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Acute neuro topics
- TBI
- cranial surgeries
- SC injury
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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
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norm vs elevated ICP
- norm = 0-15 mmHg
- elevated = 15+ mmHg
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measure ICP if GCS is what
8 or below
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you treat ICP for how much pressure
20 mmHg or more
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epidural transducer
- not really used anymore
- device to measure ICP that doesn't enter skull/dura
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probe directly into brain measures
- brain tissue oxygen
- temperature
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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
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what is hypothermia treatment for brain trauma
- controversial
- stabilizes BBB
- decreases metabolic rate, which decreases CO2 and lactate)
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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
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with head trauma and ICP pt, be careful not to what re: fluid balance
overhydrate
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what solutions would you hang for a ICP pt
- hypertonic, i.e.
- D5NS
- D5LR
- D5.45NS
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osmolalities of hyper vs. hypo-tonic solutions
- hypotonic = less than 240
- hypertonic = greater than 340
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when is peak swelling for ICP/head trauma pt.
- 1-3 days
- after 3 days usually peak is over
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why is temp ctrl impt for ICP/head trauma pts
increased temp means increased metabolism, which increases CO2, which potently vasodilates, which increases swelling
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what is a potent vasodilator
CO2, and it will lead to cerebral edema
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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
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what do you do if BP is not high enough and you have an ICP pt
put them on pressors
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why would an ICP pt need a ventilator
to ctrl CO2 levels
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what ABG level would you want CO2 at for a ICP pt
nearer to the 35 end (low CO2 to decrease risk for edema)
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osmotic diuretics are for what
- fluid shifts from tissues to BVs via osmosis
- reduced ICP
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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
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name ALL osmotic diuretics
- mannitol (osmitrol)
- 3% saline drip (titrate per Na lvl sliding scale)
- 23% saline for severely high ICP
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if you have severely high ICP, hang what
23% saline
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what do you need to know re: 3% saline drip
- titrate per Na lvl sliding scale
- osmotic diuretic to help ctrl ICP
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what do you need to know re: mannitol?
- lose lots of water in urine, esp K+
- give lots of KCl w/ mannitol to replace
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what two med types give ICP pt
- osmotic diuretic
- corticosteroids
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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
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name 2 corticosteroids you give for ICP pt
- dexamethasone (decadron)
- medrol packs -- ctrls edema for cranial surgeries but not as helpful for TBI
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why put sb in barbiturate coma w/ phenobarbital
deeper coma causes person to shut down more metabolically, so decreases CO2 -- good!
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best indicator for neuro status changes
change in lvl of consciousness
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what does "changes in lvl of consciousness" look like
person may just be restless, confused, sleepy, or agitated
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cushing triad
- increase in systolic BP
- widened pluse pressure
- decrease in pulse
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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
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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
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most common nrain injury deficits
- motor/sensory changes
- cog. impairment
- headaches
- cranial nerve involvement
- tiredness
- memory problems
- difficulty walking
- poor back to work/school
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reasons for cranial surgery
brain tumors
evacuation of bleeding/hematomas
aneurysm clipping
drainage of brain abscesses
shunt insertions
insertion of PD/depression devices
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name 5 cranial surgeries
- Burr hole
- craniotomy
- cranioplasty
- stereotaxis
- shunt procedure (VP or VA)
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burr hole def and why
- remove blood beneath dura
- open into cranium with a drill
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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
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cranioplasty def and why
- repair of cranial defect r/t trauma
- artificial material may replace lost bone
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stereotaxis - why do
used for biopsy or radiosurgery
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shunt procedure (VP or VA shunt) does what
redirects CSF via a tube from ventricle to abdomen (or heart)
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main complication of cranial surgery
increased ICP
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NIs post-op cranial surgery
- freq neuro assess
- freq VS
- prevent ICP/positioning
- monitor dressing/incision
- pain mgmt
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what is the most critical factor for spinal cord injuries
edema, b/c it can make the condt worse than the original problem
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how to spinal cord injuries happen (4 mechanisms of injury)
- flexion
- compression
- hyperextension
- flexion-rotation
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how do you classify the level of injury for spinal cord injuries
- skeletal - damage to vertebral bones and ligaments
- neurological - cervical, thoracic, lumbar
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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
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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
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