Bone Marrow Transplant (Hematopoietic Stem Cell Transplant) (HSCT)

considerations for use: -leukemia, lymphoma (dz of bone marrow) -testicular/ovarian CA (SE of chemo--BMT is used as rescue) -multiple myeloma -sickle cell dz -aplastic anemia -malignant melanoma sources: -bone marrow -peripheral circulating blood -umbilical cord blood harvest: -posterior iliac crest, sternum -multiple punctures (20-30) -large bore needle (8 guage) -from peripheral cells-cell separator equipment, use colony stimulating factors; like pheresis

Signs/Symptoms of Graft vs. Host Disease <

skin rash-erythroderma liver-increased billirubin GI tract-diarrhea

-Stages of grief: denial, anger, bargaining, depression, acceptance -interdisciplinary -pain control -QOL -MD must state pt has <6months -stop all curative tx -must have 24h caregiver

-Autogenic -Allogenic-donor is human leukocyte antigen matched -Syngeneic (identicl twin) -MUD (matched unrelated donor) -harvest frombone marrow or peripheral

-immunosuppressive therapy (methotrexate, cyclosporine) for life--compliance issues -corticosteroids to suppress immune inflm response -symptomatic tx of skin, liver, GI -occurs within 100 days -chronic complications=after 100 days=cataracts, gonad dysfunction, hyypothyroidism, secondary malignancies; can live for years with these complications--just not a normal life-span.

Risk Factors for Fractures and Osteoporosis

-occupation -contact sports -drugs: steroids, AEDs, thyroid drugs, tetracycline, chemo drugs (methotrexate), radiation -too much vit A (>1.5mg/day) -overweight -elderly -sex: men -lack of weight bearing exercise -diminished senses -systemic dz: renal, CA, hypothyroid

-cleaning of extremity -padding=webril, stockinette, moleskin -hydrate plaster of Paris (releases heat) several layers -start distal, work proximal -will feel tight at first, will feel heavy -casts are breathable, don't do anything to prevent that -petal-ing cast is ok -will loosen slightly over time -report colored spots on cast if wound underneath -keep extremity elevated -nerve and circ checks -report fever -report bloody cast -report excessive pain -upon removal--assess muscle tone

-top of crutches should be 4-6 inches from axilla -stairs: good up, bad down -2,3, and 4 point gait (4 point if some weight bearing is OK) -2 point when weight bearing is allowed on both feet-resembles regular walking -3 point if no weight bearing on one foot

-Normal INR is 5, give vit K antidote

-dual energy X-ray absorptiometry -measures bone mineral density (BMD) -in hip, spine, forearm -T-1 and above is good -osteoposis if T< -2.5 -T between -1 and -2.5 = osteopenia -q2 years

Amputations: Post-Op Care

Complications: bleeding-tournaquet at bedside -flexion contracture no pillow under residual limb, lay prone 20-30min qid, no sitting > 1 hr

AH II Test 2 Flashcards by Liz Hall

Bone Marrow Transplant

(Hematopoietic Stem Cell Transplant)

(HSCT)

considerations for use:

-leukemia, lymphoma (dz of bone marrow)

-testicular/ovarian CA (SE of chemo--BMT is used as "rescue")

-multiple myeloma

-sickle cell dz

-aplastic anemia

-malignant melanoma

sources:

-bone marrow

-peripheral circulating blood

-umbilical cord blood

harvest:

-posterior iliac crest, sternum

-multiple punctures (20-30)

-large bore needle (8 guage)

-from peripheral cells-cell separator equipment, use colony stimulating factors; like pheresis

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Signs/Symptoms of

Graft vs. Host Disease

<

<ol>
<li>
skin rash-erythroderma</li>
<li>
liver-increased billirubin</li>
<li>
GI tract-diarrhea</li>
</ol>

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Pathophys-Leukemia

-fluid CA of blood, bone marrow, lymph nodes, spleen

-id by type of WBC involved (leukocyte)

-id by acute or chronic

-susceptibility to infection bc it's a CA of WBCs

-Tx=BMT, chemo (no radiation-unless BMT)

-acute or chronic myelogenous leukemia (granulocytes)

-acute or chronic lymphocytic leukemia (lymphocytes)

