-
Acute neuro topics
- TBI
- cranial surgeries
- SC injury
-
TBI stats/facts
- 1.4 million per yr treated in USA
- 50,000 die immediately
- 250,000 hospitalized each year
- high chance for residual deficits
-
norm vs elevated ICP
- norm = 0-15 mmHg
- elevated = 15+ mmHg
-
measure ICP if GCS is what
8 or below
-
-
you treat ICP for how much pressure
20 mmHg or more
-
epidural transducer
- not really used anymore
- device to measure ICP that doesn't enter skull/dura
-
probe directly into brain measures
- brain tissue oxygen
- temperature
-
microdialysis
- w/ catheter into brain tissue
- samples are take periodically
- analyze glucose, lactate, pyruvate, glutamate
- determine changes in cellular nrg metabolism to help understand mechanisms of secondary injury
-
what is hypothermia treatment for brain trauma
- controversial
- stabilizes BBB
- decreases metabolic rate, which decreases CO2 and lactate)
-
NIs for head trauma and increased ICP
- fluid balance
- stimulation/activity
- positioning
- temp ctrl
- pain ctrl
- valsalva's maneuver
- CSF drainage
- BP
- ABGs (CO2)
- medications
- barbiturate coma
- assessment
-
with head trauma and ICP pt, be careful not to what re: fluid balance
overhydrate
-
what solutions would you hang for a ICP pt
- hypertonic, i.e.
- D5NS
- D5LR
- D5.45NS
-
osmolalities of hyper vs. hypo-tonic solutions
- hypotonic = less than 240
- hypertonic = greater than 340
-
when is peak swelling for ICP/head trauma pt.
- 1-3 days
- after 3 days usually peak is over
-
why is temp ctrl impt for ICP/head trauma pts
increased temp means increased metabolism, which increases CO2, which potently vasodilates, which increases swelling
-
what is a potent vasodilator
CO2, and it will lead to cerebral edema
-
do you want high or low BP re: ICP pt
- high, to assure perfusion
- body will attempt to do this on its own via cushings triad
-
what do you do if BP is not high enough and you have an ICP pt
put them on pressors
-
why would an ICP pt need a ventilator
to ctrl CO2 levels
-
what ABG level would you want CO2 at for a ICP pt
nearer to the 35 end (low CO2 to decrease risk for edema)
-
osmotic diuretics are for what
- fluid shifts from tissues to BVs via osmosis
- reduced ICP
-
name an osmotic diuretic for ICP ctrl
- mannitol (osmitrol)
- hyperosmotic diuretic
- causes fluid to move from brain tissue to BVs
- give KCl w/ it to replace K+ lost in urine
-
name ALL osmotic diuretics
- mannitol (osmitrol)
- 3% saline drip (titrate per Na lvl sliding scale)
- 23% saline for severely high ICP
-
if you have severely high ICP, hang what
23% saline
-
what do you need to know re: 3% saline drip
- titrate per Na lvl sliding scale
- osmotic diuretic to help ctrl ICP
-
what do you need to know re: mannitol?
- lose lots of water in urine, esp K+
- give lots of KCl w/ mannitol to replace
-
what two med types give ICP pt
- osmotic diuretic
- corticosteroids
-
what need to know re: corticosteroids for ICP pts
- must be tapered off; can't stop them abruptly
- causes BG to go up; sometimes give insulin w/ it
-
name 2 corticosteroids you give for ICP pt
- dexamethasone (decadron)
- medrol packs -- ctrls edema for cranial surgeries but not as helpful for TBI
-
why put sb in barbiturate coma w/ phenobarbital
deeper coma causes person to shut down more metabolically, so decreases CO2 -- good!
-
best indicator for neuro status changes
change in lvl of consciousness
-
what does "changes in lvl of consciousness" look like
person may just be restless, confused, sleepy, or agitated
-
cushing triad
- increase in systolic BP
- widened pluse pressure
- decrease in pulse
-
symptoms of increased ICP
- changes in lvl of consciousness
- headache
- visual disturbances
- vomitting
- resp changes (cheyne-stokes, hypervent., cluster, ataxic)
- VS changes
- cushing triad
- papiledema
- motor/sensory dysfunction
- CN dysfunction
- cerebellar signs: imbalance, unsteady, incoord.
- changes in reflexes
-
factors influencing outcome of ICP pt
- extent/type of injury
- increased age - elderly do worse
- abn motor response
- absent eye mvmt or pupil light reflexes
- early hypotension, hypoxemia, hypercapnia
- medical and nursing care
-
most common nrain injury deficits
- motor/sensory changes
- cog. impairment
- headaches
- cranial nerve involvement
- tiredness
- memory problems
- difficulty walking
- poor back to work/school
-
reasons for cranial surgery
brain tumors
evacuation of bleeding/hematomas
aneurysm clipping
drainage of brain abscesses
shunt insertions
insertion of PD/depression devices
-
name 5 cranial surgeries
- Burr hole
- craniotomy
- cranioplasty
- stereotaxis
- shunt procedure (VP or VA)
-
burr hole def and why
- remove blood beneath dura
- open into cranium with a drill
-
craniotomy def and why
- open into cranium w/ removal of bone flap to excise tumor, abscess, clot, lesion, or to relieve ICP
- drains may be placed, ICU until stable
-
cranioplasty def and why
- repair of cranial defect r/t trauma
- artificial material may replace lost bone
-
stereotaxis - why do
used for biopsy or radiosurgery
-
shunt procedure (VP or VA shunt) does what
redirects CSF via a tube from ventricle to abdomen (or heart)
-
main complication of cranial surgery
increased ICP
-
NIs post-op cranial surgery
- freq neuro assess
- freq VS
- prevent ICP/positioning
- monitor dressing/incision
- pain mgmt
-
what is the most critical factor for spinal cord injuries
edema, b/c it can make the condt worse than the original problem
-
how to spinal cord injuries happen (4 mechanisms of injury)
- flexion
- compression
- hyperextension
- flexion-rotation
-
how do you classify the level of injury for spinal cord injuries
- skeletal - damage to vertebral bones and ligaments
- neurological - cervical, thoracic, lumbar
-
cervical (neck) injuries result in what for pt
- quadriplegia
- above C4 may require ventilator
- loss of resp/chest muscles
- motor/sensory loss of upper and lower extremities
-
thoracic/lumbar level injuries result in what for pt
- paraplegia
- poor trunk ctrl as result of lack of abd muscles
- motor/sensory loss of lower extremities
|
|