More Neuro Crud!!!

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  1. Clinical manifestations of Increased ICP
    • Decreased LOC
    • Pupillary changes....CN #3
    • BP changes
    • Pulse changes
    • RR changes
    • Increased temp
    • Loss of motor fxn
    • Papilledema
    • Headache
    • Vomitting
  2. How do pupils change with increased ICP?
    • first occurs on ipsilateral side
    • then constriction to dilation
    • from sluggish to non reactive
    • Ptosis
    • terminal.... is fixed bilateral pupils
  3. BP changes with increased ICP
    • initially systemic increase with widened pulse pressure
    • as patient deteriorates BP will fail
  4. Pulse and increased ICP
    • increase with compensatory stage
    • decreases and decompensating
    • end becomes irregular and thready
  5. Decorticate posturing....tells me what?  Describe.
    cerebral cortex isnt functioning, and diencephalon is in control

    upper arms are tight to sides with elbows, wrists and fingers flexed...coming in to their core
  6. Decerebrate posturing....tells me what?  Describe.
    only the brain stem is functioning

    arms adducted and stiffly extended at the elbows with forearms pronated and wrists, hands and fingers the outside
  7. What are the feet doing with decerebrate and decorticate posturing?
    they are extended
  8. What's papilledema?
    it is a late sign of ICP, due to interrupted blood flow

    seen as blurred disc borders, distended veins, pulseless arteries
  9. Changes I will see when a patient is starting to get in to trouble from increasing ICP
    LOC-not patient needs more stimulation to display the same response

    Motor- was a 5/5 and now is a 4/5

    Pupils-they are now sluggish

    BP, P, RR-no reliable changes
  10. Changes I will see when a patient is in the late stages of increased ICP and it is not good.....
    • LOC-not arrousable
    • Motor signs-no response
    • Pupils-one blown pupil, then both are fixed and dilated
    • BP, P, RR-Cushings Triad
  11. Cushings Triad
    • Increased SBP
    • Brady
    • Abnormal Respirations
  12. What is the goal for measuring ICP?
    keep it below 20
  13. What does a Intraventricular catheter do?  How?
    directly measures ICP

    it is placed in the right side of the brain, in to the right ventircle
  14. Advantages and Disadvanges of Intraventricular catheter
    advantage....accurate measurement of CSF

    disadvantage....risk of infection
  15. How do you monitor brain tissue oxygenation?
    Licox monitor

    it's inserted in to ischemic brain tissue to directly measure brain tissue oxygen levels
  16. What is a normal Licox monitor reading for oxygen?
  17. First tier treatment for a person with increasing ICP
    • ABCD
    • Monitor ICP
    • CT scan
    • Maintain CPP at 70-100
  18. In first tier therapy for a person with increased ICP how do I maintain CPP between 70-100?
    • drain the ventricles
    • hyperventilation
    • osmotic therapy....minnitor
  19. Second tier treatment for a person with increasing ICP
    • Decompressive craniectomy
    • High dose barbituates
    • Aggressive hyperventilation
  20. How do you position a person with increased ICP?
    bed at 30 and head in neural position
  21. How do you make sure the brain is being perfused with increased ICP?
    • maintain fluid balance
    • maintain SBP from 100-160
    • maintain CPP >70
    • reduce cerebral metabolism
  22. How do you reduce cerebral metabolism?
    • propofol
    • cool patient
    • anti convulsants
  23. What does hyperventilation do?
    brief periods of hyperventilation may be useful in refractory intracranial hypertension
  24. In a person with increased ICP, how do we prevent DVT's?
    SCD's or TEDS....not Lovenox or Heparin.....bleeding problems???
  25. 2 nursing diagnoses for a person with increased ICP
    ineffective cerebral tissue perfusion

    ineffective airway clearance
  26. Closed head injury
    blunt trauma
  27. Open head injury
    fracture with piercing of the skull
  28. Coup injury
    site of impact
  29. Countercoup injury
    brain bounces back and forth
  30. Missile injury
    gun shot wound
  31. Primary head injury
    stress within the brain from trauma
  32. Secondary head injury
    increase in ICP
  33. Minor head injury vs. Major head injury....glasgow coma scale score and intervention
    Minor 13-15, will observe and treat