-S/S=swollen lymph nodes, fever, bruising, bone/joint pain, fatigue, anorexia, weight loss

-low RBCs, Hb, Hct, Plt, high WBCs

-complication=cellulitis

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Pathophys-Lymphoma

-lymphocytes are cancerous

-originates in bone marrow and lymph structures

-dx-bone marrow aspiration

-Hodgkins=Reed-Sternberg cell in bone marrow, same sx as leukemia, remains in lymphnodes, spreads in predictable pattern, localized, Tx=chemo, radiation, surgery, GOOD prognosis (worse if positive nodes above and below diaphragm) B-lymphocytes

-Non-Hodgkins=lymphoma begins at extranodal sites, very aggressive, disseminated, Tx=chem, BMT; B and T lymphocytes

-B-symptoms include fever, night sweats, weight loss

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Hospice Care

-Stages of grief: denial, anger, bargaining, depression, acceptance

-interdisciplinary

-pain control

-QOL

-MD must state pt has <6months

-stop all curative tx

-must have 24h caregiver

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Multiple Myeloma

-cancer that starts in the plasma cells in bone marrow

-Plasma cells help your body fight infection by producing proteins called antibodies

-abnormal proliferation of malignant B lymphocytes

-bone destruction=pain, osteoporosis, pathological fx

-s/s= anemia, thrombocytopenia, *hypercalcemia from bone destruction

-normal Ca=8.6-10.2; force fluids to eliminate, diuretics (furosemide), Pamidronate (lowers Ca by inhibiting osteoclasts), chemo, BMT, HSCT

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Types of BMTs

-Autogenic

-Allogenic-donor is human leukocyte antigen matched

-Syngeneic (identicl twin)

-MUD (matched unrelated donor)

-harvest frombone marrow or peripheral

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Graft vs. Host Dz

-immunosuppressive  therapy (methotrexate, cyclosporine) for life--compliance issues

-corticosteroids to suppress immune inflm response

-symptomatic tx of skin, liver, GI

-occurs within 100 days

-chronic complications=after 100 days=cataracts, gonad dysfunction, hyypothyroidism, secondary malignancies; can live for years with these complications--just not a normal life-span.

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Risk Factors for

Fractures and Osteoporosis

-occupation

-contact sports

-drugs: steroids, AEDs, thyroid drugs, tetracycline, chemo drugs (methotrexate), radiation

-too much vit A (>1.5mg/day)

-overweight

-elderly

-sex: men

-lack of weight bearing exercise

-diminished senses

-systemic dz: renal, CA, hypothyroid

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Signs/Symptoms of Fractures

-edema and swelling (risk for compartment syndrome)

-pain and tenderness

-loss of function

-deformity (cardinal sign)

-discoloration

-ecchymosis/contusion

-crepitation-do not test ROM

-muscle spasm

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Nerve and Circ Checks

Nursing--8 Ps of nuring fx assessment

-pain

-parasthesias (numbness/tingling)

-pallor

-pulselessness

-paralysis

-polar (hot/cold)

-perception (sensations-sharp v. dull)

-pressure (tension)

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Cast Care

-cleaning of extremity

-padding=webril, stockinette, moleskin

-hydrate plaster of Paris (releases heat) several layers

-start distal, work proximal

-will feel tight at first, will feel heavy

-casts are breathable, don't do anything to prevent that

-petal-ing cast is ok

-will loosen slightly over time

-report colored spots on cast if wound underneath

-keep extremity elevated

-nerve and circ checks

-report fever

-report bloody cast

-report excessive pain

-upon removal--assess muscle tone

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Crutch Walking

-top of crutches should be 4-6 inches from axilla

-stairs:  good up, bad down

-2,3, and 4 point gait (4 point if some weight bearing is OK)

-2 point when weight bearing is allowed on both feet-resembles regular walking

-3 point if no weight bearing on one foot

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Complications of Fractures

-Compartment Syndrome=progressive muscle necrosis due to swelling and impaired blood flow; rise in compartment pressure (>30-50mmHg of capillary pressure) puts more pressure on nerves and prevents venous return; long bone fractures, extensive soft tissue damage, burns, tight dressings, poor positioning, hypotension=Nerve and Circ problem!!!  Stryker machine measures capillary pressure in compartment; can result in amputation.  s/s-swelling, increased pain unrelieved by analgesics, diminished/absent pulse, numbness/tingling, color change, feels COLD.  Tx=bivalve cast, diuretics (low MW dextran or Mannitol), decompression fasciotomy, monitor CPK-MM, urine for myoglobin (muscle destruction can damage kidneys)

