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Final Review > Neurological Assessment > Flashcards

Neurological Assessment Flashcards

1
Q

AVPU

A

Alert, Verbal, Pain, Unresponsive

AVPU is a simplified version of the GSC and should be done at a bare minimum

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2
Q

Full Consciousness

A

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)

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3
Q

Lethargy

A

Pt. is drowsy but remains partially awaken to stimuli

Will answer and follow commands but does so slowly and inattentively

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4
Q

Obtundation

A

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

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5
Q

Stupor

A

Will arouse to vigorous and continuous stimulation, typically painful stimulus is required

Only response if trying to withdrawal from stimuli

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6
Q

Coma

A

Patient does not response to stimuli

Only response is possibly a reflux

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7
Q

Glasgow Coma Scale

A

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

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8
Q

GCS of 12-15

A

GCS of 12-15=Non ICU observation

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9
Q

GCS of 9-12

A

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

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10
Q

GCS Less than 9

A

GCS Less than 9=Severe coma and requires endotracheal intubation as patient is no longer awake enough to protect their own airway

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11
Q

GCS-Motor Response

A

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

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12
Q

GCS-Verbal Response

A

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)

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13
Q

GCS-Eye Opening Response

A

Score of 4-Spontaneously

Score of 3-To Speech

Score of 2-To Pain

Score of 1-None

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14
Q

Glossopharyngeal Nerve

A

Cranial Nerve IX

Controls-Gagging, Swallowing (Sensory), and Taste

Assessed through oral care

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15
Q

Vagus Nerves

A

Cranial Nerve X

Controls-Gagging, Swallowing, Speech and Cough

Assessed through suctioning

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16
Q

Protective Refluxes

A

Gagging is not a protective reflux becuse it can make a person aspirate

Coughing is a protective reflux

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17
Q

Phrenic Nerve

A

C3, 4, 5 keep the diaphragm alive!

C4 Breaths no more

C5 still working-enough intact that you can still breath

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18
Q

Motor Strength

A

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

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19
Q

Decorticate

A

Abnormal Flexion

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20
Q

Decerebate

A

Abnormal Extension

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21
Q

Deep Tendon Reflex

A

Also known as the patellar reflex

Evaluates the spinal nerves and done in someone with a spinal injury

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22
Q

Superficial Reflex

A

The plantar reflex should be done in a comatose state or with injury in the lower spinal cord

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23
Q

Reflexes

A

All reflexes should be tested with someone who has a spinal injury

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24
Q

Brainstem Reflexes

A

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

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25
Q

Doll’s Eyes Reflex

A

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.

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26
Q

Pupils/Pupillary Relfex

A

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

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27
Q

Anisocoria

A

One pupil is larger than the other

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28
Q

Myosis

A

Pontine Hemorrhage

Narcotics

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29
Q

Mydriasis

A

Dilated Pupils

Brain injury

Anticholinergics

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30
Q

Mid-Position Fixed Pupils

A

Severe cerebral damage

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31
Q

Fixed and Dilated

A

Ominous sign, but there are other reasons beside brain death

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32
Q

Inadequate Sedation

A

Anxiety

Pain

Patient-vent dysynchrony

Agitation self-removal of tubes/catheters

Myocardial ischemia

Assault of the care-provider

Family dissatisfaction

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33
Q

Excessive Sedation

A
  • Prolonged mech. ventilation and length of ICU stay
    • Tracheostomy
      • Inability to communicate
    • DVT
    • Added cost
    • VAP Additional testing
  • Cannot evaluate for delirium
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34
Q

RASS -3

A

Patient has any movement in response to voice but no eye contact

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35
Q

RASS -4

A

Patient has any movement to physical stimulation

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36
Q

RASS -5

A

Patient has no response to any stimulation

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37
Q

Richmond Agitation Sedation Scale (RASS)

A

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

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38
Q

Delirium

A

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

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39
Q

Delirium Also Known As

A

ICU Psychosis

ICU Syndrome

Acute Confusional State

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40
Q

States of Delirium

A

Hyperactive (ICU Psychosis)

Hypoactive

Mixed

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41
Q

Validated Monitoring Instruments for Delirium

A

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

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42
Q

Causes of Delirium-DELIRIOUS

A

D-Drugs

E-Enviromental Factors

L-Labs

I-Infection

R-Respiratory Status

I-Immobility

O-Organ Failure

U-Unrecongnized Dementia

S-Shock

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43
Q

Causes of Delirium-THINK

A

T-Toxic situations,

H-Hypoxemia

I-Infection

N-Nonpharmacological

K-K+ or elctroylte problems

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44
Q

The Most Important Step in Delirium Management

A

The most important step in delirium management is early assessment

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45
Q

Management of Delirium

A

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.”

