Neuro ICU Flashcards
indications for admission to ICU
- threatened airway
- all respiratory arrests
- respiratory rate >40% or <90% on >50% oxygen
- all cardiac arrests
- pulse rate <40 or >140 bpm
- SBP <90 mmHg
- sudden fall in level of consciousness (fall in Glasgow coma score >2 points)
- repeated or prolonged seizures
- rising arterial CO2 tension with respiratory acidosis
- any pt giving cause for concern
Neuro Dx leading to ICU admission
- CVA
- GBS
- Acquired TBI
- Acquired SCI
- MG
- Seizures
- Brain tumors
- Hydrocephalus
ICU Chart Review
- MD POC
- Diagnostic Imaging
- Lab Values
- Meds
- Current Pt Status
- Lines, Drains, Tubes
Neurosurgery vs Neurology Team
- NSGY
- consulted whenever dx may warrant invasive interventions for the brain or spinal cord
- also orthopedic injuries to the spine
- consulted whenever dx may warrant invasive interventions for the brain or spinal cord
- Neuro
- primary team when invasive interventions not warranted and/or when pt demos sig fluctuations in neuro status
Trauma vs Ortho team
- Trauma
- primary team admitting dx is a result of trauma
- can be involved in surgical interventions
- Ortho
- consulted whenever orthopedic injury to extremities
- can be involved in surgical interventions
major search points for reviewing prior MD notes and active orders
- Reason for admission to ICU
- PMHx and relevant interventions
- HPI and relevant interventions
- 24-hour plan
- Precautions
Lab Values CBC
- should be relatively stable, with some considerations for admitting dx
- ex → hemorrhage → decreased hgb/hct, increased platelets
- if not further up/downward, usually okay to see
- check with RN or POC (transfusion, etc.)
Lab Values: Electrolyte Panel
- Patients are very symptomatically sensitive to changes in Na after a neurological event
- cognitive changes
- Sig changes in Cl, Ca, Mg, PO4 and K are less common post neurological insult
Lab Values: Kidney Function
- BUN and serum creatinine generally stable unless relevant comorbidities present
- if complications seen, tends to be more subacute/chronic stages recovery
Lab Values: Endocrine Function
- Helpful to review blood glucose prior to mobilization, common to see fluctuations
- hyper and hypoglycemia both lead to poor activity tolerance
Lab Values: Thyroid Function
- Hypothyroidism → has been associated with signs of aortic or coronary atherosclerosis
- slowed cog function, ataxia, weakness, paresthesia, edema, bradycardia, CHF, HTN
- Hyperthyroidism → associated with atrial fibrillation and cardioembolic stroke
- tremors, weakness/atrophy, tachycardia, arrhythmias, hypotension
Lab Values: Acid-Base Disorders
- Respiratory Alkalosis common sequelae of CVA
- dizziness, paresthesias, chest pain, confusion, seizures
- Respiratory Acidosis common with prolonged ventilatory support and neuromuscular disease
- confusion, fatigue/somnolence, SOB
Arousal, Cognition, Behavior Outcome Scales
- GCS (Glascow Coma Scale)
- CRS-R (Coma Recovery Scale)
- ABS (Agitated Behavior Scale)
- RASS (Richmond Agitation and Sedation Scale)
- CAM (Confusion Assessment Method)
- RN Assessment - Delirium
green light status for the RASS
- +1 (restless)
- 0 (alert and calm)
- -1 (drowsy)
- -2 (light sedation)
yellow light status for RASS
- +2 (agitated)
- -3 (moderated sedation)
red light status for RASS
- +4 (combative)
- +3 (very agitated)
- -4 (deep sedation)
- -5 (unarouable)
common medications for agitation and whether you should treat them if they are on it
- propofol → red light do not treat, huge sedative
- fentanyl → yellow light, strong sedative and pain killer
- precedex → green light, mild sedative
Is it appropriate for PT to treat someone who is medically induced paralysis?