-Fat Embolism-Risk=long bone, crushing injuries; fat globules released into blood, migrate to lungs.  s/s=24-72 hr post injury, >RR, >HR, >temp, peteciae in buccal mucosa, conjuctiva, chest, chest pain,

-DVT-s/s=unilaterl leg pain, tenderness on palp, unilateral edema, warm skin, erythema, fever possible.  prevention=TED, SCD, lovenox; Dx-doppler; Tx-heparin drip, coumadin x 3months, IVC filter plct

-Infection (Oseomyelitis)-s/s=low grade fever, malaise, local tenderness, swelling, WARMTH, purulent discharge.  Tx=debridement and antibiotics, prophylactic atb prior to all invasive procedures to prevent future infections

-Hypovolemic Shock-d/t blood loss at fx site; s/s=incr HR, decr BP, decr urine, pale, cool clamy skin, decr Hgb/Hct, confusion, restlessness; Tx=fluid resuscitation, blood transf, vasoconstring drugs, O2

-Fx Blister-at fx site-result of injury to dermal-epidermal junction d/t strain during fx formation--LEAVE blister in tact!

VASOCONSTRICTORS=epi, norepi, vasopressin, pseudoephedrine, antihistamines, decongestants, stimulants

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Arthroplasty

-NWB, TTWB, PWB, WBAT, FWB

-Nerve and Circ checks

-meds=ATB, anticoags, analgesics, laxatives

-drainage-sanguinous 100-150 ml/h for first 4h, then decreases drastically, change to serosanguinous, then serous

-complications-infection, avascular necrosis, PE, dislocation

-Hip precautions-don't decr angle <90, don't cross legs, sit with feet 6" apart

-get OOB on affected side, don't stoop, squat, bend for 3-6 months, keep knees below hips.

-TKA (total knee arthroplasty), NO pillow under knee, immobilizer when OOB, CPM machine, continous ice packs, blood reinfusion sys; must be either in CPM machine or immobilizer

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Coumadin

-Normal INR is <1.3, therapeutic is 2-3

-fall precautions

-observe for hematuria; confusion (cerebral bleed)

-no ASA, ibuprofen

-eat high vit K food consistently (green leafy)

-coumadin is therapeutic for 72 hrs, heparin leaves sys in an hour or 2.  heparin-monitor PTT

-bf surgery repl coumadin with heparin

-for INR>5, give vit K antidote

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DEXA Scan

-dual energy X-ray absorptiometry

-measures bone mineral density (BMD)

-in hip, spine, forearm

-T-1 and above is good

-osteoposis if T< -2.5

-T between -1 and -2.5 = osteopenia

-q2 years

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Medications for Osteoporosis

-calcium/vitamin D-body can only absorb 500 mg at a time, slows bone loss-does NOT increase mass; drugs that interfere with Ca absorption=thyroid hormones, tetracycline, corticosteroids, iron, antacids

-Calcitonin - nasal spray, IM or subQ, inhibits osteoclasts, can cause nasal irritation, do not inhale

-Bisphosphonates-Fosamax (alendronate), inhibits resorption, first thing in the AM 30 min bf food/drink, take with water only, SE=esophagitis.  AKA Didronel, Actonel, Boniva.

-Selective Estrogen Receptor Modulators-Evista (raloxifene), mimics effect of estrogen on bone, reduces bone resorption.  SE=leg cramps, hot flashes

-Recumbinant Human Parathyroid Hormone=Teriparatide (Forteo)=new drug, stimulates osteoblasts, increases GI and renal abs of Ca, increases BMD, bone mass, and strength, SubQ, refrigerate, may cause dizziness.

-Denosumab (Prolia)-from hamsters, for women with T-4 or fx on bisphosphonates, check serum Ca, vit D, creatine clearance must be normal.

