Neurological Assessment Flashcards
AVPU
Alert, Verbal, Pain, Unresponsive
AVPU is a simplified version of the GSC and should be done at a bare minimum
Full Consciousness
Pt. is alert attentive, follow commands, responds properly to external stimuli if asleep and once awake remain attentive
When spontaneously breathing you measure LOC through orientation to three (time, place, and person)
Lethargy
Pt. is drowsy but remains partially awaken to stimuli
Will answer and follow commands but does so slowly and inattentively
Obtundation
Difficult to arouse and needs constant stimulation to follow a simple command
Can have a verbal response of one or two words
Will drift back to sleep between stimulation
Stupor
Will arouse to vigorous and continuous stimulation, typically painful stimulus is required
Only response if trying to withdrawal from stimuli
Coma
Patient does not response to stimuli
Only response is possibly a reflux
Glasgow Coma Scale
Most widely used instrument to quantity neurological impairment
Scale goes from 3 (deep coma) to 15 (fully awake)
If intubated place a T after the score to indicate why they placed lower in the verbal response
GCS of 12-15
GCS of 12-15=Non ICU observation
GCS of 9-12
GCS of 9-12=Significant insult
GCS Less than 9=Severe coma and requires endotracheal intubation as patient is no longer awake enough to protect their own airway
If intubated place a T after the score to indicate why they placed lower in the verbal response
GCS Less than 9
GCS Less than 9=Severe coma and requires endotracheal intubation as patient is no longer awake enough to protect their own airway
GCS-Motor Response
Score of 6-Obey Commands
Score of 5-Localized Pain: Will use other appendage to stop the painful stimulus and is higher level response as opposed to withdrawal
Score of 4-Withdrawal: Attempt to pull away from painful stimuli
Score of 3-Abnormal Flexion: Arms come up and curl and toes will curl over tends to be bilateral
Score of 2-Abnormal Extension: Arms extend and tends to be a bilateral extension
Score of 1-Flaccid: No response completely limp
GCS-Verbal Response
Score of 5-Oriented
Score of 4-Confused
Score of 3-Inappropriate Words
Score of 2-Inappropriate Sounds
Score of 1-No Response
Poorly suited for patients with impaired verbal response (e.g., aphasia, hearing loss, tracheal intubation)
If intubated put a “T” after the level (e.g. 5 T) because it will affect their score as they cant score higher than 1)
GCS-Eye Opening Response
Score of 4-Spontaneously
Score of 3-To Speech
Score of 2-To Pain
Score of 1-None
Glossopharyngeal Nerve
Cranial Nerve IX
Controls-Gagging, Swallowing (Sensory), and Taste
Assessed through oral care
Vagus Nerves
Cranial Nerve X
Controls-Gagging, Swallowing, Speech and Cough
Assessed through suctioning
Protective Refluxes
Gagging is not a protective reflux becuse it can make a person aspirate
Coughing is a protective reflux
Phrenic Nerve
C3, 4, 5 keep the diaphragm alive!
C4 Breaths no more
C5 still working-enough intact that you can still breath
Motor Strength
Assess bilaterally on a scale of 0 (no movement) to 5 (full range of motion with strength)
In the unconscious patient it is assessed by applying a noxious stimuli and assessing the response
Central stimulation-sternal rub; squeeze trapezius
Peripheral stimulation (nail bed pressure) can be reflexive in nature and not a good assessment for motor function
A full motor exam is typically done by the physician and out of the scope of the RTs role
Decorticate
Abnormal Flexion
Decerebate
Abnormal Extension
Deep Tendon Reflex
Also known as the patellar reflex
Evaluates the spinal nerves and done in someone with a spinal injury
Superficial Reflex
The plantar reflex should be done in a comatose state or with injury in the lower spinal cord
Reflexes
All reflexes should be tested with someone who has a spinal injury
Brainstem Reflexes
Will be done in comatose/stupor pt. to see if brain death has occurred
Includes protective reflexes such as the gag, cough, and corneal response
Sedatives, analgesics, and paralytics can all interfere with the ability to assess and motor function and reflexes
Doll’s Eyes Reflex
Typically the doll’s eyes reflex is elicited by turning the head of the unconscious patient while observing the eyes.
The eyes will normally move as if the patient is fixating on a stationary object.
If there is a negative doll’s eyes reflex then the eyes remain stationary with respect to the head.
