Acute neuro logical injuries Flashcards
what is in the brainstem and its function
- pons
- medulla
- helps with basic breathing and hr and auto regulation of the body
what is frontal in charge of
thought and reasoning
what is occipital in charge of
vision
cerebellum is in charge of
balance
pons and medulla in charge of
breathing and HR
CSF location
-in vents and around brain, sc, and subarachnoid space
what is CSF
- the cushion around the brain and spinal cord
- gives nutrients to brain
normal CSF
- clear
- 20-30 ml/hr
- total volume at any given time: 90-150 ml/hr
- 500 ml/day
why is the circle of willis an area of concern
- bifurcation of the vessels
- are that can have aneurysms and clots that get stuck is bad because big supplier of blood to the brain
anterior circulation
- give brain 02
- middle cerebral: feeds anterior 2/3 of frontal, temporal, parietal lobes and is the most common area for a stroke
poster circulation
- basilar artery which feeds the brain stem. a stroke here can be quickly devastating
- these strokes are hard to get to = tx hard
- can get locked in syndrome where they can only move their eyes
- affect sleep wake cycles
Neuro assessment for anyone with a brain injury
- baseline
- airway respiratory function
- cerebral o2/perfusion
- regain maximal cognitive motor and sensory function
- subtle changes are key (GCS)
what is the conscious exam
- loc
- orientation
- concentration
- affect/behavior, memory, logic
what is the cognitive exam
- reasoning
- expressive aphasia (cant get words out)
- receptive aphasia (dont understand what is being said to them)
- global aphasia (mix of both)
define transient ischemic attack (TIA)
<24 hours symptoms resolve no infarct on scans
define ishcemic attack (stroke)
->24 hours process that leads to destruction of neural tissue and consequent brain damage
define hemorrhagic stroke
leakage of blood or blood vessel into brain tissue
TIA
- Brief episode of neurological dysfunction symptoms
- typically less than 1 hour
- You can have multiple TIAs and no stroke
- Blood flow is re-established before damage brain infarction
- Warning sign of potential stroke
ischemic stroke types
- Thrombotic: injury to the blood vessel wall and the formation of a blood clot
- Embolic: when an embolus occludes a cerebral artery the embolus travels to the circulation (it could be blood or other debris), common cause are due to issues within the heart like atrial fibrillation
types of hemorrhagic strokes
- Intracerebral hemorrhage (ICH): is bleeding in the brain usually the basal ganglia with a poor prognosis, HTN is most common cause
- Subarachnoid hemorrhage (SAH): intracranial bleeding in the cerebrospinal fluid filled space between the arachnoid villa and pia mater, most common cause is ruptured aneurysm
AVM
- arteriovenous malformation
- abnormal dilated blood vessels with an inappropriate capillary network, thin walled, and tortuous and are at risk for clot formation and/or rupture.
manifestations of a stroke
- Weakness/paralysis
- Numbness/tingling
- Speech
- Personality changes
- Blurred vision
- Double vision
- Motor function
- Communication
- Affect
- Intellectual function
- Spatial perceptual alterations
- Elimination (only initially)
DX of stroke
- non contrast CT scan
- MRI: will have greater specificity but may not be done right away if dont know if there is metal in pt body
- be aware of allergies with contrast scans (iodine, seafood, radioactive dyes)
- DSA- has highest resolution for the detection of intracranial aneurysms and is gold standard
other dx if had stroke or TIA
- Cerebral blood flow like an angiograph
- ECG/ 24 hour heart monitor
- Chest x-ray
- Echocardiogram
- Coagulation studies
BP maintenance with someone who is given ateplase
- less than 180 sys
- no heparin, warfarin, aspirin, clopidogrel, or dipyridamole for 24 hours then start as ordered
BP maintenance without ateplase
- allow to auto-regulate and only treat if sys BP is greater than 220
- antithrombotic ordered within 24 hours
ateplase
- Recombinant tissue plasminogen activator
- a protein that is used to break up blood clots
- Given within 3-4.5 hours after onset
- Ischemic only
- Time=brain
things that need to be addressed for stroke pt before discharge (stroke core measures)
- Venous thromboembolism
- Discharge on antithrombotic therapy
- Anticoagulation therapy for atrial fibrillation/flutter
- Thrombolytic therapy (help dissolve clots)
- Antithrombotic therapy by the end of hospital day 2
- Stroke education
- Assess for rehabilitation
antithrombotics for strokes
- not for hemorrhagic
- aspirin, clopidogrel
- prevent a thrombus
ANTICOAGULANTS for strokes
- with atrial fibrillation
- Heparin/lovenox
- Coumadin (INR 2-3)
- Rivaroxaban (xarelto)
- likely be put on coumadin or Xarelto but will initially require lovenox or heparin until the INR levels are therapeutic at 2-3.