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Amputations:

Post-Op Care

Complications:

bleeding-tournaquet at bedside

-flexion contracture no pillow under residual limb, lay prone 20-30min qid, no sitting > 1 hr

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Muskuloskeletal Conditions

-Strain=stretching of muscle ususally large muscle group

-sprain=injury to the ligament surrounding a joint

(ligaments join bone to bone, tendons join muscle to bone)

-fracture=break in bone continuity

Patient in Traction

-to reduce and immobilize fracture, provides proper alignment and reduces muscle spasm.

-skin traction-short term until Sx or cast, no more than 10 lbs of weight; assess skin under splint q8h

-skeletal traction-can have >10lbs; assess for proper alignment, center of bed, weights correct (must have order), weights swing freely, pulleys aligned, not frayed, feet not touching end of bed, knots secured; pin site-NS or 1/2 strength H2O2, sterile tech, wrap loose gauze around pin, note puckering of skin around insertion site

-NERVE and CIRC checks!

-Risk for bone infection

Risk factors for Osteoporosis

-smoking

->65 yo

-low Ca intake

-lack of sun exposure

-too much sodium or protein causes increased Ca excretion

-lack of exercise

-late menarchy (>12-14 yo)

-early menopause

-prolonged amenorrhea

-caucasion, Asian (black=low risk)

-small, lean frame

-family Hx, personal Hx of fx

-decreased estrogen after menopause

-medications (steroids, AEDs, chemo, XS thyroid drugs)

-kidney dz, DM, intestinal malabsorption

IICP

Diagnostics

-CT-with contrast can show tissues/organs; contrast can damage kidneys (BUN, creatine (0.6-1.3)WNL), shellfish allergy, benadryl/steroids, need consent, NPO for 6h, hold Metformin, lie still, may feel hot, flush, metallic taste, htobottom from contrast USED: intracranial bleed, space-occupying lesions, cerebral edema, infarctions, hydrocephalus, cerebral atrophy, shifts of brain structures. Post-assess allergy, force fluids to flush contrast

-MRI-magnetic energy, id's types of tissues, tumors and vascular abnormalities, may use Gadolinium contrast (creatinine), NO ionizing radiation. No metal. Lie still for 1 hour, valium for claustrophobia.

-PET scan-glucose/oxygen metabolism, cerebral blood flow.  Inject IV a molecule of deoxyglucose tagged with isotope.  NPO, no caffeine, ETOH, tobacco for 24h, no sedatives/tranquilizers, no glucose preps or drugs that alter glu metab

-Angiogram-inject contrast thru femoral artery up thru cerebral circulation, need consent, shellfish allergy, normal creatinine, meds that may react with contrast-AED, antidepressants, metformin, empty bladder, NPO. Post-leg immobilized, lie flat 4-6h, check peripheral pulse, assess femoral for bleeding, sandbags and pressure dressing, force fluids to get rid of contrast, nerve and circ checks

-LP-lumbar puncture-needle below L2 to subarachnoid space to obtain CSF, measure pressure, instill air, contrast or meds.  contraindicated for pts with IICP, need consent, empty bladder, strict asepsis.  Post-keep flat, force fluids to repl CSF, prevent spinal HA, risk for meningitis

Normal ICP

-measured in lateral ventricles =

5-15mmHg

Ventriculostomy

-ICP monitoring

-catheter inserted into the ventricles

-transducer records pressures of CSF

-may be used to drain CSF if IICP

-may be used to admin meds

Intracranial Pressure Autoregulation

-brain's ability to change the diameter of its blood vessels automatically to maintain a constant cerebral blood flow during alterations in systemic blood pressure

Pressure autoregulation-as SBP goes up, vessels in brain constrict, as SBP goes down, vessels dilate so that brain will be perfused; without this cerebral blood flow would vary according to BP. Vessels dilate a lot more than they can constrict.
Metabolic autoregulation-due to changes in O2, CO2, temperature. Low O2 + high CO2 = cerebral vasodilation (increases cerebral blood flow). Increased T=increased metabolic needs, incresed O2 demand, increased CO2 production=dilation of cerebral arteries

Failure of Autoregulation--CPP<50 or >150, acidosis (high CO2), severe brain injury, loss of BBB

