Neuro ICU

Question 1

indications for admission to ICU

Answer 1

1. threatened airway
2. all respiratory arrests
3. respiratory rate >40 or <90 on >50% oxygen
4. all cardiac arrests
5. pulse rate <40 or >140 bpm
6. SBP <90 mmHg
7. sudden fall in level of consciousness (fall in Glasgow coma score >2 points)
8. repeated or prolonged seizures
9. rising arterial CO2 tension with respiratory acidosis
10. any pt giving cause for concern

Question 2

Neuro Dx leading to ICU admission

Answer 2

1. CVA
2. GBS
3. Acquired TBI
4. Acquired SCI
5. MG
6. Seizures
7. Brain tumors
8. Hydrocephalus

Question 3

ICU Chart Review

Answer 3

1. MD POC
2. Diagnostic Imaging
3. Lab Values
4. Meds
5. Current Pt Status
6. Lines, Drains, Tubes

Question 4

Neurosurgery vs Neurology Team

Answer 4

1. NSGY
   
   • consulted whenever dx may warrant invasive interventions for the brain or spinal cord
     
     • also orthopedic injuries to the spine
2. Neuro
   
   • primary team when invasive interventions not warranted and/or when pt demos sig fluctuations in neuro status

Question 5

Trauma vs Ortho team

Answer 5

1. Trauma
   
   • primary team admitting dx is a result of trauma
   • can be involved in surgical interventions
2. Ortho
   
   • consulted whenever orthopedic injury to extremities
   • can be involved in surgical interventions

Question 6

major search points for reviewing prior MD notes and active orders

Answer 6

1. Reason for admission to ICU
2. PMHx and relevant interventions
3. HPI and relevant interventions
4. 24-hour plan
5. Precautions

Question 7

Lab Values CBC

Answer 7

1. should be relatively stable, with some considerations for admitting dx
   
   • ex → hemorrhage → decreased hgb/hct, increased platelets
2. if not further up/downward, usually okay to see
   
   • check with RN or POC (transfusion, etc.)

Question 8

Lab Values: Electrolyte Panel

Answer 8

1. Patients are very symptomatically sensitive to changes in Na after a neurological event
   
   • cognitive changes
2. Sig changes in Cl, Ca, Mg, PO4 and K are less common post neurological insult

Question 9

Lab Values: Kidney Function

Answer 9

1. BUN and serum creatinine generally stable unless relevant comorbidities present
   
   • if complications seen, tends to be more subacute/chronic stages recovery

Question 10

Lab Values: Endocrine Function

Answer 10

1. Helpful to review blood glucose prior to mobilization, common to see fluctuations
   
   • hyper and hypoglycemia both lead to poor activity tolerance

Question 11

Lab Values: Thyroid Function

Answer 11

1. Hypothyroidism → has been associated with signs of aortic or coronary atherosclerosis
   
   • slowed cog function, ataxia, weakness, paresthesia, edema, bradycardia, CHF, HTN
2. Hyperthyroidism → associated with atrial fibrillation and cardioembolic stroke
   
   • tremors, weakness/atrophy, tachycardia, arrhythmias, hypotension

Question 12

Lab Values: Acid-Base Disorders

Answer 12

1. Respiratory Alkalosis common sequelae of CVA
   
   • dizziness, paresthesias, chest pain, confusion, seizures
2. Respiratory Acidosis common with prolonged ventilatory support and neuromuscular disease
   
   • confusion, fatigue/somnolence, SOB

Question 13

Arousal, Cognition, Behavior Outcome Scales

Answer 13

1. GCS (Glascow Coma Scale)
2. CRS-R (Coma Recovery Scale)
3. ABS (Agitated Behavior Scale)
4. RASS (Richmond Agitation and Sedation Scale)
5. CAM (Confusion Assessment Method)
   
   • RN Assessment - Delirium

Question 14

green light status for the RASS

Answer 14

• +1 (restless)
• 0 (alert and calm)
• -1 (drowsy)
• -2 (light sedation)

Question 15

yellow light status for RASS

Answer 15

• +2 (agitated)
• -3 (moderated sedation)

Question 16

red light status for RASS

Answer 16

• +4 (combative)
• +3 (very agitated)
• -4 (deep sedation)
• -5 (unarouable)

Question 17

common medications for agitation and whether you should treat them if they are on it

Answer 17

1. propofol → red light do not treat, huge sedative
2. fentanyl → yellow light, strong sedative and pain killer
3. precedex → green light, mild sedative

Question 18

T/F: is it appropriate for PT to treat someone who is medically induced paralysis?

Answer 18

FALSE

typically placed in this situation to combat severe pressure dynamics

Question 19

T/F: you can mobilize someone on a ventilator

Answer 19

TRUE

Question 20

Contraindications/Precautions to mobility in SCI

Answer 20

1. Spine stability
2. Spinal shock
3. Autonomic dysreflexia

Question 21

Contraindications/Precautions for mobilizing TBI

Answer 21

1. Autonomic storming
   
   • PT typically deferred until storming subsides
   • can be consulted for bed-level positioning managment
2. Vasospasm
   
   • delayed event after SAH, peak 7-9 days after bleed
   • Transcranial Doppler (TCD): measures mean blood flow velocity of arteries in neck and brain
   • >100-120 cm/s generally contraindicative for mobility

Question 22

Contraindications/Precautions for mobilizing Strokes

Answer 22

1. tPA
   
   • ischemic or thrombotic CVAs
   • no OOB for 24 hrs post admin
2. Typical hemodynamic parameters
   