Pupils/Pupillary Relfex
Testing by passing a bright light in front of both open eyes and watching for movement
PERRLA (Pupils Equal, Round, Reactive to Light, Accommodation)
Describe size, congruency, response to light, and accommodation
Will assess cranial nerves II and III
Anisocoria
One pupil is larger than the other
Myosis
Pontine Hemorrhage
Narcotics
Mydriasis
Dilated Pupils
Brain injury
Anticholinergics
Mid-Position Fixed Pupils
Severe cerebral damage
Fixed and Dilated
Ominous sign, but there are other reasons beside brain death
Inadequate Sedation
Anxiety
Pain
Patient-vent dysynchrony
Agitation self-removal of tubes/catheters
Myocardial ischemia
Assault of the care-provider
Family dissatisfaction
Excessive Sedation
- Prolonged mech. ventilation and length of ICU stay
- Tracheostomy
- Inability to communicate
- DVT
- Added cost
- VAP Additional testing
- Tracheostomy
- Cannot evaluate for delirium
RASS -3
Patient has any movement in response to voice but no eye contact
RASS -4
Patient has any movement to physical stimulation
RASS -5
Patient has no response to any stimulation
Richmond Agitation Sedation Scale (RASS)
1. Observe the Patient-The patient is alert, restless, or agitated (Score 0 to +4)
2.If Not Alert, State Patient Name and Ask to Open Eyes and Look at Speaker
3.There is No Response to Verbal Stimulation then Physically Stimulate Pt. by Shaking Shoulder and/or Rubbing Sternum
Delirium
Delirium is a sign of acute brain dysfunction and is a disturbance of consciousness with a reduced ability to sustain or shift attention
Will develop over a short period of time and tends to fluctuate over the course of the day
The presence of delirium indicates an underlying medical issue such as sepsis, CHF, substance intoxication, or a side effect of other medications
Over sedation will prevent the assessment of delirium-This means we are unable to treat the condition that it causing it
Delirium Also Known As
ICU Psychosis
ICU Syndrome
Acute Confusional State
States of Delirium
Hyperactive (ICU Psychosis)
Hypoactive
Mixed
Validated Monitoring Instruments for Delirium
The Confusion Assessment for ICU (CAM-ICU)
The Intensive Care Delirium Screening Checklist (ICDSC)-Used in Calgary
Both assessment are similar
Monitoring will help to optimize the delivery of sedatives and analgesics, and other psychoactive drugs, and look for other underlying medical causes to ultimately to improve patient outcomes
Causes of Delirium-DELIRIOUS
D-Drugs
E-Enviromental Factors
L-Labs
I-Infection
R-Respiratory Status
I-Immobility
O-Organ Failure
U-Unrecongnized Dementia
S-Shock
Causes of Delirium-THINK
T-Toxic situations,
H-Hypoxemia
I-Infection
N-Nonpharmacological
K-K+ or elctroylte problems
The Most Important Step in Delirium Management
The most important step in delirium management is early assessment
Management of Delirium
Identify etiology
Identify risk factors
Implement non-pharmacologic management (when RASS is -3)
Consider pharmacologic treatment- Assess current sedation level, SATs and which meds are being used. Consider anti-psychotic meds
How important is it? -“Patients whose daily sedation was interrupted had significantly fewer symptoms of PTSD after critical illness.”
Nonpharmacological Treatment for Delirium
- Used when RASS is ≥ 3
- Frequent reorientation of patient
- Trying to keep the patient alert and oriented
- Convey day, date, place, and reason for hospitalization
- Update the whiteboards with caregiver names
- Request placement of a clock and calendar in room
- Discuss current events
- Cognitively stimulating activities
- Sleep protocol (day/night routines)
- Normal day-night variation in illumination
- Use “time out” strategy to minimize interruptions in sleep
- Maintain ventilator synchrony
- Promote comfort and relaxation (e.g., back care, oral care, washing face/hands, and daytime bath, massage)
- Early mobility and ROM exercises
- All patient should be eligible for early exercise and mobility
- Timely removal of catheters, restraints…
- Use of eye-glasses, hearing aids etc
- Will help them to be more alert in their surroundings
- Early correction of dehydration
- Minimize unnecessary noises
- Noise reduction strategies (e.g. minimize noise outside the room, offer white noise or earplugs)
- Monitor patient’s pain level Use an objective scale FACES, BPS, VAS, CPOT, etc
ABCDE Protocol
Designed to standardize care processes and improve collaboration among the healthcare team
Its use will help break the cycle of over sedation and prolonged ventilation
ABC=Awakening and Breathing Coordination D=Delirium Non pharm Interventions E=Early Exercise and Mobility
Spontaneous Awakening Trial (SAT)
SAT is period of time when the sedative medications are discontinued and the patient is allowed to wake up and achieve a normal level of alertness
Will prevent the accumulation of sedative drugs by giving them a chance to metabolize (decreases the risk of delirium)
Provides an opportunity for more effective weaning from the ventilator
Spontaneous Breathing Trial and Spontaneous Awakening Trials
Often for better results when we are doing a awakening trial we will also get the patient to try and breath on their own too rather than do the trials separately
When combined they may be referred to as a wake up a breath trial
The combination of these two is superior to conventional sedation and spontaneous breathing trails
To perform safely must make sure there are no contra indications in the patient
ICP
Normal ICP is 10-15 mmHg
Small fluctuations normal; variability > 10 mmHg a bad sign
At 15-20 mmHg capillary bed is compressed and microcirculation is compromised
>20 mmHg is considered intracranial hypertension.
