More Neuro Crud!!!

• Decreased LOC
• Pupillary changes....CN #3
• BP changes
• Pulse changes
• RR changes
• Increased temp
• Loss of motor fxn
• Papilledema
• Headache
• Vomitting

• first occurs on ipsilateral side
• then constriction to dilation
• from sluggish to non reactive
• Ptosis
• terminal.... is fixed bilateral pupils

• initially systemic increase with widened pulse pressure
• as patient deteriorates BP will fail

• increase with compensatory stage
• decreases and decompensating
• end becomes irregular and thready

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

only the brain stem is functioning

arms adducted and stiffly extended at the elbows with forearms pronated and wrists, hands and fingers flexed....to the outside

they are extended

it is a late sign of ICP, due to interrupted blood flow

seen as blurred disc borders, distended veins, pulseless arteries

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

• LOC-not arrousable
• Motor signs-no response
• Pupils-one blown pupil, then both are fixed and dilated
• BP, P, RR-Cushings Triad

• Increased SBP
• Brady
• Abnormal Respirations

keep it below 20

directly measures ICP

it is placed in the right side of the brain, in to the right ventircle

advantage....accurate measurement of CSF

disadvantage....risk of infection

Licox monitor

it's inserted in to ischemic brain tissue to directly measure brain tissue oxygen levels

20-35

• ABCD
• Monitor ICP
• CT scan
• Maintain CPP at 70-100

• drain the ventricles
• hyperventilation
• osmotic therapy....minnitor

• Decompressive craniectomy
• High dose barbituates
• Aggressive hyperventilation

bed at 30 and head in neural position

• maintain fluid balance
• maintain SBP from 100-160
• maintain CPP >70
• reduce cerebral metabolism

• propofol
• cool patient
• anti convulsants

brief periods of hyperventilation may be useful in refractory intracranial hypertension

SCD's or TEDS....not Lovenox or Heparin.....bleeding problems???

ineffective cerebral tissue perfusion

ineffective airway clearance

blunt trauma

fracture with piercing of the skull

site of impact

brain bounces back and forth

gun shot wound

stress within the brain from trauma

increase in ICP

Minor 13-15, will observe and treat

Major <8, long critical care stay

• #1 ABC
• cervical spine precautions
• monitor ICP
• max brain O2
• assess for other injuries
• seizure precautions
• monitor/manage temp

crack in the surface of the skull without bony displacement

inward depression of bone fragments

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

fracture at the base of the skull....this is complex cuz it is close to the brain stem

• Monitor neuro status, LOC
• watch for signs if increased ICP

change in HR, BP, RR....close to brain stem

• Rhinorrhea
• Raccoon eyes
• Otorrhea-leaking from ear
• Battle sign-blood by ears

• LAY PATIENT FLAT!!
• Manage HR, BP and RR
• Look at CSF if it is leaking for Halo sign
• Treat increased ICP

mild damage to the brain that affects gray matter....structural damage...minor head trauma

• brief loss of consciousness
• amnesia
• brady
• loss of reflexes

can have post concussion syndrome for up to 1 year or more

• 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

• stay with patient
• assess pupils and LOC
• check q2h
• take Tylenol....but not aspirin
• no sedatives
• no alcohol for 48 hrs

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

actual tearing of brain tissues....considered major head trauma

• can NOT repair surgically...prognosis is poor.
• Manage ABC's, control bleeding and watch ICP

• loss of neuro fxn
• hemorrhage/hematoma
• seizures
• cerebral edema
• increased ICP

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

• decreased LOC
• decerbration/decortication
• increased ICP

secondary injury caused by vascular damage by shearing force of trauma

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

pass out, come back around, then pass out again

• acute-happened within 48 hrs
• sub acute- 48 hrs to 2 weeks
• chronic-2 weeks to months

• possible LOC decrease
• possible seizures
• symptoms of increased ICP
• headache
• lethargy
• confusion

arterial

• Manage ABC's
• control bleeding and watch ICP

If no problems....may observe and make sure not on anti coagulants

bleeding within cerebral tissues

FOCUS on controlling ICP and bleeding...possible surgery

bleeding in to the subarachnoid spaced 

caused by aneurysms

loss of 30-50mL

a microorganism wears at the wall of a vessel...making it weak and creating a tear, allowing for bleeding

• ABC
• control bleeding
• watch ICP
• manage vasospasm
• surgery-coil/clip

• Hypertensives....bp needs to be higher to increase tissue perfusion
• Hypervolemic....give lots of fluids
• Hemodilution

waxing and waining.....

spasm=

no spasm=

• dim lights
• limit visitors
• decrease stimulation
• elevate HOB
• avoid valsalva
• give sedatives/analgesics

irreversible cessation of all functions of the entire brain, including the brain stem

• 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

• coma/unresponsiveness
• absence of cerebral responsiveness
• absense of cerebral motor responses to pain in all extremeties
• absence of brain stem reflexes and apnea

• no gag
• no cough
• no corneal reflex
• negative dolls eyes
• negative occulovestibular reflex
• wont be breathing above ventilator set rate

• EEG....30 min. of nothing
• Transcranial doppler...dr. does
• somatosensory and brain stem auditory evoked

• it is no reversible
• time of death is determined and stated as the time they were determined brain dead

Spouse is the 1st....if no spouse, then adult kids

wake up with a headache, but feel better as they walk around because venous return is decreasing because of gravity

all intercranial tumors, even benign ones are potentially fatal

• from local destruction and compression of brain tissues
• progressive increase in ICP can cause herniation

6-18 months

• headache
• N/V
• Papilledema
• Seizures
• Dizzy/vertigo
• change in mental status...tired, confused

early dx and treatment!!!

meant for evacuation of extra cerebral clot or in prep for craniotomy

suck out clot

surgical opening of the skull to provide acfcess to the brain in order to remove a tumor, aneurysm or clot

portion of the skull is removed to relieve cerebral edema