Neuro ICU Flashcards
NSICU indications
CVA
Guillain-Barre Syndrome
Acquired TBI
Acquired SCI
Myasthenic Crisis
Seizures
Brain Tumors
Hydrocephalus
Multiple Sclerosis – less common
Parkinson’s Disease – less common
Amyotrophic Lateral Sclerosis – less common
STICU indications
TBI
SCI
polytrauma
neurosurgery
vs
neurology
NSGY: Consulted whenever diagnosis may warrant invasive interventions for the brain or spinal cord
Also with orthopedic injuries to SPINE
Neuro: Primary team when invasive interventions not warranted and/or when pt demo’ing significant fluctuations in neuro status
trauma vs ortho
Trauma: Primary team when admitting diagnoses is a result of trauma.
Can be involved in surgical interventions
Ortho: Consulted whenever orthopedic injury to EXTREMITIES.
Can be involved in surgical interventions.
common precautions to check
OOB status
WB status
Bracing needs
spinal
cranial
seizure
seizure precautions
close monitoring, avoid rigorous activity
skin grafts can
range from no restrictions to no AROM to NWB
CBC lab values
Should be relatively stable, with some considerations for admitting diagnosis.
Ex: hemorrhage decreased hgb/hct, increased platelets
If no further up/downtrend, usually okay to see
electrolyte panel lab values
Patients are very symptomatically sensitive to △s in Na after a neurological event
- Cognitive changes
kidney function lab values
BUN and Serum Creatinine generally stable unless relevant comorbidities present
If complications seen, tends to be more subacute/chronic stages of recovery
hypothyroid function lab values
Hypothyroidism: has been associated with signs of aortic or coronary atherosclerosis
Slowed cognitive function, ataxia, weakness, paresthesias, edema, bradycardia, CHF, HTN
hyperthyroid function lab values
Hyperthyroidism: associated with atrial fibrillation and cardioembolicstroke
Tremors, weakness/atrophy, tachycardia, arrhythmias, hypotension
acid base respiratory alkalosis lab values
Respiratory Alkalosis common sequelae of CVA (strokes)
Dizziness, paresthesias, chest pain, confusion, seizures
acid base respiratory acidosis lab values
Respiratory Acidosis common with prolonged ventilatory support and neuromuscular disease
Confusion, fatigue/somnolence, SOB
anti HTN
examples
AE
diuretics, ACEi BB, CC
hypotension!!!!
dizzy
lightheaded
fatigue
N&V
vasoconstrictors
examples
AE
midodrine
supine HTN!!!
HA
blurred vision
dizzy
seizure control or prophylaxis
examples
AE
Keppra
Agitation, aggressiveness, irritability, restlessness
Fatigue, apathy, depersonalization, depression
agitation
medications
AE
Precedex, Fentanyl, Propofol
Decreased arousal, drowsiness
Bradycardia vs tachycardia, hypotension vs hypertension, irregular heartbeat, edema
decreased arousal
meds
AE
amantadine
Blurred vision,nausea, loss of appetite, drowsiness,dizziness, lightheadedness
tone management
meds
AE
Baclofen, Dantrolene, Tizanidine
Hypotonia, weakness, drowswiness
pain meds- narcotics
meds
AE
Hydrocodone, Hydromorphone, Codeine
Drowsiness, N&V, hypoxia
RASS levels
+4
+3
+2
+1
0
-1
-2
-3
-4
-5
+4 combative
+3 very agitated
+2 agitated
+1 restlessness
0 alert & calm
-1 drowsy
-2 light sedation
-3 moderate sedation
-4 deep sedation
-5 unarousable
common meds for agitation
Propofol – RASS = -4 or -5
Fentanyl - pause
Precedex – good to go
What are some of the major considerations for initiation of mobility in the NS/STICU for patients with cardiovascular impairment?
CV complications common
CVAs are commonly preceded by:
Diagnosed/undiagnosed HTN
A-Fib
TBI storming can lead to sever cardiovascular compromise that can linger post episode
SCI spinal shock accompanied by changes in BP (hyper hypo)
Always investigate need for HR/BP parameters prior to initiating mobility
What are some of the major considerations for initiation of mobility in the NS/STICU for patients with pulmonary impairment?
**Pulmonary: Vent/O2 settings **
Check in with RT:
How much support is the ventilator providing? How is the patient responding to these settings?
Is the patient undergoing/is there a plan for a Spontaneous Breathing Trial? - SBT
If on supplementary O2, has weaning trials begun? If not, can trials start with PT?
We can, and absolutely should, mobilize patients on the vent!!
What are some of the major considerations for initiation of mobility in the NS/STICU for patients with SCIs?
**Spine stability **– spinal precautions
Spinal Shock
Above T6
Vitals most important
Initially = ↑ ↑ BP ↓ BP, HR, hypothermia, venous stasis
Resolves usually within 24 hours to days
Sacral/anal reflexes come back 1st
Autonomic Dysreflexia
s/s
pounding HA due to ↑ ↑ BP
goose bumps
sweating – above NLI
bradycardia
skin blotching
RR
SIT THEM UP
NEVER LIE DOWN
Check cath
Check clothing
Check skin
Initiate emergency response if not resolved within 10 min
transcranial doppler for TBIs
paramaters - contra for mob
**Transcranial Doppler (TCD): Measures mean blood flow velocity of arteries in neck & brain
>100-120 cm/s (centimeters per second) generally contraindicative for mobility **
What are some of the major considerations for initiation of mobility in the NS/STICU for patients with TBIs?