cholesterol lowering agents for strokes
- Statins such as atorvastatin , simvastatin
- reduce the risk of fatty plaques breaking off from walls of your arteries
diabetic medications for strokes
-Insulin, metformin
antihypertensive meds for strokes
- Metoprolol: A-fib
- Lisinopril: HTN (think cough)
surgical tx/prevention for strokes
- Carotid endarterectomy (CEA)- remove plaque from artery
- Transluminal angioplasty- balloon to open up stenosed artery
- Stenting- keeps the cerebral artery patent
Prevention= Post Stroke CareModifiable risk factors
HTN Health diet: low in fatty acids, sugar, salt Weight control Regular exercise Smoking cessation Limit ETOH Know signs/symptoms
why is hemorrhage in pons concerning
-affects life functions like breathing.
with bleeding in brain what do you get
- increased ICP and changes in LOC.
- with SAH: have issues with CSF reabsoprtion and vasospasms.
SAH interventions
-Medications
Want BP < 160 sys
-tx vasospasm (nimodipine): Know BP before giving
-Hold if BP <90 sys
-Hypervolemic, hypertensive, hemodiluation (triple H therapy) to prevent vasospasms
-Interventional radiology: coiling
-Surgical management:
Resection and maybe embolizing blood vessels
-Minimize deficits, prevent rebleed
-May have aneurysm clipping or coiling
-At risk for hydrocephalus because SAH is in subarachnoid space where CSF is reabsorbed
-Why may do ventriculostomy
care for stroke: resp
PNA d/t dysphagia and airway protection
care for stroke: neuro
changes in LOC, seizures, ICP
care for stroke: cardiac
monitoring arrhythmias, risk for VTE (Venous thromboembolism (VTE) refers to blood clots that form in veins)
care for stroke: musculo
ROM, positioning
care for stroke: GI
constipation, how do they eat, what consistency
Care for stroke: GU
remove Foley ASAP, scheduled toileting, intermittent cath prn
care for stroke: nutrition
oral or PEG, speech consult
primary or direct TBI
- damage caused by impact
- Laceration: bleed alot
- Skull fracture: CSF leak risk
- Concussion:
- Diffuse axonal injury: widespread
- Focal lesions of laceration: localized
- Open penetrating/Closed
secondary TBI
- results from primary TBI
- swelling
- Infection
- Hypoxic brain injury (ischemia)
- we want to prevent secondary with our care
types of focal TBI
- contusions & hemorrhages
- epidural (extradural) hematoma: arterial= neuro symptoms sho wup fast
- subdural hematoma: venous
- intracerebral hematoma: arterial or venous= symptoms can be delayed
TBI management
- Neuro checks: change in LOC
- Monitor for increased ICP
- Storming (high HR, BP, and sweating)- symptomatic response that is not controlled and will have posturing, dystonia, HTN, tachy cardia and pnea, dilation, sweating, hyoerthermia- concern for fluid loss
- Surgery: Burr holes to evacuate blood
- Safety: high fall risk
- Risk for seizures
types of brain tumors
- Primary: originates from the cells/structures of the brain
- Metastatic: originate from outside the brain
- Neuroembryonic origins: tumors from the ectodermic layer (outer layer of embryo)
- Anatomic location: Supratentorial, infratentorial
- Malignant vs. Benign
brain tumor
- Tumors occupy space in brain
- Can infiltrate and destroy brain tissue
- Can be encapsulated and displace tissue
- Can just present with a headache
- Compression of tissue and vessels produces ischemia, edema, IICP, focal deficits
gliomas
grow rapidly, infiltrative, difficult to completely remove, malignant
meningiomas
are slow growing, usually benign
pituitary adenomas
affect endocrine function and vision
neuromas
from cranial nerves, CN VIII
primary site for metastatic tumors
lungs, breast, colon
mnaifestations of brain tumors
Focal affects: seizure weakness, personality changes, speech, paralysis
DX of brain tumors
CT/MRI, EEG, biopsy
brain tumor management
- Surgery: remove is possible
- Ventricular shunt if there is hydrocephalus
- Radiation and/or chemotherapy
- New treatments
- Behavior management
care of craniotomy patient
-Surgical opening in skull to remove tumor, evacuate hematoma, relieve ICP, clip an aneurysm
-Normal preop nursing interventions/ responsibilities incl.