Neurological Assessment

-LOC is most important neuro asssessment!!! (LOC is not orientation)

-Orientation-person, place, time, why

-GCS-pts best response is recorded: eyes (opens), verbal (oriented x4), motor (obeys commands...); score of less than 7 is bad, highest possible is 15

-Painful Stimuli-check bilaterally, best response=localizing (reaches across body to push noxious stimulus away)

-Posturing-bad responses to pain=abnormal flexion (decorticate); abnormal extension (decerebrate)

-Doll's Eyes-oculocephalic (CN 4 and 6)-turn head (if no cord injury)-normally eyes rotate to left as head turns to right; abnormal/absent-eyes remain centered as head turns.

-Cold Water Calorics-oculovestibular (CN 4 and 6)-squirt cold water into ear (if tympanic is intact)

-Cushing's Triad-symptoms of IICP=bradypnea, BP (systolic increases, diastolic decreases=widening PP), bradycardia (full and bounding)--VS's change to try to increase cerbral blood flow.

-Pupils-shape, response, ipsilateral (unequal-ominous)

-Babinski's-abnormal over 18 months

-Grasp-squeeze my fingers and now let go-abnormal if they don't let go

Treatment for IICP

O2 to avoid hypoxia
plct of ICP monitor - drain CSF
control hyperthermia >38
control seizures
limit suctioning to <10sec
maintain MAP
reduce cellular demands (sedate with propofol; paralyze with Vecuronium)
steroids for cerebral edema
HOB 30 degrees to aid venous drainage
keep neck neutral to aid in venous drainage
diuretics to reduce cerebral edema (Mannitol-filter needle, monitor electrolytes (K+), lots of urine via foley)
stool softener to reduce valsalva (increases ICP)
anti-ulcer meds (proton pump inhibs, H2 receptor blockers-ranitidine, omprazole) bc steroids cause GI bleeds
manage pain bc it can increase ICP-pain meds may mask LOC; NO Demerol-toxic metabolite causes seizures
Normal saline-don't overhydrate
monitor for DI and SIADH-edema on pituitary
fever-d/t pressure on hypothalmus

Types of Head Injuries

-Basilar Skull Fx-base of brain-racoon eyes, battle's sign (behind ear), crosses a sinus and tears the dura resulting in rhinorrhea (CSF from nose), otorrhea (CSF from ear), fluid tests positive for glucose

-Concussion-jarring of brain, temp loss of consciousness, short-term amnesia, HA, observe for s/s of IICP, awaken q2h, don't give meds that lower LOC, no bleeding :)

-Contusion-bruising of brain, areas of hemorrhage, infarction, necrosis, cerebral edema; coup/contrecoup injury, seizures are often complication, LOC: post-traumatic amnesia for weeks to months. CT scan w/o contrast to check for bleeding

-Laceration-tear of brain tissue of d/t depressed or open fx and penetrating injuries, permanent brain damage, may lead to hematomas-epidural, subdural, intracerebral

-open = tear in the dura

-closed HI = dura is intact

-skull fx-depressed, comminuted, linear, basal

-Secondary HI=complications that result in additional pathophys changes and dysfunction=intracranial (IICP, edema, bleeding, infection, seizures), Systemic (hypoxia, anemia, hypotension, hyperthermia, hypercapnea, resp complics, electrolyte imbalance

complications--SIADH and DI

Post-Op Craniotomy Care

-preformed to remove damaged tissue, stop bleeding, remove accumulated blood, remove tumors, repair vascular abnormalities.

-change in LOC is first sign of deteriorating neuro status

-VS including temp

-respiratory function including ABGs-hypoxia can lead to IICP

-Inspection of surgical dressing for bleeding or CSF drainage

-meds to reduce cerebral edema (decadron or mannitol)

-position pt as ordered

-I &O's

-electrolytes--hypo or hypernatremia

-monitor for seizure activity

-DVT prevention

-drainage from hemovac, J-P drain should be <30-50ml/shift

Complications=IICP from cerebral edema, intracerbral hemorrhage, cranial nerve damage, infection=wound or meningitis, fluid and electrolyte imbalance -- DI or SIADH, seizures, hyperthermia, obstruction of CSF flow resulting in CSF leak or hydrocephalus

