acute Intracranial Problems Flashcards
3 types of non compressible contents in skull
Brain tissue
CSF
Blood
Monro-kellie doctrine
The sum of volumes of brain, CSF and intracranial blood is constant
Normal ICP
Increased ICP definition
Risk for what with increased ICP
Normal: 5-15
Increased icp: >20 mmHg for >5mins
Risk for herniation with increased ICP
Primary vs secondary injury
Primary:
Blunt force
Secondary:
Swelling
Ischemia
Hypoxia
(Things that are caused by primary)
Causes of increased ICP
Increased brain volume
Increased CSF
Increased cerebral blood volume
What causes increased brain volume
Edema
Hypo osmolality
Increased capillary permeability
What causes increased CSF
Hydrocephalus
Excess production of CSF
What causes increased cerebral blood volume
Ineffective ventilation
Hypoxia
Hypercapnia (vasodilation) too much CO2
Hypocapnia (vasoconstriction too little CO2
Normal CO2 range
35-45
Early signs of increased ICP
Restlessness, agitation, change in behavior (sign of change in LOC)
HA (worst HA in your life)
Visual disturbances
N/V
Vitals change
Seizures
Late sign of increased ICP
Significant change in LOC
Fixed, dilated or unequal pupils
(Cushings triad):
1.HTN w/ widening pulse pressure (systolic and diastolic get further
2. Brady cardia
3. Irregular breathing patterns (cheyne-stokes or agonal breathing)
Clinical manifestations of increased ICP
Change in LOC (due to impared cerebral blood flow 🔽 O2)
-subtle symptoms (difficult to around, flat effect(their normal then no response), disoriented)
-severe coma:no response to pain, non pupil, gag or cough reflexes
Ocular signs:
Sluggish, non-reactive, difference in size
(ipsilateral dilation is a late sign): same side as injury
Motor:
🔽 in function
Hemiparesis or hemiplegia
Decorticate posturing
Decerebrate posturing
Decerebrate vs decorticate
Decerebrate (away from core)
Damage to upper brain stem
Decorticate (to the core)
Damage to one or both corticospinal tracts
Glasgow coma scale
Eyes
Best motor response
Best verbal response
Eyes:
4 spontaneous
3 to verbal command
2 to pain
1 no response
Best motor response
6 obey
5 localizes pain
4 flexion-withdrawl
3 decorticate
2 decerebrate
1 no response
Best verbal response
5 oriented and converses
4 disoriented and converses
3 inappropriate words
2 incomprehensible sounds
1 no response
Score 3-15
Increased ICP complications
Inadequate cerebral perfusion:
CPP <60 (cerebral perfusion pressure
50=ischemia and neuro damage
30=ischemia uncompatible w/life
Cerbral herniation:
Through open skull fracture
Downward
Laterally
increased ICP diagnostic test
CT: asap, check for bleed (no contrast)
MRI: tissue changes and ischemia
ABG: CO2 or hypoventilation
EEG: check for seizures
Cerebral angiography: blockages in brain
ICP measurement devices: measure pressures
Transcranial doppler: like a CT
ICP labs
BMP: Na (may increase)
Coags
Test if you have SIADH or DI:
Urine specific gravity
Serum osmolality
Management of ICP`
-figure out what
-nutirition
-meds for what
-support what
-normal valures
Figure out cause: infection, trauma
Nutrition: tube feed or parenteral
Med for ulcer prevention
Support VS:
Meds to control BP (want MAP 50-70)
Control temp
Ventilation:
-PO2 >80
-CO2 35-45
CO2 >45 (causes cerebral vessel to dilate increasing ICP)
CO2 <35 (vasoconstriction trouble getting O2 to tissue)
ICP meds and fluids
-control metaboic demands with what meds
ALL fluids in NS NO D5W!!!
Mannitol
Hypertonic saline (doesnt cross BBB & drawls fluid out)
Corticosteroids : with abscesses or tumors
Control metabolic demands:
-sedatives
-pain meds
-antipyretics
-seziure meds: pentobarbital coma if increased ICP refractory to other TX: must be on ventilator and in ICU
- 🔽 enviornmental stimuli
Mannitol
What it does
Dose
Se
Pt must have
🔽 brain water content
Dose: 0.5-1g/kg over 15 mins
Se: HOTN, dehydration, electrolyte disturbances
Pt must have adequate intravascular volume prior to infusion:
UOP, BP, HR, quality of pulse, skin turger.