   • ischemic event
     
     • permissive HTN
     • BP <220/110
   • hemorrhagic event
     
     • BP <150/90

Question 23

Contraindications and precautions for mobilizing seizures

Answer 23

1. Mobility clearance → no active seizures in past 24 hours
   
   • may have more flexibility with small, focal seizures that are stable → check with Neuro team
2. cEEG → ok to mobilize with MD clearance → mobility limited to in-room activities due to restrictions for EEG wires

Question 24

Contraindications and precautions for mobilizing shunt placement

Answer 24

1. starting parameters of shunt relatively universal
   
   • pts will have variety of response to shunt
   • may need further adjustment by NSGY to see further improvements
2. Ok to mobilize after surgery → monitor closely for S/S of increased ICP and/or hydrocephalus and shunt dysfunction
   
   • hydrocephalus signs:
     
     • cog signs, urinary incontinence, shuffled/magnetic gait pattern

Question 25

Contraindications and precautions for mobilizing autoimmune-related neurological events

Answer 25

(includes MG and GBS) 1. these pts are typically managed with IVIg and plasmapheresis * lengthy administrations * pts often exhausted after treatment * okay to see, if tolerated, pending medical stability * best to try to see first thing in AM or on days off

Question 26

general contraindications for initation of PT in ICU setting

Answer 26

1. new admin of a pressor agent or antiarrhythmic agent 2. multiple pressors being administered 3. change in ventilator setting to provide increased ventilator support 4. non-secured airway 5. active GI bleed (consult with MD) 6. elevated ICP 7. agitation requiring increased sedative administration in the last 30 min

Question 27

normal/abnormal ICP values

Answer 27

1. normal = 5-10 mm Hg 2. abnormal \>20 mm Hg

Question 28

methods of ICP monitoring

Answer 28

1. Intraventricular catheter 2. subdural bolt (ICP bolt) 3. Implantable microtransducer sensors 4. extraventricular drain (EVD)

Question 29

describe intraventricular catheter

Answer 29

1. most accurate monitoring method (Gold Standard), but can be difficult to place when emergent 2. catheter inserted into lateral ventricle via venticulostomy 3. requires neurosurgery/neurology clearance for PT 4. can be used to drain fluid out through the catheter * →extraventricular drain (EVD)

Question 30

describe subdural bolt

Answer 30

1. immediate monitoring 2. screw inserted into subdural space 3. very easily dislodged with movement → mobility typically strictly contraindicated

Question 31

describe implantable microtransducer sensors

Answer 31

1. intraparenchymal, epidural 2. least invasive 3. very expensive, generally cannot be recalibrated once in situ → can be less accurate 4. used in situations where EVD placement is unsuccessful or when CSF drainage not necessary 5. generally not appropriate to mobilize until removed

Question 32

describe EVDs

Answer 32

1. uses gravity-positioned drain to clear excess CSF from brain 2. drain will be progressively raised, decreasing rate of draining, while pt is closely monitored for adverse symptoms * once progressed to NSGY goal, clamp trials will start. If well tolerated, drain will be removed

Question 33

difference between clamped and unclamped EVD

Answer 33

1. when unclamped, actively draining fluid * pts cannot mobilize when drain is unclamped 2. when clamped, safe to mobilize and participate in full with close monitoring * need NSGY clearance for clamping * most common adverse S/S: * decreased arousal, drowsiness, LOC 3. pts should first tolerate 30 min of EVD clamped at rest prior to mobilization

Question 34

Common barriers to mobilization in the NS/STICU

Answer 34

1. Spinal instability 2. Autonomic storming 3. tPA 4. bedrest associated with endovascular intervention 5. increased ICP 6. vasospasm 7. hemodynamic instability 8. femoral sheaths (A-line) 9. increased ventilatory support 10. active seizures 11. treatment interventions * IVIg, Plasma, Dialysis, CXT/RT, IR

Question 35

important considerations for mobilizing acute CVA

Answer 35

1. severity/type of CVA 2. interventions required 3. hemodynamic parameters 4. neuroimaging

Question 36

important considerations for mobilizing EVD

Answer 36

1. EVD clamp tolerance at rest 2. EVD plan of care 3. close monitoring for S/S of adverse response to clamping with mobility versus at rest

Question 37

important considerations for mobilizing TBI (traumatic and acquired)

Answer 37

1. severity of injury 2. acute complications 3. ICP parameters 4. behavioral status

Question 38

important considerations for mobilizing SCI

Answer 38

1. presence of frxs 2. orthopedic restrictions 3. autonomic dysreflexia 4. spinal shock 5. orthotics 6. pain tolerance comorbidities

Question 39

general tips for mobilizing pts in NS/STICU

Answer 39

1. stepwise progression of pt positioning to ensure appropriate neurological, hemodynamic, and pulmonary response to activity/upright * HOB elevated → chair position → EOB → bedside chair * EGRESS Test * sit to stand x3 * marching x3 * advancing step and return step of each foot * as soon as appropriate → ambualte

Question 40

ICU outcome measures

Answer 40

1. Functional Status Score for ICU Patients 2. Physical Function in Intensive Care Test (PFIT)

Question 41

describe the functional status score for ICU patients

Answer 41

1. 5 item performance-based measure (0-35 pts) * rolling, supine \>sit, EOB sitting, sit \>stand, walking 2. MCD: 2.0 - 5.0 points 3. MCID at ICU admission: 3 points 4. Excellent inter-rater and intra-rater reliability, internal consistency

Question 42

describe PFIT

Answer 42

1. STS assistance, marching cadence, quadriceps strength 2. qualitative metrics not as well studied * strong predictive validity comparing PFIT score on awakening and D/C home rate

Question 43

Indications for activity cessation

Answer 43

1. increased lethary/change in mental status 2. change in neuro status 3. elevated ICP 4. line/tube/drain malfunctions 5. hemodynamic instability 6. pulmonary instability 7. acute pain, severe HA