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Critical Care > ACUTE INTRACRANIAL PROBLEMS > Flashcards

ACUTE INTRACRANIAL PROBLEMS Flashcards

1
Q

Three components of ICP

A

Brain tissue 78%
Blood 12%
CSF 10%

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2
Q

Primary injury

A

occurs at the initial time of an injury

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3
Q

Secondary injury

A 
resulting in:
-hypoxemia
-ischemia
-hypotension
-edema
-increased ICP 
follows the primary injury
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4
Q

Monroe-Kellie Hypothesis

A

If one of the three components goes up and the other two will try to compensate

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5
Q

Factors that influence ICP

A

Arterial pressure, venous pressure, intraabdominal and intrathoracic pressure, posture, temperature, blood gases

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6
Q

Normal ICP

A

5 to 15mmHg

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7
Q

Panic level for ICP

A

> 20mmHg for 5 minutes is considered abnormal and must be treated!!

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8
Q

Purpose of CBF

A

Purpose: (1) To ensure a consistent CBF to provide for the metabolic needs of brain tissue and (2) to maintain cerebral perfusion pressure within normal limits

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9
Q

Blood in milliliters passing through 100g of brain tissue in 1 minute

A

Cerebral blood flow (CBF)

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10
Q

<70 mmHg means that there is low brain perfusion due to?

A

diminished blood flow

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11
Q

> 150 mmHg low brain perfusion due to?

A

vasoconstriction

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12
Q

How to calculate CPP

A

MAP-ICP

MAP needs to be high!!

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13
Q

Normal range for CPP

A

60-100 mmHg

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14
Q

When CPP is <50 mmHg-

A

brain ischemia and neuronal death

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15
Q

When CPP is <30 mmHg-

A

incompatible with life

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16
Q

What happens when CPP decreases

A

autoregulation fails and CBF decreases

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17
Q

Cushing’s reflex body attempting to improve CBF by?

A

Increase BP
Wide pulse pressure
Bradycardia

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18
Q

CBF:

↑ CO2 in the blood and ↓ O2 indicates?

A

cerebral vasodilation, increases CBF

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19
Q

CBF:

↓ CO2 in the blood and ↑ O2

A

= cerebral vasoconstriction, decreases CBF

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20
Q

Risk factors for increase ICP with Increased brain volume are

A

Cerebral edema

Intracerebral mass

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21
Q

Risk factors for increase ICP with increased cerebral blood flow

A

Impaired autoregulation
Decreased cerebral oxygenation (hypoxemia, hypercapnia)
Increased O2 demand (seizures)
Impaired venous outflow (increased intrathoracic, intraabdominal pressure)

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22
Q

Risk factors for increase ICP with increased cerebrospinal fluid (CSF)

A

Hydrocephalus

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23
Q

Increased accumulation of fluid in the extravascular spaces of brain tissue; an increase in tissue volume that can also increase ICP

A

cerebral edema

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24
Q

3 types of cerebral edema

A

Vasogenic Cerebral Edema

Cytotoxic Cerebral Edema

Interstitial Cerebral Edema

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25
Q

Vasogenic Cerebral Edema

A

Most common type of edema

Leakage of large molecules from the capillaries into the surrounding extracellular space

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26
Q

Cytotoxic Cerebral Edema

A

Results from disruption of the integrity of the cell membranes; fluid goes from ECF to inside the cell resulting to cellular swelling

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27
Q

Interstitial Cerebral Edema

A

Build-up of fluid within the ventricles and interstitium of brain

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28
Q

Causes of cerebral edema

A 
Mass Lesions:
Brain Abscess
Brain Tumor (Primary or Metastatic)
Hematoma (Subdural, Epidural
Hemorrhage (Intracerebral, Cerebellar, Brainstem)

Head Injuries & Brain Surgery:
Contusion
Hemorrhage
Posttraumatic Brain Swelling

Cerebral Infections:
Encephalitis
Meningitis

Vascular Insult:
Anoxic and Ischemic episodes
CVA (thrombotic, embolic)
Venous Sinus Thrombosis

Toxic or Metabolic Encephalopathic Conditions:
Hepatic Encephalopathy
Lead or arsenic intoxication
Uremia

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29
Q

What are the clinical manifestations of stroke

A
  • change in LOC
  • change in vital signs
  • ocular signs
  • motor function
  • headaches
  • vomiting
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30
Q

“Waxing and Waning

A

when they wake up, you ask how are you? And then they go back to sleep, come back to wake them up again and they’re restless

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31
Q

Cushing’s triad

A

increase BP, wide pulse pressure, bradycardia

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32
Q

What are some tests to check for

A
  • NUMBER 1 CT scan!
  • MRI is 2nd!
  • Transcranial doppler studies
  • EEG for brain wave and SEIZURES
  • skull xray
  • spinal xray
  • lumbar puncture contraindicated for increased ICP
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33
Q