At 30-35 mmHg venous drainage is impeded and edema develops in uninjured tissue
ICP Monitoring Indications
Monitor patients at risk for life-threatening intracranial hypertension
Monitor evidence of infection
Assess effects of therapies for reducing ICP
CPP
CPP=MAP-ICP
Cerebral perfusion cannot be maintained if ICP increases to within 40-50 mmHg of the MAP.
When ICP ≅ MAP perfusion stops and brain dies.
Two Main Types of ICP Monitoring
- Fluid Filled Systems-Use an external pressure like in hemodynamics (Interventricular catheter and subarachnoid bold)
- Solid State System-Miniature pressure transducer inserted into the lateral ventricle, brain parenchyma, suprachnoid, or epidural space
Jugular Venous Oxygen Saturation (SjVO2)
Approximates the global cerebral oxygenation
Jugular venous oxygen saturation (SjvO2) reflects the balance between cerebral oxygen delivery and the cerebral metabolic rate of oxygen (CMRO2)
Used as a form of monitoring in a patient with TBI
A catheter is inserted into the internal jugular vein and directed upwards so that the tip rests in the jugular venous bulb which is located at the base of the brain
Blood samples can be drawn from here and analyzed for JvO2 (partial pressure of O2 in jugular vein) or SjVO2 (saturation level)
A normal SjVO2 is 50-75%
Can be measured continuously with a specialized catheter
Decreased SjvO2 can Indicate:
Decreased cerebral blood flow
Cerebral hypoperfusion
Possible ischemia (Can help with early diagnosis of ischemia)
Increased cerebral metabolic rate (febrile, seizures)
Arterial hypoxemia
Increased SjvO2
Reduced cerebral metabolic rate
Hypothermia
sedatives
brain death
Clinical Factors Altering SjVO2
CBF can be decreased by head injury, thromboembolism, intracranial hypertension, hypotension, hyperventilation, or vasospasm.
If CMRO2 remains constant or increases under these conditions, SjVO2 will decrease.
Arterial hypoxia and increased CMRO2 (e.g., febrile illness, seizures) can also result in SjVO2 desaturation.
Correct interpretation of increased SjVO2 requires confirmation that the catheter tip is at the jugular bulb.
Reduced CMRO2 (e.g., hypothermia, sedatives), increased CBF, pathologic arterial-venous communications, and brain death may result in increased SjVO2
Cerebral Oximetry
A new technology that is non-invasive and determines saturation of the underlying tissue
Because it is non-invasive it may have an increased value as a monitor/diagnostic uses
Can be used to determine cerebral oxygenation or other locations
Used often in the OR and has investigative uses in the NICU Can be trended or used for “spot checks”
Just like with the SjvO2, the changes in saturation levels can indicate underlying conditions
Licox Monitoring
Even with normal ICP and CPP readings, cerebral hypoxia can still develop
Early detection of cerebral hypoxia and impending ischemia are key to preventing secondary brain injury.
The Licox system is a monitor connected to a catheter that is inserted in the brain tissue, and measures brain tissue oxygenation (PbtO2)
Done in patients who have a traumatic or neurologic brain injury
Peripheral Nerve Stimulator: Train of Four Monitoring
Twitches and ~Blockage
of Twitches Approximate % blockade
0/4 100%
1/4 90%
2/4 85%
3/4 80%
4/4 75% or less
Peripheral Nerve Stimulator: Train of Four Monitoring
Monitor the effects of neuromuscular blockade agents (paralytics)
Electrodes placed over ulnar nerve at wrist or elbow typically (though other sites can be used)
Response to stimulus is monitored by the muscle twitches and permits titration to desired effect
Use can result in less medication use and allow quicker recovery
Reduction of the NMBA infusion rate is indicated in order to prevent prolonged paralysis and severe weakness during ICU recovery.
