Acute Neuro Injuries Flashcards
Where is CSF found?
ventricles, around the brain, spinal cord and subarachnoid space
What is the purpose of CSF
to cushion, absorb shock and provide nutrients
Middle cerebral
most common artery for stroke
feeds 2/3 of the frontal, parietal and temporal lobes
Basiliar
Stroke here can quickly be devastating
Can result in locked in syndrome so you can only move your eyes and it affects sleep/wake cycles
Assessment for anyone with brain injury
- establish a baseline
- Airway/respiratory function
- cerebral oxygenation and perfusion
- regain maximal cognitive motor and sensory function
- subtle changes are key (Glasgow coma scale)
Conscious exam
Orientation
Concentration
Affect/behavior (is their behavior normal for the situation?), memory and logic
Cognitive dysfunction can be seen in
- reasoning
- Expressive aphasia (can’t get the words out)
- REceptive aphasia (don’t understand what is said to them)
- Global aphasia (mix of both)
When a patient has a short memory how should you provide patient teaching?
repeat multiple time, provide a paper copy, teach caregiver
Transient ischemic stroke
less than 24 hours
symptoms resolve - blood flow reestablished before damage
no infarct on scan
decreased blood supply
warning or potential stoke
Ischemic attack (stroke)
more than 24 hours
destruction of neural tissue
brain damage
Hemorrhagic stroke
leakage of blood or blood vessel into brain tissue
Can you have multiple TIAs without a stroke?
Yes
Ischemic stroke: thrombotic
injury to blood vessel wall –> formation of clot
Ischemic stroke: embolic
embolus occludes a cerebral artery –> embolus travels to circulation
Common cause is issues with the heart like a.fib
What is the difference between a thrombotic and embolic stroke?
The type of clot and where it came from
Where are the majority of aneurysms?
in the circle of willis
Intracerebral hemorrhage (ICH)
bleeding in the brain, usually basal ganglia, poor prognosis, HTN is common cause
Subarachnoid hemorrhage (SAH)
intracranial bleeding in the CSF filled space between arachnoid villa and Pia mater, aneurysm is the common cause
AVM (arteriovenous malformation)
abnormal dilated blood vessel with inappropriate capillary network, thin walls, tortuous and at risk for clot formation
Can interfere with perfusion to brain
Penumbra
area of hypoxia/ischemia or edema that can lead to damage
Clinical manifestations of a stroke
- weakness/paralysis
- numbness and tingling
- speech
- personality changes
- blurred. vision
- double vision
- motor function
- communication
- affect
- intellectual functioning
- spatial perception alterations
- elimination
What do you ask a patient before using contrast?
do you have any allergies to iodine, shellfish, or radioactive dyes?
What is important to ensure the patient has none for before an MRI?
NO METAL
no metal in the body or on the body
No jewelry, pacemakers, stents, or surgical implants
Diagnostics for stroke
- CT - most important
- MRI - more specific
- CTA - cerebral arteries
- MRA - vascular legions and blockages
- Intra-arterial digital subtraction angiography (DSA) - gold standard for aneurysms
Other tests for patient that have suffered a stroke
- cerebral blood flow angiogram
- ECG and 24 hour heat monitoring
- Chest x-ray
- Echocardiogram
- Coagulation studies
Alteplase
Recombinant tissue plasminogen activator
Protein that breaks up clots
Given within 3-3.4 hours after onset
Ischemic strokes only
Stroke core measure/what needs to happen before discharge
- Venous thromboembolism
- discharge on antithrombotic therapy
- Anticoagulation therapy for a.fib/flutter
- Thrombolytic therapy
- Antithrombolytic therapy by end of hospital day 2
- Stroke education
- Assess for rehabilitation
Medication for stroke
- Antithrombotic (asirpin)
2, Anticoagulants with a. fib (heparin/levenox) - Cholesterol lowering agent (statin)
- Diabetic medication (insulin, metformin)
- Antihypertensive medication (metoprolol, lisinopril)
Surgical treatment/prevention of stroke
- Carotid endarterectomy
- Transluminal angioplasty
- Stenting
What is a carotid endarterectomy?
removes plaque from arteries
What is a transluminal angioplasty?
uses balloon to open up stenosed artery
What are modifiable risk factors to prevent a stroke?
- hypertension
- health diet: low fat, sugar and salt
- Weight control
- Regular exercise
- Smoking cessation
- Limit alcohol
- Know s/s of stroke
- Treat a.fib since it is a precursor to stroke
Watchman implant
inhibits blood to pool in this area so ischemic strokes can be prevented
Benefit: no long term anticoagulation medications
What does a SAH interfere with?
CSF reabsorption, hydrocephalus results and leads to vasospasms
What does a hemorrhagic stroke cause?