CSF Leaks

-Function of CSF=cushion, shock absorption, provides nutrients, removes wastes

-produce 500-750 cc/day, 150 cc circulate at any one time

-normal CSF contains minimal WBCs and no RBCs

-test for glucose (test tape)

-halo ring

-post-nasal drip is salty if CSF

-Pt complains of HA which improves when lying down, recurs when up

-neck rigidity

Management of CSF Leaks:

-bedrest, HOB 15 or less, no valsalva, no sucking--incentive spirometers, straws, cigs, avoid blowing nose, cough, sneezing, NG tubes

-external lumbar drain to reduce CSFpressure so wound will heal--catheter into subarachnoid space, STERILE, don't raise bag above ventricles (backflow), clamp catheter for movement/amulation. check hourly drainage, should be water-like, check for leakage/infection, must be certified to change bag.

Specific Gravity

-measure of density of urine compared to dnesity of water

-normal: 1.003-1.030

-measure with strips or urinometer

Types of Seizures

-paroxysmal, uncontrolled electrical discharge of neurons in the brain that interupt normal function

-epilepsy=spontaneously recurring seizures caused by chronic underlying disorder, often unknown; brain tumor, hypoglycemia, electrolyte imbalance, ETOH withdrawal, stroke, HI, idiopathic

partial (local/focal)=part of brain (hypoxia, infection, tumor, infarction); simple-no loss of consciousness or complex-alteration in consciousness
generalized=all of brain (genetic-abn neurons, environ toxins, illicit and prescription drugs)=Absence (no motor involvement), Myoclonic, Atonic, Generalized tonic-clonic

Dx-r/ometabolic causes or structural lesions (brain tumor); EEG, CT, MRI, cerebral angiogram, PET scan

EEG Preparation

-graphic recording of electrical activity of brain, done within 24h of suspected seizure

-does not measure mental status

-avoid caffeine and ETOH

-do NOT get good night's sleep

-nothing in hair

-electrical flow from pt to machine

-remain still

-sedative (have ride home)

-may hold AEDs, stimulants, depressants, antidepressants for 24-48h prior

Dilantin

-therapeutic: 10-20 mcg/ml

-one of the only AEDs that can be given IV

-IV push 50 mg/min (elderly 25 mg/min)

-if given too fast=purple glove syndrome, brady and hypotension

-only give with NS!!

-large doses need to be divided, wait 30 min between doses

-elixir can't be given with tube feeding-binds and won't be absorbed, it is hyperosmolar (diarrhea); give 1 hr before or after tube feeding

-SE's: Stevens-Johnson=measles-like, skin and MMs, can be fatal (sulfonamides, PCN, salicylates and COX-2 inhibs also), bone marrow depression *leukopenia, osteoporosis, gum hyperplasia, nystagmus, ataxia, drowsiness, teratogenic (give lowest dose possible)

-don't stop abruptly (sz will return); if dose is missed, take asap; AEDs < BCPs; elderly-start low, go slow

SE's of Seizure Meds

Stevens-Johnson=measles-like, skin and MMs, can be fatal (sulfonamides, PCN, salicylates and COX-2 inhibs also)

bone marrow depression, osteoporosis, gum hyperplasia, nystagmus, ataxia, drowsiness, teratogenic (give lowest dose possible)

-don't stop abruptly (sz will return)

if dose is missed, take asap

AEDs < BCPs

elderly-start low, go slow

Status Epilepticus

-2+ sz's between which there is incomplete recovery of consciousness

-neurological emergency-high mortality rate due to hypoxia, hypoglycemia, systemic acidosis, hyperthermia, exhaustion

-precipitated by-abrupt stopping of AEDs, fever, acute ETOH withdrawal, head trauma, metabolic disturbances, infection

-Tx=AEDs (IV Dilantin), IV valium, ativan, O2, cool, protect, treat underlying cause

Seizure Precautions

-padded side rails,up

-O2 and suction at bedside

-saline lock in place

-no glass thermometers

-bed in lowest position

post-sz tests: glucose,electrolytes, O2 sats, serum levels of AED

NOTE: time, duration, first thing pt does, types of movements, body parts involved, eyes-pupils, incontinence, ability to follow commands, cognitive status at the end.