Electroencephalography (EEG)
A recording of the brains electrical activity via the scalp
Used to diagnose and monitor: Epilepsy and other seizure activity, Coma Encephalopathies, Brain death
Therapeutic Hyperventilation
Increasing minute volume with the goal of decreasing the PaCO2 (They technically are not hyperventilating)
Know the PaCO2 (35-40) and PaO2 (80-120) TBI goals
Although hyperventilation decreases ICP, cerebral perfusion pressure (CPP) is the most critical element to monitor!
Therapeutic Hyperventilation Indications:
Only done acutely /short-term
Therapeutic Hyperventilation Effects:
The low PaCO2 results in vasoconstriction of the cerebral arteries, reducing blood in the … and thus reducing the intracranial pressure
Therapeutic Hyperventilation Cautions:
The decreased blood flow to the brain results in decreased oxygen delivery and anoxic brain injury
Extra-Ventricular Drain (EVP) Procedure:
General anesthesia
Cleaning of site
Incision via frontal or parietal region
Burr hole drilled till through the skull
Underlying dura is incised
Catheter inserted into ventricle (lateral)
Incision closed; monitored
Extra-Ventricular Drain (EVP) Indications:
To allow for monitoring of ICP
To reduce ICP
For example, physician orders state “open EVD when ICP >25 mmHg”
When EVD is opened ICP cannot be monitored
Relieve hydrocephalus (fluid/blood in the intracranial cavity)
Extra-Ventricular Drain (EVP) Risks:
Hemorrhage
Infection
Malfunction of equipment (blockage; displacement)
Therapeutic Hypothermia
Lowering of the patient’s body temperature to help reduce the risk of ischemic injury after a period of insufficient blood flow
Most deaths caused by therapeutic hypothermia occurred during the rewarming phase of the procedure, deaths that could have been easily avoided by slow and precise rewarming.
Goal temperature 32-34° C.
Therapeutic Hypothermia Indications
Post-cardiac arrest
Stroke
Traumatic brain or spinal cord injury
Therapeutic Hypothermia Mechanism
The benefits was though to be caused through the decrease in cellular metabolism, but now it is thought that there is more to it than that and possible mechanisms include
Interrupt cell apoptosis
Stabilizes cell membrane, making it more impermeable and therefore withstand unwanted ion shifting
Also helps reduce reperfusion injury (damage caused by oxidative stress)
Therapeutic Hypothermia Risks
Arrhythmias
Clotting problems
Increased risk of infection
Increased risk of electrolyte imbalance.
Therapeutic Hypothermia-Invasive
Cooling catheters (femoral vein, cooled saline; highly accurate control of temp)-Fastest, most precise and efficient
Transnasal evaporative cooling (two cannula inserted in nasal cavity; sprays a cool mist)
Therapeutic Hypothermia-Non Invasive
Water blankets, torso vest, leg wraps
Cool caps
Cool collars
Drawbacks to Sedation and Analgesic Therapy
Oversedation
Failure to initiate SBTs; longer duration of mechanical ventilation
Longer duration of ICU stay
Impede assessment of neurological function Increases risk for delirium
Numerous agent-specific adverse events
Sedative
Any drug that reduces CNS arousal
Sleep is not the same as sedative
Includes: Benzodiazepines, Nonbenzodiazepines, Barbituates
Hypnotic
any drug that induces sleep
Anxiolytic
any drug that reduces symptoms of anxiety
Analgesia
Any drug that reduces the sensation of pain
General anesthesia has four characteristics: unconsciousness, analgesia, muscle relaxation, and depression of reflexes.
Anesthetics
Any drug that reduces the ability to perceive sensations
Pharmacological Therapies
Many drugs can have multiple effects!
Effect(s) often dose dependent
Can get sedation effects at low dose and full anesthetic at high dose.