NO
typically placed in this situation to combat severe pressure dynamics
T/F: you can mobilize someone on a ventilator
TRUE
Contraindications/Precautions to mobility in SCI
- Spine stability
- Spinal shock
- Autonomic dysreflexia
Contraindications/Precautions for mobilizing TBI
- Autonomic storming
- PT typically deferred until storming subsides
- can be consulted for bed-level positioning managment
- 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
Contraindications/Precautions for mobilizing Strokes
- tPA
- ischemic or thrombotic CVAs
- no OOB for 24 hrs post admin
- Typical hemodynamic parameters
- ischemic event
- permissive HTN
- BP <220/110
- hemorrhagic event
- BP <150/90
- ischemic event
Contraindications and precautions for mobilizing seizures
- Mobility clearance → no active seizures in past 24 hours
- may have more flexibility with small, focal seizures that are stable → check with Neuro team
- cEEG → ok to mobilize with MD clearance → mobility limited to in-room activities due to restrictions for EEG wires
Contraindications and precautions for mobilizing shunt placement
- starting parameters of shunt relatively universal
- pts will have variety of response to shunt
- may need further adjustment by NSGY to see further improvements
- 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
- hydrocephalus signs:
Contraindications and precautions for mobilizing autoimmune-related neurological events
(includes MG and GBS)
- these pts are typically managed with IVIg and plasmaheresis
- 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
general contraindications for initation of PT in ICU setting (7)
- new admin of a pressor agent or antiarrhythmic agent
- multiple pressors being administered
- change in ventilator setting to provide increased ventilator support
- non-secured airway
- active GI bleed (consult with MD)
- elevated ICP
- agitation requiring increased sedative administration in the last 30 min
normal/abnormal ICP values
- normal = 5-10 mm Hg
- abnormal >20 mm Hg
methods of ICP monitoring
- Intraventricular catheter
- subdural bolt (ICP bolt)
- Implantable microtransducer sensors
- extraventricular drain (EVD)
describe intraventricular catheter
what are the PT considerations?
- most accurate monitoring method (Gold Standard), but can be difficult to place when emergent
- catheter inserted into lateral ventricle via venticulostomy
- requires neurosurgery/neurology clearance for PT
- can be used to drain fluid out through the catheter
- →extraventricular drain (EVD)
describe subdural bolt
can you work with someone with a subdural bolt?
- immediate monitoring
- screw inserted into subdural space
- very easily dislodged with movement → mobility typically strictly contraindicated
describe implantable microtransducer sensors
Can you work with someone who has these?
- intraparenchymal, epidural
- least invasive
- very expensive, generally cannot be recalibrated once in situ → can be less accurate
- used in situations where EVD placement is unsuccessful or when CSF drainage not necessary
- generally not appropriate to mobilize until removed
describe EVDs
- uses gravity-positioned drain to clear excess CSF from brain
- 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
difference between clamped and unclamped EVD
what are the mobility considerations?
- when unclamped, actively draining fluid
- pts cannot mobilize when drain is unclamped
- 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
- pts should first tolerate 30 min of EVD clamped at rest prior to mobilization
Common barriers to mobilization in the NS/STICU
- Spinal instability
- Autonomic storming
- tPA
- bedrest associated with endovascular intervention
- increased ICP
- vasospasm
- hemodynamic instability
- femoral sheaths (A-line)
- increased ventilatory support
- active seizures
- treatment interventions
- IVIg, Plasma, Dialysis, CXT/RT, IR
important considerations for mobilizing acute CVA (4)
- severity/type of CVA
- interventions required
- hemodynamic parameters
- neuroimaging
important considerations for mobilizing EVD
- EVD clamp tolerance at rest
- EVD plan of care
- close monitoring for S/S of adverse response to clamping with mobility versus at rest
important considerations for mobilizing TBI (traumatic and acquired)
- severity of injury
- acute complications
- ICP parameters
- behavioral status
important considerations for mobilizing SCI
- presence of frxs
- orthopedic restrictions
- autonomic dysreflexia
- spinal shock
- orthotics
- pain tolerance comorbidities
general tips for mobilizing pts in NS/STICU
- 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
ICU outcome measures
- Functional Status Score for ICU Patients
- Physical Function in Intensive Care Test (PFIT)
describe the functional status score for ICU patients
- 5 item performance-based measure (0-35 pts)
- rolling, supine >sit, EOB sitting, sit >stand, walking
- MCD: 2.0 - 5.0 points
- MCID at ICU admission: 3 points
- Excellent inter-rater and intra-rater reliability, internal consistency
describe PFIT
- STS assistance, marching cadence, quadriceps strength
- qualitative metrics not as well studied
- strong predictive validity comparing PFIT score on awakening and D/C home rate
Indications for activity cessation (7)
- increased lethary/change in mental status
- change in neuro status
- elevated ICP
- line/tube/drain malfunctions
- hemodynamic instability
- pulmonary instability
- acute pain, severe HA