Autonomic Storming
PT typically deferred until storming subsides
Can be consulted for bed-level positioning management
Vasospasm
Delayed event after SAH, peak 7-9 days after bleed
Symptoms: Often asymptomatic, can show △ neurological or mental status
If unchecked secondary aneurysms or hemorrhaging
**Transcranial Doppler (TCD): Measures mean blood flow velocity of arteries in neck & brain
>100-120 cm/s (centimeters per second) generally contraindicative for mobility **
Always consult with NSGY, varies patient to patient
What are some of the major considerations for initiation of mobility in the NS/STICU for patients with CVA?
BP parameters as well
tPA
Ischemic or thrombotic CVAs
No OOB for 24 hours post administration
Typical Hemodynamic Parameters
Ischemic Event:
Permissive HTN – they could allow this to try to break through an ischemic block
BP <220/110
Hemorrhagic Event:
BP <150/90
What are some of the major considerations for initiation of mobility in the NS/STICU for patients with seizure?
Mobility clearance: no active seizures in past 24 hours
May have more flexibility with small, focal seizures that are stable – check with Neurology team
cEEG: OK to mobilize with MD clearance – mobility limited to in-room activities due to restrictions for EEG wires
What are some of the major considerations for initiation of mobility in the NS/STICU for patients with shunt placement?
Starting parameters of shunt relatively universal
Patients 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 ↑ ICP and/or hydrocephalus and shunt dysfunction
Hydrocephalus signs: Cognitive changes, urinary incontinence, shuffled/magnetic gait pattern
What are some of the major considerations for initiation of mobility in the NS/STICU for patients with GBS placement?
Medical Management
IVIg, Plasmapheresis
Lengthy administrations
Patients 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
contra indi of PT in ICU
New administration 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 minutes
importance of ICP monitoring
normal ICP and abnormal
Increased pressure can compress brain tissue, decrease perfusion to brain tissues or possible herniation
**
Normal ICP = 5-10 mm Hg
Abnormal ICP + > 20 mm Hg**
ICP monitoring intraventricular catheter
what
where
requires
used for
Most accurate monitoring method (Gold Standard), but can be difficult to place when emergent
Catheter inserted into lateral ventricle via ventriculostomy
Requires Neurosurgery/Neurology clearance for PT
Can be used to drain fluid out through the catheter
Extraventricular Drain (EVD)
ICP monitoring subdural bolt
what
**hard stop for PT
Immediate monitoring **
Screw inserted into subdural space
VERY easily dislodged with movement - mobility typically strictly contraindicated
ICP monitoring implantable microtransducers
what
when is it used
Intraparenchymal most common
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
NSICU ICP monitoring device
EVD - extra ventricular drain
EVD icp monitoring
what
Uses gravity-positioned drain to clear excess CSF from brain
Drain will be progressively raised, decreasing rate of draining, while patient is closely monitored for adverse symptoms
Once progressed to NSGY goal, clamp trials will start. If well tolerated, drain will be removed.
EVD why clamp
Clamped versus unclamped drain
When unclamped, actively draining fluid
Patients 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
pt should first tolerate 30 mins of EVD clamped at rest prior to mobilization!!!!!
What does the evidence say about early mobilization in the NSICU for individuals with a stroke?
improved QOL, motor function, walking and ADLs
What does the evidence say about early mobilization in the NSICU for individuals with a EVDs?
Significant increase in mobility, decrease in hospital LOS and # of days requiring restraints, improved discharge disposition, decreased tracheostomy placement
What does the evidence say about early mobilization in the NSICU for individuals with a TBI/ABI?
Moderate – Severe TBI: Limited research on early mobilization
Disorders of Consciousness: Significant improvement in CRS-R scores when implementation of verticalization protocols (tilt table, ERIGO) within 2 weeks of injury
better OMs
Additional benefits found with reduction of exercise-induced complications such as syncope or orthostasis
What does the evidence say about early mobilization in the NSICU for individuals with a SCI?
chronic complications of SCI including respiratory compromise, bladder dysfunction, Charcot joints, and pressure sores
Additional support for role in prevention of atelectasis and PNA, contractures, HO
What does the evidence say about early mobilization in the NSICU for individuals with a vented?
Safe, effective, and feasible
Improve muscle strength, ability to wean from vent use, decrease hospital LOS, decreased 1 year mortality rate
PT can be extremely helpful during Spontaneous Awakening Trials (SATs) and Spontaneous Breathing Trials (SBT)
Command following and respiration sitting EOB»_space;> Supine
components of EGRESS test
Sit to Stand x 3
Marching x 3
Advancing step and return step of each foot
As soon as appropriate – ambulate!
What is the function of the FSS-ICU, and what are its MCD and MCIDs?
Rolling, supine > sit, EOB sitting, sit > stand, walking
MCD: 2.0-5.0 points
MCID at ICU admission: 3 points
What is the function of the PFIT?
Sit to stand assistance, marching cadence, quadriceps strength
Strong predictive validity comparing PFIT score on awakening and discharge home rates
what to do if you see a lower RASS level
just try inc HOB