Most available evidence regarding sedatives and analgesics in ICU patients indicates that it may be less important which drugs are delivered than their proper titration using goal-directed delivery (RASS Target) to optimize patient comfort while avoiding complications such as prolonged mechanical ventilation or reintubation
Benzodiazepines
Used for its effects of sedative (madadala), hypnotic (valum), anxiolytic
Used to treat: anxiety, agitation, insomnia, seizures/ status epilepticus, muscle spasms, alcohol withdrawal (DTs)
Can be short, intermediate or long-acting (longer-acting used for anxiety)
Benzodiazepines Cautions
Can cause loss of airway reflexes at high doses and decreased tidal volume at lower doses
Benzodiazepines Reversal Agent
flumazenil (Romazicon)
Benzos for Sleep:
Flurazepam
Triazolam (Halcion)
Zopiclone (Imovane)
Midazolam
Category: Benzodiazepines
Generic Name: Midazolam
Trade Name: Versed
Reversal Agent: Flumazenil (Romazicon)
Cation: High dose loss of air reflexes, low doses decreased tidal volume
Used For: Anxiety/ Hypnotic
Lorazepam
Category: Benzodiazepines
Generic Name: Lorazepam
Trade Name: Ativan
Reversal Agent: Flumazenil (Romazicon)
Cation: High dose loss of air reflexes, low doses decreased tidal volume
Used For: Anxiety/ Hypnotic
Diazepam
Category: Benzodiazepines
Generic Name: Diazepam
Trade Name: Valium
Reversal Agent: Flumazenil (Romazicon)
Cation: High dose loss of air reflexes, low doses decreased tidal volume
Used For: Anxiety/ Hypnotic
Zopiclone
Category: Benzodiazepines
Generic Name: Zopiclone
Trade Name: Imovane
Reversal Agent: Flumazenil (Romazicon)
Cation: High dose loss of air reflexes, low doses decreased tidal volume
Used For: Sleep
Triazolam
Category: Benzodiazepines
Generic Name: Triazolam
Trade Name: Halcion
Reversal Agent: Flumazenil (Romazicon)
Cation: High dose loss of air reflexes, low doses decreased tidal volume
Used For: Sleep
Flurazepam
Category: Benzodiazepines
Generic Name: Flurazepam
Trade Name: Dalmane
Reversal Agent: Flumazenil (Romazicon)
Cation: High dose loss of air reflexes, low doses decreased tidal volume
Used For: Sleep
Alprazolam
Category: Benzodiazepines
Generic Name: Alprazolam
Trade Name: Xanax
Reversal Agent: Flumazenil (Romazicon)
Cation: High dose loss of air reflexes, low doses decreased tidal volume
Used For: Anxiety/ Hypnotic
Dexmedetomidine
Generic Name: Dexmedetomidine
Trade Name: Precedex
Effects: Sedative, analgesic, sympatholytic, and anxiolytic effects that blunt many of the cardiovascular responses in the perioperative period
Commonly used in ICU and OR
Can provides sedation without respiratory system depression
It has many benefits (less delirium, shortened time to extubation, reduced ICU stay…) but is very expensive! Per pill it is way more expensive, but it will reduce cost of a prolonged ICU stay
Considerd to be superior or lorazepam and midazolam It reduces the requirements for volatile anesthetics, sedatives and analgesics without causing significant respiratory depression
Barbituates
E.g. Thiopental (Sodium Pentothal), phenobarbital (Luminal) One of the oldest group of sedative drugs; use has largely been replaced by benzo’s Can be used as anesthetics (thiopental) or hypnotics
Phenobarbital
Category: Barbituates
Generic Name: Phenobarbital
Trade Name: Luminal
Reversal Agent: None
Used For: Anticonvulsant for seizures
Sodium Pentothal
Category: Barbituates
Generic Name: Sodium Pentothal
Trade Name: Thiopental
Reversal Agent: None
Used For: Anesthesia
Anesthetics Stages
Stage 1:Aanalgesia; patient retains consciousness without experiencing pain (“conscious sedation”)
Stage 2: Loss of consciousness
Stage 3: respiratory depression; loss of reflexes (“surgical anesthesia”)
Stage 4: complete loss of respiratory drive; may be loss of cardiovascular tone]
All of the drugs discussed, in a dose-dependent fashion, can result in the different stages of anesthesia! (i.e. not just anesthetic drugs!)
