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Neuro 2 > Neuro ICU > Flashcards

Neuro ICU Flashcards

1
Q

indications for admission to ICU

A
  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
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2
Q

Neuro Dx leading to ICU admission

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

ICU Chart Review

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

Neurosurgery vs Neurology Team

A
  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
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5
Q

Trauma vs Ortho team

A
  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
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6
Q

major search points for reviewing prior MD notes and active orders

A
  1. Reason for admission to ICU
  2. PMHx and relevant interventions
  3. HPI and relevant interventions
  4. 24-hour plan
  5. Precautions
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7
Q

Lab Values CBC

A
  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.)
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8
Q

Lab Values: Electrolyte Panel

A
  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
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9
Q

Lab Values: Kidney Function

A
  1. BUN and serum creatinine generally stable unless relevant comorbidities present
    • if complications seen, tends to be more subacute/chronic stages recovery
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10
Q

Lab Values: Endocrine Function

A
  1. Helpful to review blood glucose prior to mobilization, common to see fluctuations
    • hyper and hypoglycemia both lead to poor activity tolerance
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11
Q

Lab Values: Thyroid Function

A
  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
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12
Q

Lab Values: Acid-Base Disorders

A
  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
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13
Q

Arousal, Cognition, Behavior Outcome Scales

A
  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
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14
Q

green light status for the RASS

A
  • +1 (restless)
  • 0 (alert and calm)
  • -1 (drowsy)
  • -2 (light sedation)
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15
Q

yellow light status for RASS

A
  • +2 (agitated)
  • -3 (moderated sedation)
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16
Q

red light status for RASS

A
  • +4 (combative)
  • +3 (very agitated)
  • -4 (deep sedation)
  • -5 (unarouable)
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17
Q

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

A
  1. propofol → red light do not treat, huge sedative
  2. fentanyl → yellow light, strong sedative and pain killer
  3. precedex → green light, mild sedative
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18
Q

Is it appropriate for PT to treat someone who is medically induced paralysis?

A

NO

typically placed in this situation to combat severe pressure dynamics

19
Q

T/F: you can mobilize someone on a ventilator

A

TRUE

20
Q

Contraindications/Precautions to mobility in SCI

A
  1. Spine stability
  2. Spinal shock
  3. Autonomic dysreflexia
21
Q

Contraindications/Precautions for mobilizing TBI

A
  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
22
Q

Contraindications/Precautions for mobilizing Strokes

A
  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
23
Q

Contraindications and precautions for mobilizing seizures

A
  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
24
Q

Contraindications and precautions for mobilizing shunt placement

A
  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
25
Q

Contraindications and precautions for mobilizing autoimmune-related neurological events

A

(includes MG and GBS)

  1. 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
26
Q

general contraindications for initation of PT in ICU setting (7)

A
  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
27
Q

normal/abnormal ICP values

A
  1. normal = 5-10 mm Hg
  2. abnormal >20 mm Hg
28
Q

methods of ICP monitoring

A
  1. Intraventricular catheter
  2. subdural bolt (ICP bolt)
  3. Implantable microtransducer sensors
  4. extraventricular drain (EVD)
29
Q

describe intraventricular catheter

what are the PT considerations?

A
  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)
30
Q

describe subdural bolt

can you work with someone with a subdural bolt?

A
  1. immediate monitoring
  2. screw inserted into subdural space
  3. very easily dislodged with movement → mobility typically strictly contraindicated
31
Q

describe implantable microtransducer sensors

Can you work with someone who has these?

A
  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
32
Q

describe EVDs

A
  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
33
Q

difference between clamped and unclamped EVD

what are the mobility considerations?

A
  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
34
Q

Common barriers to mobilization in the NS/STICU

A
  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
35
Q

important considerations for mobilizing acute CVA (4)

A
  1. severity/type of CVA
  2. interventions required
  3. hemodynamic parameters
  4. neuroimaging
36
Q

important considerations for mobilizing EVD

A
  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
37
Q

important considerations for mobilizing TBI (traumatic and acquired)

A
  1. severity of injury
  2. acute complications
  3. ICP parameters
  4. behavioral status
38
Q

important considerations for mobilizing SCI

A
  1. presence of frxs
  2. orthopedic restrictions
  3. autonomic dysreflexia
  4. spinal shock
  5. orthotics
  6. pain tolerance comorbidities
39
Q

general tips for mobilizing pts in NS/STICU

A
  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
40
Q

ICU outcome measures

A
  1. Functional Status Score for ICU Patients
  2. Physical Function in Intensive Care Test (PFIT)
41
Q

describe the functional status score for ICU patients

A
  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
42
Q

describe PFIT

A
  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
43
Q

Indications for activity cessation (7)

A
  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

Neuro 2 (30 decks)

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