Ventriculostomy

A

Gold standard on monitoring ICP
Catheter inserted into lateral ventricle connected to a transducer projected into monitor
Facilitates removal and/or sampling of CSF, and allows for intraventricular drug administration
A reference point ventriculostomy is the tragus

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34
Q

Inaccurate ICP readings can be caused by:

A
  • CSF leaks around the monitoring device
  • Obstruction of the intraventricular catheter
  • Difference between the height of the catheter and the transducer
  • Kinks in the tubing
  • Incorrect height of the drainage system
  • Bubbles or air in the tubing
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35
Q

Examples of mass lesions include

A

Brain Abscess
Brain Tumor (Primary or Metastatic)
Hematoma (Subdural, Epidural
Hemorrhage (Intracerebral, Cerebellar, Brainstem)

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36
Q

What’s the difference between hemorrhagic stroke vs ischemic stroke?

A

Hemorrhagic- bleeding occurs inside or around the brain tissue

Ischemic-clot blocks the blood flow to an area of the brain

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37
Q

Causes of Ischemic stroke are

A

Large Artery Thrombosis (20%)
Small Penetrating Art.Thrombosis (25%)
Cardiogenic emboli (20%) Cryptogenic (no known cause) (30%)
Other (5%)

38
Q

Causes of Hemorrhagic stroke are:

A

Intracerebral
Subarachnoid
Cerebral aneurysm
AV Malformation

39
Q

Clinical manifestations for ICP :

A 
Changes in LOC
Changes in VS
Ocular signs (CN || and |||)
Decrease in motor function
Headache
Vomiting
Seizures
40
Q

Decorticate posturing

A

BUE: Adduction, flexion of
arms, wrists, fingers
• BLE: extension, internal rotation, plantar flexion

41
Q

Decerebrate posturing

A

• BUE, BLE rigid extension, with hyperpronation of forearms and plantar flexion of feet

42
Q

Herniation syndrome that Shift of brain tissue from one cerebral hemisphere under the falx cerebri to the other

A

Cingulate

43
Q

Downward shift cerebral hemisphere, basal ganglia, through tentorial notch compressing brainstem

A

Central

44
Q

Unilateral lesion forces uncus to displace through tentorial notch

A

Uncal

45
Q

Displacement of cerebella tonsil through foramen magnum, compressing pons and medulla; Changes on breathing and cardiac functions

A

Cerebellar tonsil

46
Q

Management for ICP

A

Elevation of head of bed to 30 degrees with head in a neutral position

47
Q

Infection is a serious complication with ICP monitoring.

A
  • Routinely assess the insertion site
  • Use aseptic technique
  • Monitor CSF for a change in drainage color or clarity
48
Q

Possible association with air in forehead tissue, CSF rhinorrhea, or pneumocranium (air between cranium and dura mater)

A

Frontal skull facture

49
Q

Periorbital ecchymosis (raccoon eyes), optic nerve injury

A

Orbital skull fracture

50
Q

Oval-shaped bruise behind ear in mastoid region (Battle’s sign), CSF otorrhea, middle meningeal artery disruption, epidural hematoma

A

Temporal skull fracture

51
Q

Deafness, CSF or brain otorrhea, bulging of tympanic membrane caused by blood or CSF, facial paralysis, loss of taste, Battle’s sign

A

Parietal skull fracture

52
Q

Occipital bruising resulting in cortical blindness, visual field defects, rare appearance of ataxia or other cerebellar signs

A

Posterior fossa

53
Q

CSF or brain otorrhea, bulging of tympanic membrane caused by blood or CSF, Battle’s sign, tinnitus or hearing difficulty, rhinorrhea, facial paralysis, conjugate deviation of gaze, vertigo

A

Basilar skull fracture

54
Q

P1 percussion wave

A

Arterial pulsation

55
Q

P2 rebound/tidal wave

A

Intracranial compliance or brain volume; If P2 higher that P1, intracranial compliance compromised

56
Q

P3 dicrotic wave

A

Follows dicrotic notch , AV valve closure

57
Q

Two testing to determine whether fluid leaking from the nose or ear is CSF

A

➢ Dextrostix

➢ Tes-Tape strip

58
Q

Risk for meningitis is?