Diprivan (Propofol)
Category: Anesthetic
Generic Name: Propofol
Trade Name: Diprivan
Reversal Agent: None
Used For: Sedation (especially in mechanically ventilated pt.) for both induction, maintenance of anesthesia, as well as conscious sedation
Notes: Short-acting hypnotic agent.Recovery is rapid and “clear”. Does NOT have analgesic properties
Diprivan (Propofol) Side Effects
Hypotension
Respiratory depression
Pain on injection
Diprivan (Propofol) Uses
Induction and maintenance of general anesthesia
Sedation for mechanically ventilated patients
Procedural sedation
Narcotics (Opioids)
Opioid – derivative of naturally occurring drug mixture opium, derived from the Poppy
Narcotics (Opioids) Overdose
Pinpoint pupils, coma, and respiratory depression
Narcotics (Opioids) Reversal Agent
Reversal agents are the narcotic antagonists
Naloxone (Narcan) or naltrexone (ReVia).
Note: the reversal agent doesn’t last as long as the drug itself! Redosing may be needed!
How are Common Narcotics Given
Can be given via a bolus or infusion;
Morphine
Category: Narcotic
Generic Name: Morphine
Trade Name: N/A
Reversal Agent: Naloxone (Narcan) or Naltrexone (ReVia).
Used For: Can be aerosolized for palliative care
Fentanyl
Category: Narcotic
Generic Name: Fentanyl
Trade Name: Sublimaze
Reversal Agent: Naloxone (Narcan) or Naltrexone (ReVia).
Used For: Analgesics, Sedation, Decreased preload and afterload on left ventricle, and antitussive (cough supression)
Oxycodone
Category: Narcotic
Generic Name: Oxycodone
Trade Name: N/A
Reversal Agent: Naloxone (Narcan) or Naltrexone (ReVia).
Used For: Analgesics, Sedation, Decreased preload and afterload on left ventricle, and antitussive (cough supression)
Codeine
Category: Narcotic
Generic Name: Codeine
Trade Name: N/A
Reversal Agent: Naloxone (Narcan) or Naltrexone (ReVia).
Used For: Analgesics, Sedation, Decreased preload and afterload on left ventricle, and antitussive (cough supression)
Meperidine
Category: Narcotic
Generic Name: Meperidine
Trade Name: Demerol
Reversal Agent: Naloxone (Narcan) or Naltrexone (ReVia).
Used For: Analgesics, Sedation, Decreased preload and afterload on left ventricle, and antitussive (cough supression)
Oxycodone + acetaminophen
Percocet
Narcotics (Opioids) Effects
Analgesia
Sedation
Decreases preload and afterload on the left ventricle
Antitussive qualities (cough supression)
Narcotics (Opioids) Side Effects:
Nausea and vomiting
Constipation
Tolerance/addiction
Causes release of histamine-Thus narcotic use in someone with hypersentive airways is discouraged! Bronchospasm, rashes, inflammation can result
Non Steroidal Anti-Inflammatory Drugs (NSAIDs)
Acetaminophen (e.g. Tylenol/acetaminophen) Salicylates (Aspirin/acetylsalicylic acid) Ibuprofen (e.g. Advil/ibuprofen)
Acetaminophen
Category: Non Steroid Anti Inflammatory
Generic Name: Acetaminophen
Trade Name: Tylenol
Reversal Agent: Mucomyst (Acetylcysteine)
Used For: In ICU used for it’s anti-pyretic effects and not for pain control
Notes: Overdose of acetaminophen can cause hepatotoxicity
Salicylates (Aspirin/acetylsalicylic acid)
Category: Non Steroid Anti Inflammatory
Generic Name: Asiprin/ Acetylsaicylic Acid
Trade Name: Aspirin
Reversal Agent: None
Used For: Given in acute coronary syndromes as it inhibits platelet aggregation
Notes: Asthmatics can be sensitive to aspirin resulting in bronchospasm!
Ibuprofen
Category: Non Steroid Anti Inflammatory
Generic Name: Ibuprofen
Trade Name: Advil
Reversal Agent: None
Used For: Has analgesic, anti-inflammatory and antipyretic effects
Notes: Not typically used in ICU environment
Haloperidol
Category: Anti-Psychotics
Generic Name: Haloperidol
Trade Name: Haldol
Reversal Agent: None
Used For: Control active psychotic symptons, delirium management
Paralytics (Neuromuscular Blocking Agents – NMBAs)
= Paralytics or skeletal muscle relaxants
All patients require proper eye care as no more blinking; light taping of eyes
Paralyze only!! (i.e. lack amnesic, sedative and analgesic properties!)
MUST sedate patient and use analgesics as necessary!
Two types: 1) Non-depolarizing 2) Depolarizing
Non-depolarizing NMBAs
Slow onset of action with a longer duration
Mechanism of action: Competitively blocking the binding of acetylcholine to its receptors preventing Acetylcholine from depolarizing the muscle fiber causing vagolytic effedct
The increased MAP can incresae ICP!