Increased ICP and changes in LOC
Does size, location and times of hemorrhage matter?
Yes they do.
Location- pons affects breathing
Size - the larger it is, the more damage and mortality
Time: if it spread quicker, increase in damage and mortality
SAH intervention
Medications: to decrease BP below 160
Interventional radiology: coiling
Surgical management: resection and emboli zing blood vessel
Minimize deficits, prevent rebleed, prevent vasospasms (nimodipine)
Hypervolemic, hypertensive, hemodiluation (tripe H therapy to prevent vasospasms)
Ventrculostomy
Nimodipine
Helps to prevent vasospasms
CCB
Check BP before giving the medication and hold if systolic is less than 90
What does the diet of a stroke patient look like?
Diet restriction and thicker liquids
Are stroke patients a fall risk?
Yes, they need to wear non-slip socks, bed alarm set, frequent checks, room near nurses station, ensure the call light is on the side they can see because they have visual deficits
Traumatic brain injury
Trauma to the skull, scalp, or brain
When do deaths occur after a TBI?
- immediately at the time of injury
- within 2 hours of the injury
- 3 weeks later
Primary/direct TBI
- laceration
- skull fracture
- concussion
- diffuse axonal injury
- focal lesions of laceration
- open penetrating/closed
Secondary TBI results from… and includes…
results from primary TBI and includes swelling, infection and hypoxic brain injury
Coup-contrecoup
coup - first impact
contrecoup - damage on opposite side when brain move back from primary impact
Epidural Arterial hematoma
neuro s/s appear quickly
Subdural Venous hematoma
neuro s/s can be delayed
Signs of a basilar skull fracture
Battles sign (bruising behind ear) and raccoon eyes
Worry about CSF leaks and antibiotics are given if CSF leak is suspected because there is a risk of meningitis
Concussion
May have a brief loss of consciousness
HA, dizzy, concentration, sensitivities, amnesia of the event
Post concussion syndrome
weeks-months post concussion
impact is often underestimated
patient has memory/concentration concerns
Dull chronic headaches
Poor school performance
increase irritability
What is a concern with a skull fracture?
CSF leaks
TBI management
Neuro checks for change in LOC
Monitor for increased ICP
Stroming
Surgery:burr holes to remove blood
Safety: high fall risk
Risk for seizures
What is storming
uncontrolled sympathetic response
S/S: high HR, high BP, sweating, high RR, dilation of the pupils, hyperthermia
What is a major concern when a patient is storming?
fluid loss because they are sweating so much
Brain tumors
occupy space in the brain
Brain tumors can…
infiltrate and destroy brain tissue
be encapsulated and displace tissue
just present with a HA
compress tissue and vessels –> ischemia, edema, IICP, focal deficits
Gliomas
grow rapidly, infiltrates, difficult to remove completely, malignant
Meningiomas
slow growing, usually benign
Pituitary adenoma
affect endocrine function and vision
Neuromas
from cranial nerves, CN VIII
Primary sites for metastatic tumors are
lungs, breasts and colon
Brain tumor clinical manifestations
seizure, weakness, personality changes, speech. paralysis
Brain tumor diagnostics
CT/MRI and biopsy
Brain tumor management
Surgery if possibly
Ventricular shunt if hydrocephalus
Radiation/chemo
New treatments
Nursing care for brain tumor
Behavior management
Language deficits
Supporting family
Seizures
Craniotomy
Remove part of the skull to remove tumor, hematoma, relieve ICP or bleed, clip aneurysm and then replace it
Pre-op interventions for craniotomy
Baseline neuro exam
Vital signs
Post-op craniotomy
Neuro exam
Vital signs every 30 for 4 hours and then every hour
Pain
N/V - do not want patient to puke because it increase ICP
Maintain cerebral perfusion and normal ICP
Prevent and minimize complications
Post craniotomy your patient is vomiting and has LOC changes, what do you do?
Get them a CT immediately
Hemicraniotomy
Portion of skull removed and remains off
Allows for swelling
Only thin skin protecting the brain so place sign above bed says no bone flap, helmet when up!
Ongoing assessments for craniotomy patients
Neuro and VS - every 30 minutes for 4 hours, then every hour.
Report any deficits and monitor for pain, N/V and change in LOC
Pituitary tumors clinical manifestations
Vision changes, HA, endocrine disorders like ACTH, GH
Where are most pituitary tumors?
Most are in the anterior lobe which provides ADH and is close to the eyes
Treatment of pituitary tumor
Surgical removal: transphenoidal - through the nose
Post-op transphenoidal removal
- AVOID sneezing, straws, anything inserted into nose
- Evaluate clear fluid leakage in case it is CSF
- Evaluate SIADH or DI
- vision changes every 8 hours to check for a bleed
- Neuro/vitals every 4 hours
- monitor I/Os and encourage drink to thirst
Is nasal drainage normal after transphenoidal removal?