baseline neuro exam, VS
-Patient returned to ICU post op
VS closely, Neuro exam, pain, and N/V
-give antiemetics: vommiting can increase ICP
-someone who you are concerned about who is vomiting even projectile and is showing changes in LOC and increased ICP needs to get to a CT immediately
-Hemicraniectomy
portion of skull was removed for surgery and remains off
place sign above the HOB ex: no bone flap
post op goals for craniotomy pt
Maintain cerebral perfusion, normal ICP
Prevent or minimize complications
Detect changes in patient status
ongoing assessments for craniotomy pt
Neuro VS q 30 min for 4 hrs, then q hr*
Report deficits
Monitor for pain, N/V, change in LOC
pituitary tumors mani
-vision, HA, or endocrine disorders like ACTH, GH secretion
how to we remove pituitary tumors
-going through the nares breaking through the sinus and getting the tumor.
-transphenoidal approach
-Post Op Considerations
Avoid sneezing, straws, anything in the nares
Evaluate clear fluid leakage ?CSF
how to evaluate for CSF?
Evaluate DI/SIADH
Vision
how to evaluate for CSF
-looking for the halo on the pillow or collecting a sample.
how to monitor for DI/SIADH
- urine specific gravity
- If they are going into DI the urine specific gravity will be much closer to water so close to 1.000
- if they are going into SIADH it will have more solute so closer to 1.030.
- If you are concerned about either DI or SIADH you will need to send off both a urine and blood sample for sodium and osmolality.
key nursing management points for after pit. tumor removal
Education on restrictions
Neuro/vitals Q4, monitor CSF leak
Visual acuity Q8: Rosenbaum exam
Urine specific gravity Q void: dipstick urine
Daily serum NA and Osom: monitor for DI/SIADH
If they go into DI
Send serum NA and osom. and urine NA and osom
Monitor I/O’s closely encourage drink to thirst
inter cranial pressure
hydrostatic force measured in the brain CSF compartment, Normal ICP 5-15mmHG great than 20mmHg requires treatment
cerebral blood flow
the amount of blood in milliliters passing through brain tissue in 1 minute
cerebral perfusion pressure
the pressure needed to ensure blood flow to the brain
CPP >60 is generally what we want
Ranges can vary from 60-70 for the baseline depends on patient presentation and health care team preference
CPP <30 is incompatible with life
Normal intracranial pressure/normal functioning
- Brain requires a constant supply of oxygen and glucose.
- The brain uses 20% of the body’s oxygen and 25% of its glucose.
- To keep intracranial pressure and cerebral blood flow constant the body can:
- Alter CSF amounts, cerebral vasoconstriction/dilation
- 70-150 mmhg
how to assess ICP
-Changes in LOC most sensitive and reliable indicator: early sign while everything else is late
(GCS)
-Pupil exam/brainstem exam
-Fixed unilateral pupil size and shape=EMERGENCY
-Motor function
(Hemiparesis, hemiplegia, posturing)
-HA
-Vomiting
-Change in vital signs
Cushing’s triad: HTN, widening pulse pressure, bradycardia, irregular respirations
posturing
a. Decorticate: person is stiff with bent arms, clenched fists, and legs held out straight
b. Decerebrate: arms and legs being held straight out, the toes being pointed downward, and the head and neck being arched backward.