These tend to be used to maintain paralysis in ICU
Non-depolarizing NMBAs Side effects
Cardiovascular effects (tachycardia, vasoconstriction and hypertension). Pavulon the worst.
Have a tendency to release histamine
Need to provide ventilation!
Non-depolarizing NMBAs Reversal Agent
Neostigmine-Neostigmine is a cholinesterase inhibitor (cholinesterase is the enzyme that breaks down AcH)
Rocuronium
Category: Non Depolarizing Neuromuscular Blocking Agent
Generic Name: Rocuronium
Trade Name: Zemuron
Reversal Agent: Neostigmine (prostigmin)
Used For: Maintain Paralysis in ICU
Pancuronium
Category: Non Depolarizing Neuromuscular Blocking Agent
Generic Name: Pancuronium
Trade Name: Pavulon
Reversal Agent: Neostigmine (prostigmin)
Used For: Maintain Paralysis in ICU
Atracurium
Category: Non Depolarizing Neuromuscular Blocking Agent
Generic Name: Atracurium
Trade Name: Trecrium
Reversal Agent: Neostigmine (prostigmin)
Used For: Maintain Paralysis in ICU
Tubocurarine
Category: Non Depolarizing Neuromuscular Blocking Agent
Generic Name: Tubocurarine
Trade Name: N/A
Reversal Agent: Neostigmine (prostigmin)
Used For: Maintain Paralysis in ICU
Depolarizing NMBAs
Rapid onset; short duration Used for short procedures (e.g. intubation) Succinylcholine (Anectine) There are NO reversal agents!! Sensitivity to Succinycholine –metabolized by plasma cholinesterase. Pts with abnormal or deficient pseudocholinesterase do not meatbolize effective and have a prolonged recovery requiring mechanical ventialitn
Depolarizing NMBAs Mechanism of Action
Act by depolarizing the muscle fiber and prolonging the depolarized state
results in fasiculations (uncoordinated skeletal muscle contractions)
First depolarize the muscle fiber and then prolong the depolarized state to prevent repolarization
Depolarizing NMBAs Side Effects
Tachycardia, hypertension
Histamine release (and thus brochospasm; hypotension)
Hyperkalemia
Increased ICP
Malignant hyperthermia (rarely)
Sensitivity to Succinycholine
Muscle pain and soreness
Malignant hyperthermia
Is a genetic defect of muscle metabolis and potentiall fatal hypermetabolic state.
Treated with dantrolene
Depolarizing NMBAs When are they Used
For intubation
Reduce ICP in intubated patients with uncontrollable ICP
To achieve patient-ventilator synchrony
To reduce oxygen consumption
To stop status epilepticus or shivering (therapeutic hypothermia)
In surgery, or to facilitate procedures or diagnostic studies
To paralyze selected patients who must remain immobile (e.g. trauma patients).
TBI PaCO2 and PaO2 Target
PacO2=35-40
PaO2-80-120
Give 2 examples of drugs with a positive chronotropic effects.
Anything that stimulates B1 thus: epi, norepi, dopamine (moderate/cardiac dose), Dobutamine, Atropine
List a drug that is a powerful α1 agonist.
Levophed, Phenylephrine and dopamine (high/pressor dose).
Describe the effects of β2 stimulation.
Bronchodilation (for receptors in the lungs) and vasodilation (due to the receptors in the periphery)
Describe the cautions associated with β1 stimulation.
The increased HR and contractility cause an increase in myocardial demand/oxygen consumption and myocardial irritability. Also decreased time in diastole…may impact filling time at high rates.
Describe the effects of dopamine.
Dose Dependent!! While there is overlap it is primarily:
Low Dose (1-5 mcg/kg/min) results in renal and splanchnic vasodilation (due to dopaminergic receptor stimulation)
Moderate Dose (5-10 mcg/kg/min) results in increased HR, contractility and rate of conduction due to B1 stimulation
High Dose (10-20 mcg/kg/min) results in increased SVR and increased BP due to a1 stimulation
Describe when a bolus of epinephrine is given.
In pulsesless states! VT, VFib, PEA and asystole
List the alternative drug that may be given instead of epi in these cases.-Vasopressin
Describe why this alternative drug may have advantages over epinephrine in this situation.-No B1 stimulation thus doesn’t further stress the heart (beyond the increased afterload it results) with the increased HR and increased irritability
Describe how “inodilator” drugs work and why they are helpful in CHF patients.