Mannitol nursing implications
Assess and labs
Use what to infuse
Serum osmo 2 hrs after dose
BUN & creatinine
Neuro assessment Q1
Must use a filter to infuse (crystalizes)
Assess med prior to infusion for these crystals
Hypertonic saline
What it does (decreases what, increases what, prevents what)
Goal
How to administer and where
Assess what
🔽 cerebral water content
Increases MAP & CPP
Prevents hypernatremia
Goal:
Serum Na 145-155
Serum osmo <320
Administer as continuous infusion or single bolus dose
Must administer via central line
Assess lungs and CXR (risk of pulmonary edema)
Nursing management
ABC
Neuro
Fluid and electrolytes
Seizure precautions
ABC:
Pt awake enough to protect airway
Must have adequate BP (MAP) for perfusion
Neuro:
GCS
Pupil
Motor
Reflexes: corneal reflex, cough and gag
Fluid & electrolyte: SIADH and DI
Seizure precaution
Nursing actions to manage ICP
HOB 30 degrees (venous drainage)
Head midline with body (C-collar check fit)
Pre-oxygenate prior to suctionng
Space nursing activities out
Avoid excess stimulation
TBI
Traumatic brain injury
Predictors of poor outcomes
GCS <8
Older
Associated hematoma
Posturing
Hypoxemia
Hypercapnia
TBI patho
-what it is
-words to classify it
-skull fx types
-risk of
Damage to scalp, skull meninges and brain
Open or closed
Acceleration-deceleration (coup contracoup)
Skull fractuir:
-Linear fx: assess CSF leak, halo test, raccoon eyes, battle signs
-depressed fx: injury to skull and possible dura
If dura torn: brain exposed to environment
Risk for seizure
TBI
Concussion
Contusion
Concussion:
Mechanical force to skill
May lose consciousness
Memory problems
Long term effects later with repeated blows to head
Contusion:
Coup and contracoup injury
Bleeding and bruising of brian
TBI
Penetrating injury
Scalp laceration
Penetrating injury:
Low or high velocity force
Scalp laceration:
Clean, debride, assess for Fx
Bleeding
Avulsion (tendon or ligament come off bone)
Hematomas:
Epidural
Subdural
Intracerebral
Epidural:
Blood between skull and dura
(associated wit artery, blood accumulates fast)
Subdural:
blood accumulates below dura and above arachnoid covering of brain
(Venous bleeds slower)
Intercerebral:
Hematoma within the brain tissue
Diffuse axonal injury
Acceleration-deceleration mechanism
Shearing of axons
Cerebral edema: injury to cells/neurons
Pt remains unconscious
Lasting effects and requires pt/ot
Secondary brain injury
Related to initial trauma:
Increased capaillary permeability
Increased cerebral edema
🔽 perfusion
Hypoxia
Infection
Surgical interventions for ICP
Craniectomy: remove bone flap on affected side
Evacuate hematoma
May leave bone off and allow brain to swell
Cranioplasty: replace bone later
Post of care for ICP
Assess ICP, VS, CSF leak
mechanical ventilation if needed
If EVD (external ventricular drain) monitor output
Nursing management: head injury
assessment like ICP
Assess:
ABC
Neuro status Q1
GCS
Brain tumors types
Primary
Secondary
Benign
Malignant
Primary lesion:
originates in brain
Secondary:
Metastasis: outside of brain comes to brain
Benign: slower growing
Malignant: faster more dangerous
Brain tumor CM
HA
N/V
Seixures
Cognitive changes
Weakness
Aphasia (slurred speech)
Brain tumor diagnostic studies
CT
MRI
EEG
History
Brain tumor tx
Sx
Procedures
Other kinds
How it is adminsitered
Sx:
Craniotomy
Burr hole: drill holes to release pressure
Shunt: drain into ventricles of the brain allow us to move CSF elsewhere
Radiation
chemo
-meds that cross BBB
-Ommaya reservoir:intrathcal admin:
*Can administrate chemo and abx into csf
Meningitis
What it is
Types and their types
Inflammation of meningeal tissue
Bacterial: more deadly:
-streptococcus pneuoniae
-neisseria meningitis
Viral:
-HIV, HSV
-abx given until confirmed then supportive, manage s/s
Bacterial meningitis and viral miningitis CM
Similar ones
Fever
Iritability
Severe HA
Nuchal rigidity
Photophobia
Bacterial meningitis CM seperate
Tachycardia
N/V
Seizures
Signs of elevated ICP
Decreased LOC
Petechial rash
(Viral could have but theyll be milder)
Meningitis nuchal rigidity test
Brudzinski’s neck sign:
Flex neck causes flex in hip&knee
Kernigs sign:
Hip flexed and plain when straightening leg out
Meningitis diagnostic test
1st then 2nd
Do what before ABX
What is expected in bacterial sample vs viral
1st: CT (see if it is safe to get it0
2nd: CSF via lumbar puncture only after CT scan
(Prevent herniation if too much fluid off too fast)
Culture before abx:
Bacterial: sample csf:
low glucose, high protein, WBCs (cloudy CSF) and culture will grow
Viral: sample csf:
Normal glucose, High protein, negative culture, less wbcs
Bacterial meningitis tx
Meds
Monitor
Isolation
Meds:
-ABX IV
-Corticosteroids (drexomethazone)
-Manage fever (because ⬆️ BMR = ⬆️ O2 demand)
Anticonvulsants (prevent seizures)
Monitor:
F&E
Neuro status
Safety precautions: (pad rails, O2, suction, fall precautions)
Isolation:
Droplet
Viral meningitis tx
No isolation
Start abx until dx confirmed, then DC
Antiviral: herpes or influenza the cause
Anticonvulsants
Usually just let it run its course
Bacterial meningitis prevention
Vaccination
Handwashing
Abx for contacts if your not vaccinated
Viral meingitis prevention
Reduce direct contact
Handwashing
Enteroviruses spread in stools too