A

high with a CSF leak

59
Q

GCS Scale includes

A
  • Minor (GCS 13 to 15)
  • Moderate (GCS 9 to 12)
  • Severe (GCS 3 to 8)
60
Q

Classic signs of epidural hematoma:

A 
• Initial period of unconsciousness at
the scene
• Brief lucid interval followed by a decrease in LOC
• Headache
• Nausea and vomiting
61
Q

Subdural hematoma

A

Occurs from bleeding between the dura mater and arachnoid layer of the meninges
Results from injury to the brain tissue and its blood vessels
May be caused by arterial hemorrhage May be acute, subacute, or chronic

62
Q

Acute subdural hematoma

A

manifests within 24 to 48 hours of injury

63
Q

Subacute subdural hematoma

A

usually occurs within 2 to 14 days of the injury

64
Q

Chronic subdural hematoma

A

develops over weeks or months after a seemingly minor head injury

65
Q

Drug therapy for Ischemic/Hemorrhagic stroke

A

Alteplase (clot buster) will not decrease ICP
Osmotic diuretic (mannitol) big molecule of sugar
Hypertonic saline (use this instead)
NaCl 3%
Antiseizure drugs (e.g., phenytoin [Dilantin])
Corticosteroids (dexamethasone)
Histamine (H2)-receptor antagonist (e.g., cimetidine) or proton pump inhibitor (e.g., pantoprazole [Protonix]) to prevent GI ulcers and bleeding

66
Q

Management for ICP

A

Elevation of head of bed to 30 degrees with head in a neutral position
Intubation and mechanical ventilation

67
Q

Most common cause of ischemic/hemorrhagic stroke

A

uncontrolled hypertension

68
Q

Ventriculostomy includes

A

Gold standard on monitoring ICP
Catheter inserted into lateral ventricle connected to a transducer projected into monitor
Facilitates removal and/or sampling of CSF, and allows for intraventricular drug administration
A reference point ventriculostomy is the tragus
ICP >20 mmHg for 5 minutes should be reported to physician

69
Q

How often should you do neuro assessment for a patient with ICP

A

Q15 mins x 2 hours, Q30 mins x 2, Q1 hr until discontinued

70
Q

Two testing to determine whether fluid leaking from the nose or ear is CSF:

when its bleeding??

A

Dextrostix
Test-Tape strip
If there’s bleeding from the CSF, test for halo sign

71
Q

GCS measures …

A

eye opening
motor response
verbal response

Minor (GCS 13 to 15)
Moderate (GCS 9 to 12)
Severe (GCS 3 to 8)

GCS less than 8= intubate!!

72
Q

Typical signs of concussion:

A

Brief disruption in LOC (woke up for a little bit and goes back to sleep)
Amnesia regarding the event (retrograde amnesia)
Headache

73
Q

Classic signs of epidural hematoma:

A

Initial period of unconsciousness at the scene
Brief lucid interval followed by a decrease in LOC
Headache
Nausea and vomiting
Focal findings

74
Q

Occurs from bleeding between the dura mater and arachnoid layer of the meninges

A

subdural hematoma

75
Q

the most common primary tumor from the CNS

A

Meningiomas

76
Q

Brain tumor management includes

A
  • Surgical therapy
  • Ventricular Shunts
  • Radiation Therapy and Stereotactic Radiosurgery
  • Chemotherapy and Targeted Therapy
77
Q

Opening into the cranium with a drill. Used to remove localized fluid and blood beneath the dura.

A

craniotomy

78
Q

Excision into the cranium to cut away bone flap

A

craniectomy

79
Q

Repair of cranial defect Artificial material used to replace damaged or lost bone

A

cranioplasty

80
Q

the leading cause of bacterial meningitis

A

Streptococcus pneumoniae and Neisseria meningitidis

81
Q

test used to rapidly diagnose viral meningitis

A

Xpert EV test

82
Q

Ticks and mosquitoes transmit ..

A

encephalitis

83
Q

Kernig’s sign

A

pain at the back of the neck (meningitis)

84
Q

Brudzinski’s sign

A

pain in the back of the lower back in the lumbar area; stretching the meninges
(meningitis)

85
Q

Most common causes of viral meningitis:

A

Enteroviruses
Arboviruses
HIV
Herpes simplex virus

86
Q

Accumulation of pus within the brain tissue that can result from a local or systematic infection

A

brain abscess

87
Q

Shift of brain tissue from one cerebral hemisphere under the falx cerebri to the other; no specific symptoms

A

cingulate

88
Q

Downward shift cerebral hemisphere, basal ganglia, through tentorial notch compressing brainstem; Decrease LOC, Motor weakness, Cheyne-Stoke respiration, small reactive pupils (late: dilated) posturing

A

central/tentorial herniation

89
Q

Unilateral lesion forces uncus to displace through tentorial notch; Increase muscle tone, Babinski, ipsilateral dilated pupil

A

Uncal

90
Q

Displacement of cerebella tonsil through foramen magnum, compressing pons and medulla; Changes on breathing and cardiac functions

A

cerebellar tonsil

Critical Care (6 decks)

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