Yes, you just have to make sure that it is not CSF and to only dab it, no blowing
How do you evaluate for CSF?
halo on pillow or sample collection
What is the number 1 symptom of a CSF leak?
headache
How do you evaluate SIADH/DI?
urine specific gravity is done with each void and a daily serum Na and osmolarity
Close to 1.000 is DI
Close to 1.030 is SIADH
What do you do if they go into DI?
send a serum Na and osmolarity and a urine Na and osmolarity
What is increased ICP a complication of?
stroke, TBI, tumor
CSF
hydrostatic forced measured in the brain’s CSF compartment
Normal: 5-15
More than 20 –> treatment
Cerebral blood flow
blood passing through the brain tissue in 1 minute
Cerebral perfusion pressure
pressure needed to ensure blood flow to the brain and is affected by BP
Normal: 60-70, want above 60
Below 30 is incompatible with life
What does the brain need to function?
Glucose and oxygen - it can’t store these so it needs to have constant flow of this
What can the body do to keep ICP and cerebral blood flow constant to the brain?
Alter CSF amounts and cerebral vasoconstriction/dilation
In order to maintain good CBF you need a MAP of..
70-150
How do you assess ICP?
- Changes in LOC (most sensitive)
- Pupil exam/brainstem exam - late sign (fixed unilateral pupil size and shape - EMERGENCY)
- Motoring functioning (hemiparesis, hemiplegia, posturing)
- HA
- Vomiting
- Change in VS (cushings triad) - late
What is cushings triad
HTN, widening pulse pressure, bradycardia, irregular respirations
Herniation
happens with increase ICP, and is fatal when unrelieved
Will cause increased neuro deficits if untreated
Diagnostics/monitoring ICP
- Intraventricular monitors - “ventriculostomy” is the gold standard
- Sensors that go in the brain in either the intraparenchymal, subarachnoid, or epidural space
Factors that influence ICP
- Arterial/venous pressure
- Blood gasses (CO2)
- Intra-abdominal and intrathoracic pressure
- posture
- temperature
Relationship between ICP and CPP
as ICP increases, CCP decreases
Progression of a brain injury related to ICP
Cerebral edema and ICP peak in 2-3 days
Decrease of 1-2 weeks
Blood pressure and ICP
Blood pressure needs to be within a good range to have adequate CCP
If it is too high it can cause too high of ICP
If it is too low it can cause too low of ICP
How can you increase BP?
give fluids
colloids
vasoactive
osmotic diuretics (pull fluid from brain and encourage elimination)
When do you treat HTN?
when CPP is above 120
When do you treat ICP?
if it is above 20
Blood gases and ICP
- Arteries dilate: increased CO2 –> decreased resistance –> increase CBF
- Arteries constrict: decreased CO2 –> increased resistance –> decreased CBF
Positioning and ICP
Optimal HOB 30-45 degrees
Neck alignment is important
Caution any knee catching/elevating
Suction less than 10 seconds, 2 passes
Temperature and ICP
Increased temperature –> increase ICP
What can you do to reduce the temp of the patient? And how do you measure the temp of a patient?
Goal: normal body temp
Acetaminophen and mechanical cooling - beware of shivering because increase ICP
Measure internally such as rectal or bladder
Medications to decrease ICP:
- osmotic diuretics - draws water from tissue into circulation (mannitol)
- Hypertonic 3% saline - increases osmolarity to decrease cerebral water
What are considerations for mannitol and 3% saline?
Sodium, glucose, K, Mag levels
Serum osmolarity
Pain management with ICP
morphine, propofol
Medication for swelling with ICP
Decaron
Need to have a PPI or H2 blocker with it for GI bleeding
Barbituates for ICP
Phenobarbital decreases cerebral metabolism
Antiseizure meds can be given with ICP if..
seizure activity occurs
Monroe Kelly hypothesis and ICP
If something in the brain is increase such as a tumor or edema, then something else must decrease like CSF or venous to compensate for that.
Why are progressive changes in pt. presentation for increase ICP important?
Because it can lead to herniation if ICP is not treated and this can cause increased neuro deficits and death
Rehab challenges for neuro injury
Quick initially and then it hits a plateau with ups and downs
Challenging for patients and their families (patients may have new behaviors and personalities depending on the location of their injury
Epidermal hematoma vs subdural hematoma
Epidural: more severe and deadly because of arterial nature. Patient presents with loss of consciousness, then a period of lucidity, then rapid decline. Symptoms onset rapidly
Subdural: slower to present because of venous nature
How is CBF regulated?
BP, CPP, MAP, CO2
Is ischemia more likely with increased CBF or decreased CBF?
It can happen with both but is more likely to happen with decreased CBF