    Major <8, long critical care stay
  34. What will I do to manage a person with head trauma
    • #1 ABC
    • cervical spine precautions
    • monitor ICP
    • max brain O2
    • assess for other injuries
    • seizure precautions
    • monitor/manage temp
  35. Linear skull fx
    crack in the surface of the skull without bony displacement
  36. Depressed skull fx
    inward depression of bone fragments
  37. Compound skull fx
    depressed skull fx with laceration of the scalp, allowing for a communication pathway to intracranial cavity

    bleeding with bony displacement of skull

    will need surgery
  38. Basilar skull fx
    fracture at the base of the skull....this is complex cuz it is close to the brain stem
  39. How do we treat linear, depressed and compound skull fx's?
    • Monitor neuro status, LOC
    • watch for signs if increased ICP
  40. What will I see in a person with basilar skull fx?
    change in HR, BP, RR....close to brain stem

    • Rhinorrhea
    • Raccoon eyes
    • Otorrhea-leaking from ear
    • Battle sign-blood by ears
  41. How do I treat a person with a basilar skull fx?
    • Manage HR, BP and RR
    • Look at CSF if it is leaking for Halo sign
    • Treat increased ICP
  42. Concussion
    mild damage to the brain that affects gray matter....structural damage...minor head trauma
  43. Patient presentation when they have a concussion
    • brief loss of consciousness
    • amnesia
    • brady
    • loss of reflexes

    can have post concussion syndrome for up to 1 year or more
  44. What do I monitor on a patient who has a concussion?
    • neuro status
    • LOC
    • signs of deterioration
    • signs of increased ICP
    • pupil changes
    • vomiting
    • headache

    wake patient up q 2hours and ask them a question they need to think about to answer.  Not something easy, like what is your name
  45. Teach the family when a person has a concussion....
    • stay with patient
    • assess pupils and LOC
    • check q2h
    • take Tylenol....but not aspirin
    • no sedatives
    • no alcohol for 48 hrs
  46. What a contusion? and how do I treat them?
    a bruising of the brain, may be at the site (coup)or contra coup (opposite side) of the injury

    • ABC management
    • control bleeding
    • watch for increase in ICP
  47. Brain laceration and how do I treat them?
    actual tearing of brain tissues....considered major head trauma

    • can NOT repair surgically...prognosis is poor.
    • Manage ABC's, control bleeding and watch ICP
  48. If a person has a brain laceration, how will they present?
    • loss of neuro fxn
    • hemorrhage/hematoma
    • seizures
    • cerebral edema
    • increased ICP
  49. Diffuse Axonal Injury (DAI)....and how will I treat?
    widespread axonal damage occurring after a brain injury...seen as little dots in CT scan.  Major head trauma

    usually been in a car accident

    Manage ABC and watch ICP
  50. What will a person with Diffuse Axonal Injury present to me like?
    • decreased LOC
    • decerbration/decortication
    • increased ICP
  51. Hemorrhage
    secondary injury caused by vascular damage by shearing force of trauma
  52. Epidural Hematoma vs. Subdural Hematoma
    epidural....bleeding between the skull and dura matera

    subdural.....venous bleeding in to the space beneath the dura and above the arachnoid from the tearing of bridging veins or a laceration of brain tissues
  53. If a person has an arterial hematoma, they will....
    pass out, come back around, then pass out again
  54. Acute, sub acute and chronic subdural hematomas
    • acute-happened within 48 hrs
    • sub acute- 48 hrs to 2 weeks
    • chronic-2 weeks to months
  55. How will a person present that has an epidural/subdural hematoma?
    • possible LOC decrease
    • possible seizures
    • symptoms of increased ICP
    • headache
    • lethargy
    • confusion
  56. Which type of hematoma is a medical emergency requiring surgery?"
  57. How do we manage a person with a hematoma?
    • Manage ABC's
    • control bleeding and watch ICP