c. C. Decorticate right decerebrate left: mixture of decorticate and decerebrate.
d. mixture of decorticate and decerebrate: seen more in children but is the arching of the back and neck when they are lying flat.
dx/ monitoring for ICP
- Intraventricular monitors are the gold standard “ventriculostomy”
- In the ventricles
factors that influence ICP
- Arterial/venous pressure (blood pressure)
- Blood gasses (esp C02)
- Intra-abdominal and intrathoracic pressure
- Posture
- Temperature (Temp)
as ICP increases, CPP does what
-decreases
key points about ICP
-Cerebral edema and ICP peak 2-3 days after injury
-Decreases over 1-2weeks
CPP can be localized or generalized .
-Absence of cerebral ischemia, aggressive attempts to maintain CPP above 70 mm Hg should be avoided because of the risk of ARDS
-do not always know the recovery trajectory and need to keep waiting to see how the patient responds to treatments
if increase icp is sustained…
eventually the brain will shut down which is why ICP is fatal if there is too much pressure on the brain and perfusion cannot get to the brain tissue
Blood pressure and ICP
- as BV/BP increases: there will be increase in CPP
- as BV/BP decreases: there will be a decrease in CPP
- we want not too low but not too high (there is a happy place at BP= 120-160 and CPP= 50-70
- Hypotension, especially in conjunction with hypoxemia, can induce reactive vasodilation and elevations in ICP
- Dilemma…can’t give too much volume will cerebral edema IICP
- Cautiously give crystalloids with IICP patients
- Use colloids, vasoactives, osmotic diuretics
- Treat HTN if CPP >120 mmHg
- Treat if ICP >20 mmHg.
- Monitor electrolytes- esp sodium
arterial blood gases: co2 and ICP
- increased C02= hyperventilating = dilation = increase ICP
- decreased co2= vasoconstriction = ischemia = loss of blood flow
- increased ICP = blood flow cant get anywhere when vessels are dilated
- cant just give alot of oxygen because of hyperventilation
- hyperventilation = decrease co2 = vasoconstriction = decreased blood volume
-fine balance
Intra-abdominal and intrathoracic pressure:Positioning and ICP
- Brief physiologic elevations in ICP may occur in the setting of coughing, movement, suctioning
- Maintain blood flow by neck alignment
- May need supporting devices to keep neck straight
- Caution knee catches/elevating knee section of bed to prevent patient “moving down in bed”= INCREASED icp
- Turn slowly and Q 2
- Optimal HOB 30-45 degrees
- Suction less than 10 seconds 2 passes BECAUSE IT CAN INCREASE icp
TEMPERATURE and ICP
- Elevated metabolic demand in the brain results in increased cerebral blood flow (CBF), and can elevate ICP by increasing the volume of blood in the cranial vault
- increased temp (fever) –> increased metabolism = increased ICP
- decreased temp –> decreased metabolism = DECREASED ICP
- Treatment:
1. Acetaminophen and mechanical cooling
2. Internal temperature monitor - dont let shiver because that can increase ICP
ICP: drugs and electrolytes
- Osmotic diuretics: draws free water out of tissue into circulation
Mannitol: Q 6-8 hours
Furosemide can be given with it - Hypertonic saline
3% Sodium: increases osmolality to decrease cerebral water content - With mannitol and hypertonic saline closely monitor
Sodium levels, glucose, K, Mag.
Serum osmolality - Provide pain management
Morhpine sulfate, propofol, precedex if ventilated worry about decreased BP
more pharm for ICP
1. Decadron for swelling Push to fast….oops that itches GI bleeding H2 receptor blocker Proton pump inhibitor 2. Barbiturates: pentobarbital decrease cerebral metabolism *research variable on success Monitor EEG (ICU) 3. Antiseizure: protect from seizures only give if seizure activity
interventions for pt with increased ICP
Maintain patent airway Prevent hypoxia Elevate HOB 30-45 Change position Q 2 hours Avoid extreme hip flexion Suction <10 seconds/2 passes Monitor ABGs Monitor I/O’s and electrolytes Avoid Valsalva coughing sneezing Removal of CSF
