4- Medical Complications Flashcards
What type of neurogenic bladder do TBI patient develop? Urodynamic Result? Managment?ππ
TYPE
- Uninhibited detrusor contraction (UMN)
PRESENTATION
- Frequent urge incontinent
- Poor perception of bladder fullness
- Poor sphincter control
- Empties completely
URODYNAMIC STUDY
- Bladder volume is reduced
- Empties completely
- Small voids with normal residuals.
- Normal postvoiding intravesicular residual volumes
MANAGEMENT
- Time-void program (regular scheduled interval)
- Collecting device: Diaper for cognitive impairment
- Anticholinergic meds antimuscarinic effects on smooth muscle
- Antimuscarinic effects on smooth muscle β decreases detrusor tone β increases bladder capacity
- Oxybutynin (Ditropan): Extended-release: 5-10 mg/day PO; may be increased by 5 mg/day at weekly intervals; not to exceed 30 mg/day
- Vesicare: 5 mg PO qDay, may increase to 10 mg/day if well tolerated
- S/E: anticholenergic effects
Cuccurollo 4th Edition Chapter 2 TBI pg88
List 4 cognitive side effects of anticholinergic medications
- Sedation
- Drowsiness
- Dizzyness
- Confusion
- Hallucination
- Impaired concentration
- Impaired memory
Bowel dysfunction in TBI. ππ
Type
- Incontinence (Infection causing diarrhea, fecal impaction)
- Constipation (Impaired physical mobility, dehydration)
Management
- Dietary: hydration and high fiber diet
- Stool softeners
- Stimulant suppositories
Two most common hormones affected in TBI. ππ What life-threatening neuroendocrine abnormalities should be monitored post ABI? ππ
MOST COMMON
- Growth Hormone
- ADH
LIFE THREATENING
-
ACTH deficiency
- Low blood sugar (hypoglycemia)
- Low sodium (hyponatremia)
- Low blood pressure (hypotension)
-
ADH abnormalities
- DI can cause life-threatening hypernatremia
- SIADH can cause life-threatening hyponatremia
ERABI Module 10
List the hormones released by the anterior (6) and posterior (2) pituitary glands ππ Time frame of hormonal profile for TBI patient? what do you order? ππ
π‘ Recommend that all patients undergo endocrine function evaluation at 3 months and at 1-year post injury regardless of injury severity
ANTERIOR PITUITARY
- Prolactine
- FSH
- LH
- TSH & FT4
- ACTH β AM cortisol
- GH β Insulin growth factor (IGF)-I
POSTERIOR PITUITARY
- ADH
- Oxytocin
ERABI Module 10
With a TBI and shearing of the pituitary stalk, which part of the pituitary will be affected β anterior pituitary or posterior, and why?
Anterior pituitary will be affected, as blood supply travels through the stalk/infundibulum.
Posterior pituitary spared, because blood supply is through base of the skull.
List 5 risk factors for hypothalamic-pituitary axis dysfunction after an ABI?
Injury Severity
Location of injury (basal skull fractures, diffuse axonal injury)
Increased intracranial pressure
Glasgow Coma Scale score 3-12
Length of intensive care unit stay
Length of time post injury
ERABI Model 10
List 6 sign and symptoms of GH deficiency π
COGNITIVE
- Sleep disturbance, insomnia
- Low self-esteem
- Depression
- Headaches
- Decreased cognitive function, concentration, and memory
PREFORMANCE
- Fatigue, low energy
- Reduced exercise tolerance
- Reduced lean body mass and muscle wasting
- Increased visceral adiposity
- Dyslipidemia
GROWTH
- Osteoporosis
ERABI Module 10 pg11
List 3 clinical features of Acromegaly. π
- Frontal bossing
- Skeletal overgrowth deformities (large hands/feet, thick heel pad, frontal bossing, prognathism, macroglossia)
- Obstructive sleep apnea
- Hypertension
- Glucose intolerance / DM
- Peripheral nerve entrapment syndromes (CTS)
- Cardiomegaly
- Arthritis/joint pain
- Hyperhidrosis
- Soft tissue swelling and enlargement of extremities
https://emedicine.medscape.com/article/925446-clinical
Greenberg textbook pg 441
List 6 sign and symptoms of ACTH deficiency π
- Low blood pressure
- Low serum sodium (hyponatremia)
- Hypoglycemia
- Fatigue
- Weakness
- Hair loss
- Nausea and/or vomiting
- Loss of appetite (anorexia)
- Low quality of life
What are risk factors for hypopituitarism in TBI?
- Moderate-severe TBI (with GCS 10 or less)
- Diffuse brain swelling
- Hypotensive/hypoxic episode
Ref: Brain Injury Medicine p680
List 2 types of Hyponatremia in TBI
1- Normal extracellular volume (isovolemia)
Syndrome of inappropriate antidiuretic hormone secretion (SIADH)
2- Reduced extracellular volume (hypovolemia) β Common Exam Q
Cerebral salt wasting (CSW)
Cuccurollo 4th Edition Chapter 2 TBI pg90
Patient with TBI and hyponatremia ππ EXAM
List 2 Differential diagnoses & mechanism of each.
List 1 Investigation to distinguish between your DDx (Mention the results)
List 1 Specific treatment for each differential diagnosis.?
CSW (HypoNa+, Hypovolemia)
- Salt wasting (inability to resorb Na).
- Secondary volume depletion (hypovolemia).
- Resultant release of ADH (appropriate).
SIADH (HypoNa, Isovolemia)
- Inappropriate secretion ADH (plasma iso or hypo-osmolality).
- Inability to excrete water (water resorbed through aquaporins)
- Resultant hyponatremia and concentrated urine
DI (HyperNa+, Isovolemia)
- Disruption of ADH secretion from posterior pituitary (Fracture near sella turcica, tearing pituitary stalk, etc).
- Inability to resorb water from kidneys
Cuccurollo 4th Edition Chapter 2 TBI pg90
ERABI Module 10 pg16
How to differentiate between DI and CSW (3 marks) ππ
DI
- High Serum Na+
- High Serum Osmolality
- Low Urine Osmolality
CSW
- Hypovolemia (Decreased blood volume)
- Signs of dehydration
Cuccurollo 4th Edition Chapter 2 TBI pg91
For patients with disorders of sodium, such as hyponatremia (low serum sodium) or hypernatremia (high serum sodium), patients should be assessed for (4 marks) π
- Serum sodium
- Serum osmolality
- Urine sodium
- Urine osmolality
- Total body volume (hydration status)
- Urine output
- Serum ADH