    If no problems....may observe and make sure not on anti coagulants
  58. Intracerebral hematoma....and how do I manage?
    bleeding within cerebral tissues

    FOCUS on controlling ICP and bleeding...possible surgery
  59. Subarachnoid Hematoma
    bleeding in to the subarachnoid spaced 

    caused by aneurysms
  60. How much is a massive brain bleed?
    loss of 30-50mL
  61. What is a mycotic subarachnoid hematoma?
    a microorganism wears at the wall of a vessel...making it weak and creating a tear, allowing for bleeding
  62. How do we treat a subarachnoid hematoma/aneurysm?
    • ABC
    • control bleeding
    • watch ICP
    • manage vasospasm
    • surgery-coil/clip
  63. Describe H therapy after a clip has been done to a person who had an aneurysm?
    • Hypertensives....bp needs to be higher to increase tissue perfusion
    • Hypervolemic....give lots of fluids
    • Hemodilution
  64. S/S of a person has a vasospasm in the brain?
    waxing and waining.....


    no spasm=
  65. What are aneurysm precautions for a person with an aneurysm, prior to surgery?
    • dim lights
    • limit visitors
    • decrease stimulation
    • elevate HOB
    • avoid valsalva
    • give sedatives/analgesics
  66. Definition of brain death
    irreversible cessation of all functions of the entire brain, including the brain stem
  67. Criteria for clinical determination of brain death
    • Clinical/neuro image of proof of dx -trauma/hemmorhage CT/MRI
    • Exclusion of conditions that may confound clinical assessment of brain death (acute metabolic or endocrine problems....get normal labs)
    • Confirmation of the absence of drug intoxication or poisoning
    • Core body temp >32...must be warm
  68. Cardinal findings in brain death
    • coma/unresponsiveness
    • absence of cerebral responsiveness
    • absense of cerebral motor responses to pain in all extremeties
    • absence of brain stem reflexes and apnea
  69. Give examples of absence of brain stem reflexes
    • no gag
    • no cough
    • no corneal reflex
    • negative dolls eyes
    • negative occulovestibular reflex
    • wont be breathing above ventilator set rate
  70. Confirmatory tests for the determination of brain death
    • EEG....30 min. of nothing
    • Transcranial doppler...dr. does
    • somatosensory and brain stem auditory evoked
  71. Misconception about brain death....
    • it is no reversible
    • time of death is determined and stated as the time they were determined brain dead
  72. Who can consent to the donation of organs?
    Spouse is the 1st....if no spouse, then adult kids
  73. How do people with brain tumors feel in the am, and as the day goes on?
    wake up with a headache, but feel better as they walk around because venous return is decreasing because of gravity
  74. Fatal brin tumors?
    all intercranial tumors, even benign ones are potentially fatal

    • from local destruction and compression of brain tissues
    • progressive increase in ICP can cause herniation
  75. Life expectancy of a person with a glioma brain tumor
    6-18 months
  76. S/S of brain tumors
    • headache
    • N/V
    • Papilledema
    • Seizures
    • Dizzy/vertigo
    • change in mental status...tired, confused
  77. What is the most important treatment for a person with a brain tumor?
    early dx and treatment!!!
  78. What do burr holes do?
    meant for evacuation of extra cerebral clot or in prep for craniotomy

    suck out clot
  79. Craniotomy
    surgical opening of the skull to provide acfcess to the brain in order to remove a tumor, aneurysm or clot
  80. Craniectomy
    portion of the skull is removed to relieve cerebral edema
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More Neuro Crud!!!
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