial lumen (weak vessel)
- -AVM: tangled mas of arteries and veins presenting initially as a sz/hemorrhage
-
Complications of subarachnoid hemorrhage
Vasospasm (70% of pts 4-14 days after SAH)
-
Presentation of subarachnoid hemorrhage
explosive HA
-
Treatment of subarachnoidhemorrhage
- Aneurysm: clipping
- AVM: coiling/embolization
-
Treatment of vasospasm r/t subarachnoidhemorrhage
- -Triple H therapy: hypervolemia, hemodilution, hypertension
- -Nimodipine (antispasmodic)
- -Cerebral angioplasty (last resort)
-
Indicators for i/c ICP
- d/c LOC
- pupillary changes
- worsening HA
- cognitive deficits
- cushing's triad (late sign)
- irregular respiratory patterns
- bradycardia
- sz
- aphaseia, dysconjugate gaze
- hemiparesis/hemiplegia
-
Factors in i/c ICP
- venous outflow obstruction (pt positioning--never lay flat!)
- i/c intrathoracic pressure: anything that i/c BP will d/c venous return (PEEP, coughing)
-
Diabetes insipidus
- failure to release ADH (too little)
- large amount of dilute urine
- s/s: polyuria, low urine spc gr, polydipsia, high serum osmolarity, hyeprnatremia, hypovolemia
- tx. fluid replacement & ADH replacement
-
SIADH
- i/c secretion of ADH
- *water retention--scant urine with large amounts of sodium in the urine
- s/s: d/c UOP, i/c urine spc gr., low serum osmolaity, hyponatremia
- tx.: fluid restriction, replace sodium, fluorocortisone, hypertonic saline (3%NS), loop diuretics
-
Pupil abnormalities
- small: narcotics, damage to pons
- large: atropine, agitation, darkened room
- CNIII nerve compression
- Unequal: pressure in one side
- dilated & nonreactive pupils
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