Neuro ICU Flashcards
Acute obstructive hydrocephalus
Interstitial edema since CSF is forced by hydrostatic pressure to move from the ventricular spaces to the interstitium of the parenchyma
Vasogenic edema
extracellular accumulation of fluid that is usually associated loss of BBB, leading to leaky blood vessels usually seen around neoplasms
spared grey white, looks like fingers
Cytotoxic edema
intracellular accumulation of fluid, due to failure of Na/K ATPase pumps leading intracellular edema. Most commonly seen with cytotoxic edema.
Loss of grey white differentiation vs spared in vasogenic edema
Hypothermic protocol
Primarily used for initial rhythm is V fib, however can be used for PEA or aystole. Target temp of 32-34 C x 12-24 hrs
complications- coaugulopathy, arrhythmias, electrolyte abn, infections
Uncal herniation
ipsilateral CN III, parasympathetic compression resulting in mydriasis leading to a fixed dilated pupil.
Contralateral hemiparesis from contralateral hemiparesis. Potential infarction of PCA in tentorial notch.
Intraventricular catheter indications?
The need for ventricular CSF drainage, hemorrhage, SAH w/hydrocephalus.
It can measure ICP
Parenchymal devices
inserted into the brain parenchyma and provde pressure measurements, does not allow CSF drainage and inaccurate pressure gradients with ICP readings
Subarachnoid bolts
placed through a burr hole and in communication w/ the subarachanoid space. Does not allow for CSF drainage, not as accurate as intraventricular cath, but safer.
ICP management
Bed elevation >30 degrees, normothermia (avoid fever), normoglycemia,normotensive
Reducing ICP
Hyperventilation (lasts 10-20hrs) target reduction of pCO2 by 10mmHg or target of 30mmHg), use of osmotic agents/hypertonic solution (Na 150 goal) (constantly check serum osmolarity)
Others can be used such as corticosteroids in select cases, CSF drainage, decompression, barb coma, neuromuscular blocker, hypothermia
Why would put someone in pentobarb coma?
reducing cerebral metabolic activity and blood flow. Better than propofol d/t side effects of HLD, propofol infusion syndrome.
Stupor
reduced consciousness. aroused only with strong and continuous stimulation, with impaired cognitive function upon arousal.
Coma
State of unresponsiveness in which cannot be aroused even with vigorous stimulation. Does not localize noxious stimuli.
Unresponsive wakefulness “vegetative state”
Return of sleep-wake cycles in an unresponive patient usually previously comatose, w/lack of cognitive neurologic function; no awareness of themeslves or the environment, no purposeful or voluntary behavioral responses
Malignant cerebral edema
complete MCA infractions, 50% of MCA territory on CT, younger age; plan for early hemicraniectomy <48 hours from sx onset
Nitroprusside
vasodilator, avoid in ICP and renal failure. Metabolites are nitric oxide and cyanide. Infusion can lead to toxicity –> Rx w/thiosulfate
SAH vasospasm
acute hydrocephelus 2/2 obstruction of cerebral aqueduct. Peak occurence 6-8 days. Sxs worsening headache, AMS/coma
ICP waveforms
lundberg A waves or “plateau waves” are pathalogic and associated high risk of cerebral ischemia. Duration 5-20 mins and high amplititude
B waves are normal with duration of 1-2 mins
C waves no pathologic consequence
GBS
always check NIF/VC, close cardiac and ventilatory monitoring
Hunt and Hess scale
- asymptomatic or minimal HA and slight nuchal rigid
- moderate-severe HA, nuchal rigid, CN palsy
- drowsiness, confusion, focal neuro deficit
- Stupor, hemiparesis, possible decerebrate
- Deep coma, decerebrate, moribund appearance
Fisher grading
- No SAH on CT
- diffuse or thin vertical layer blood
- localized clot and layer of blood
- Intracerebral or intraventricular clots w/diffuse or no SAH
Triple H therapy for SAH
hypervolemia, HTN, hemodilution
Apneustic breathing
pontine lesions along with pin-point pupils and decerebrate posturing
Described as respiratory pause at full inspiration alternating with end-expiratory pause.
Ataxic breathing
medullary lesions of the rhythm generator. irregular respiratory pattern (gasping pattern)
