Acute Neuro Patient - Haemorrhage

Question 1

What can raise the ICP in an individual? What is the Monro-Kellie doctrine?

Answer 1

Anything that increases volume of:

• brain
• blood
• CSF
• known as the MONRO-KELLIE doctrine

Question 2

What is normal ICP?
Markedly elevated ICP?
Critically elevated ICP?

Answer 2

Normal = <10 mmHg
Elevated 20mmHg (vomiting/decreased levels of consciousness)
Critical elevation 40mmHg - hernation through FM!

Question 3

Why is it important to monitor for CLINICAL SIGNS of raised ICP? What are these clinical signs?

Answer 3

• important bc ICP may not always be monitored digitally - so you should have a way to tell!

CLINICAL SIGNS:

• headache
• vomiting
• reduced consciousness
• raised BP (bc as ICP goes up more BP needed to perfuse the brain)
• bradycardia (as BP goes up, HR goes down)
• slow and irregular respiration (d/t inadequate blood to brainstem)

Question 4

List all the types of cerebral haemorrhage

Answer 4

ICH
EDH
SDH
SAH

Question 5

Medical management of ICH

Answer 5

• whether or not this is operated on depends on age, extent of bleed, whether the bleed is stopping on its own
  (eg. elderly with small bleed - watch+wait; younger with extensive bleed - operate)

Question 6

Medical management of EDH and SDH

Answer 6

bone flap taken out

- SDH tends to be more contained so bone flap removed and clot taken out

Question 7

What are CI’s and P’s for EDH/SDH?

Answer 7

Make sure helmet is worn out of bed

Question 8

SAH:

• describe what proportion of strokes it forms
• what age?
• what causes SAH?
• what is the prognosis?

Answer 8

• 5% of all strokes
• <60 yrs (so usually younger)
• SAH caused by AVM and cerebral aneurysm
• prognosis - 70% die or dependent

Question 9

Medical management of SAH

Answer 9

• analgesia
• immediate bed rest
• coiling
• clipping

Question 10

What are CIs/Ps for SAH?

Answer 10

• Nimodipine stops the vasospasm caused by SAH. but may also reduce BVs throughout the body
• therefore POSTURAL HYPOTENSION
• dont mobilize if there’s vasospam - too much risk of ischemic brain damage

Question 11

Medical management of TBI

Answer 11

1. Control ICP (paralyze/sedate, external ventricular drain, medications, ventilation to control Co2 pressure)
2. Decompression surgery if ICP remains elevated

Question 12

Is craniectomy helpful?

Answer 12

Cooper et al (2011) - craniectomy vs usual care for raised ICP; although craniectomy group had fewer days in ICU, fewer interventions for ICP, and lower ICP - they also has worse neuro scores and more likely to have poorer outcome!

Question 13

CIs/Ps for TBI

Answer 13

• take care of other concurrent injuries (common for TBI patients)
• PTA (amnesia) may affect assessment/treatment
• dysautonomia (pt suddenly goes into very strong/abnormal postures - can hurt themselves) - make sure casts can be taken off quickly - consider soft/bivalved casts?

Question 14

Medical management of cerebral tumours

Answer 14

Depends on:

• size
• location
• type (i.e speed of growth)
• effects on functions
• CHEMO/RADIATION might be used to shrink the tumor - then SURGERY
• MEDS for Sx control

Question 15

What is hydrocephalus? What causes it?

Answer 15

Increase in CSF in the ventricles (enlarged on MRI) - therefore increase in ICP (Monro Kellie doctrine)

CAUSES:

• • tumor
• infection
• aqueduct stenosis
• TBI
• SAH
• congenital blockage (spina bifida)

Question 16

Medical management of hydrocephalus

Answer 16

CHRONIC - drainage via a shunt (ventricular peritoneal or ventricular-atrial shunt)
VP shunt - drained from ventricles into abdomen where the body absorbs it (this is preferred as more accessible)
VA shunt - drained from ventricles to atrium of the heart

ACUTE - EVD*, Lumbar drain

• make sure EVD is always in line withthe ear - otherwise will affect CSF drainage which could be fatal

Question 17

CIs/P for hydrocephalus

Answer 17

NEVER move head without clamping off the EVD!!!!