Parts of Brain

-Brocca's area-in the frontal lobe, controls expression of speech

-Wernicke's area-in the temporal lobe, controls understanding of speech.

-blood supply comes from R/L internal carotids, R/L vertebral-anastamose at base of brain=Circle of Willis

Cranial Nerves

On Occassion Our Trusty Truck Acts Funny. Very Good Vehicle Any How.

olfactory
optic
oculomotor
trochlear
trigeminal
abducens
facial
vestibulocochlear
glossopharyngeal
vagus
accessory
hypoglossal

gag=9 and 10

corneal reflex=5 and 7

oculocephalic (dolls eyes)=6 and 4

oculovestibular (cold water calorics)=6 and 4

Causes of IICP

increased brain volume
increased blood volume
increased CSF (hydrocephalus)

Cerebral Perfusion Pressure

-is the pressure needed to ensure adequate cerebral blood flow so the brain can receive O2 and nutrients

-if it's too high or too low--irreversible neurological damage can occur

-CPP=MAP - ICP

-MAP is the average pressure at which blood moves thru the vasculature.

-MAP = SP + (2*DP)/3

-Normal MAP is 70-110 mmHg

S/S of IICP

decreased O2 sats
increased ICP
increased pCO2
decreased MAP
increased or decreased CPP
hypotension
change in LOC
Cushing's triad
pupil changes
posturing
vomiting
severe HA

Hematomas from HI's

-Epidural-lacerated=middle meningeal artery in temporal area; char'd by unconscious-conscious-unconscious; need rapid surgical intevention to remove hematoma, prevent brain stem herniation from IICP. *craniotomy!!

-Subdural (SDH)-bt dura and arachnoid layer, venous bleed; can be acute, subacute or chronic (wks-months after injury), may or may not be removed, serial CTs to watch size of hematoma

-Intracerebral Hematoma-bleeding within the brain tissue, size/location determines outcome, often fatal, diffuse damage. (penetrating injury--GSW)

Mean Arterial Pressure

MAP = SP + 2DP / 3

Normal = 70-110

Meningitis

-Bacterial: Strep. pneumonia, Neisseria meningitidis, Haemophilus influenza (Hib vaccine)

-Viral: enteroviruses, arboviruses, HIV, HSV

-s/s=fever, severe HA, N/V, nuchal rigiditiy, photophobia, decreased LOC and signs of IICP)

-Kernig's sign=pain in hamstring, inability to straighten leg when hig flexed to 90.

-Brudzinskis'=involuntary lifting of the legs when lifting pt's head while lying supine

-CSF: increased WBCs, protein levels high, glucose low, turbid, purulent

-Tx=ATB, steroids, pain meds for HA, nuchal rigidity, fever, extra fluids; family gets prophylactic ATB, respiratory isolation until blood cultures are negative, quiet and dark, sz precautions, measure I&O, may be dilutional hyponatremia, inappropriate ADH-causing fluid retention.

-vaccine=meningococcal MCV4 and MPSV4

-deficiency of production or secretion of ADH (decreased renal response to ADH)

-hypernatremia and increased urine output

-polydypsia, polyurea, fatigue, hypotension, tachy, shock, CNS changes--irritablility, mental dullness, coma

-urnine specific gravity <1.005

-5-20 L/day of urine

-Dx-water restriction test

-Tx-fluid and hormone replacement (DDAVP)-oral, IV, subQ, nasal spray

SIADH

-abnormal production or sustained secretion of ADH

-char'd by: fluid retention, serum hypoosmolarity, dilutional hyponatremia, hypochloremia, concentrated urine, normal or increased intravascular volume, normal renal function.

-cause is often malignancy (esp. small cell lung CA)

-hyponatremia=muscle cramping, pain, weakness

-s/s=low urine output, increased weight, confusion, disorientation, thirst, fatigue, vomiting, abd cramps, muscle twitching, sz....cerebral edema

-Dx-urine and serum osmolarity, urine spec gravity >1.005

-Tx-fluid restriction to 800ml to 1L per day, if severe-hypertonic saline (slow!), Lasix (if Na is at least 125)