Inhibit phosphodiesterase III (an enzyme that breaks down cAMP).
Increased levels of cAMP in the heart results in increased inotropism and increased cAMP in peripheral smooth muscles causes vasodilation
Central Nervous System
Brain and spinal cord
PNS
Made up of 12 pairs of cranial nerves and 31 pairs spinal nerves
Most of the cranial nerves originate in the brainstem
Spinal nerves from the vertebral column
RASS Score of -1
Patient is awake with sustained eye opening and eye contact
RASS Score of -2
Patient awakened with eye opening and eye contact, but not sustained
Benefits from Pharmacological Therapies
Prevent pain and anxiety
Decrease oxygen consumption
Decrease the stress response
Patient-ventilator synchrony
With newer vents better to adjust mode/setting for pt-vent synchrony.
Avoid adverse neurocognitive sequelae (depression; PTSD)
Sequelae–is a pathological condition resulting from a disease, injury or other trauma
Goals of Pharmacology Therapy
Pt. comfort has to be the primary goal
Provide for agitation/anxiety free, amnesia, comfort
Trying to achieve a balance-TIGHT TITRATION
Common Benzo’s Used for Anxiety and Hyponotic Effects
Midazolam (Versed)
Iorzepam (Ativan)
Diazepam (Valium)
Alprazolam (Xanax)
True /False-Depolarizing succinylcholine is commonly used as a neuromuscular blocking agent in short medical procedures
True
What is Normal ICP pressure?
A. <5mmHg
B. 5-10mmHg
C. 10-15mmHg
D. <15mmHg
C. 10-15mmHg
What cranial nerve is responsible for stimulating a cough?
A. Glossopharyngeal
B. Vagus
C. Phrenic
D. Hypoglossal
B. Vagus
What are risks to patients who have been excessively sedated?
A. Myocardialischemia
B. Prolonged mechanical ventilation
C. Tracheostomy
D. Patient-vent dyssynchrony
E. B andC
E. B and C
True/ False - Decorticate posturing is also known as extension
False
Which medication causes respiratory depression when administered?
A. Proprofol
B. Dexmedatomidine
C. Diprivan
D. A&B
E. A&C
F. All of the above
E. A&C
Delirium can indicate all of the following except
A. Liver Failure
B. Electrolyte Problems
C. Unrecognized Dementia
D. Brain Tumor
D. Brain Tumor
What happens when ICP reaches 30 mmHg?
A. Nothing this is a normal fluctuation
B. The capillary bed is compressed
C. Venous drainage is impeded and edema develops
D. Cerebral perfusion is maintained
C. Venous drainage is impeded and edema develops
What does an increase in SjvO2 indicate?
Reduced cerebral metabolic rate due to hypothermia, sedatives, or brain death.
What is the reversing agent for succinylcholine?
No reversal for succinylcholine.
What is the goal of therapeutic hyperventilation?
Low-normal PaCO2 to vasoconstrict the cerebral arteries and reduce intracranial pressure.
True/ False -Pancuronium is typically used as a neuromuscular blocking agent in short medical procedures
False
Which of the following can be used directly to lower ICP pressures
A. Cerebraloximetry
B. Licox
C. Extra ventricular drain
D. All of the above
E. B&C only
C. Extra ventricular drain
What are some non-pharmacological ways to manage delirium?
A. Frequent reorientation of patient
B. Good day and night routines
C. Early mobility
D. Use of glasses and hearing aids
E. All of the above
E. All of the above
What is the goal temperature of therapeutic hypothermia?
32-34 degrees celsius.
Indications for therapeutic hypothermia are?
A. Stroke
B. Brain injury
C. Pneumonia
D. Bronchiectasis
E. All of the above
F. A and B
F. A and B
According to AHS TBI protocol what are the goals for PaO2, PaCO2, and ICP?
PaO2>80-120 mmHg, PaCO2 35-40 mmHg, ICP<20 mmHg
What is the drug Luminal normally used for in modern medicine?
A. Neuromuscular blocking agent
B. Seizure control
C. Anti-inflammatory
D. Analgesic
B. Seizure control
What is the generic name for Versed and Ativan?
Midazolam (Versed) Lorazepam (Ativan)
What is the reversal agent for Zemuron, Pavulon, and Tracrium
Neostigmine
What are the effects of morphine and fentanyl?
A. Antitussive
B. Analgesia
C. Antipsychotic
D. Sedation
E. All the above
F. A,B, and D
F. A, B, and D