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46
Q

Nonpharmacological Treatment for Delirium

A
  • 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
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47
Q

ABCDE Protocol

A

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

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48
Q

Spontaneous Awakening Trial (SAT)

A

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

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49
Q

Spontaneous Breathing Trial and Spontaneous Awakening Trials

A

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

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50
Q

ICP

A

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

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51
Q

ICP Monitoring Indications

A

Monitor patients at risk for life-threatening intracranial hypertension

Monitor evidence of infection

Assess effects of therapies for reducing ICP

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52
Q

CPP

A

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.

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53
Q

Two Main Types of ICP Monitoring

A
  1. Fluid Filled Systems-Use an external pressure like in hemodynamics (Interventricular catheter and subarachnoid bold)
  2. Solid State System-Miniature pressure transducer inserted into the lateral ventricle, brain parenchyma, suprachnoid, or epidural space
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54
Q

Jugular Venous Oxygen Saturation (SjVO2)

A

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

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55
Q

Decreased SjvO2 can Indicate:

A

Decreased cerebral blood flow

Cerebral hypoperfusion

Possible ischemia (Can help with early diagnosis of ischemia)

Increased cerebral metabolic rate (febrile, seizures)

Arterial hypoxemia

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56
Q

Increased SjvO2

A

Reduced cerebral metabolic rate

Hypothermia

sedatives

brain death

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57
Q

Clinical Factors Altering SjVO2

A

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

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58
Q

Cerebral Oximetry

A

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

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59
Q

Licox Monitoring

A

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

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60
Q

Peripheral Nerve Stimulator: Train of Four Monitoring

Twitches and ~Blockage

A

of Twitches Approximate % blockade

0/4 100%

1/4 90%

2/4 85%

3/4 80%

4/4 75% or less

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61
Q

Peripheral Nerve Stimulator: Train of Four Monitoring

A

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.

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62
Q

Electroencephalography (EEG)

A

A recording of the brains electrical activity via the scalp

Used to diagnose and monitor: Epilepsy and other seizure activity, Coma Encephalopathies, Brain death

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63
Q

Therapeutic Hyperventilation

A

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!

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64
Q

Therapeutic Hyperventilation Indications:

A

Only done acutely /short-term

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65
Q

Therapeutic Hyperventilation Effects:

A

The low PaCO2 results in vasoconstriction of the cerebral arteries, reducing blood in the … and thus reducing the intracranial pressure

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66
Q

Therapeutic Hyperventilation Cautions:

A

The decreased blood flow to the brain results in decreased oxygen delivery and anoxic brain injury

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67
Q

Extra-Ventricular Drain (EVP) Procedure:

A

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

68
Q

Extra-Ventricular Drain (EVP) Indications:

A

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)

69
Q

Extra-Ventricular Drain (EVP) Risks:

A

Hemorrhage

Infection

Malfunction of equipment (blockage; displacement)

70
Q

Therapeutic Hypothermia

A

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.

71
Q

Therapeutic Hypothermia Indications

A

Post-cardiac arrest

Stroke

Traumatic brain or spinal cord injury

72
Q

Therapeutic Hypothermia Mechanism

A

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)

73
Q

Therapeutic Hypothermia Risks

A

Arrhythmias

Clotting problems

Increased risk of infection

Increased risk of electrolyte imbalance.

74
Q

Therapeutic Hypothermia-Invasive

A

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)

75
Q

Therapeutic Hypothermia-Non Invasive

A

Water blankets, torso vest, leg wraps

Cool caps

Cool collars

76
Q

Drawbacks to Sedation and Analgesic Therapy

A

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

77
Q

Sedative

A

Any drug that reduces CNS arousal

Sleep is not the same as sedative

Includes: Benzodiazepines, Nonbenzodiazepines, Barbituates

78
Q

Hypnotic

A

any drug that induces sleep

79
Q

Anxiolytic

A

any drug that reduces symptoms of anxiety

80
Q

Analgesia

A

Any drug that reduces the sensation of pain

General anesthesia has four characteristics: unconsciousness, analgesia, muscle relaxation, and depression of reflexes.

81
Q

Anesthetics

A

Any drug that reduces the ability to perceive sensations

82
Q

Pharmacological Therapies

A

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

83
Q

Benzodiazepines

A

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)

84
Q

Benzodiazepines Cautions

A

Can cause loss of airway reflexes at high doses and decreased tidal volume at lower doses

85
Q

Benzodiazepines Reversal Agent

A

flumazenil (Romazicon)

86
Q

Benzos for Sleep:

A

Flurazepam

Triazolam (Halcion)

Zopiclone (Imovane)

87
Q

Midazolam

A

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

88
Q

Lorazepam

A

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

89
Q

Diazepam

A

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

90
Q

Zopiclone

A

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

91
Q

Triazolam

A

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

92
Q

Flurazepam

A

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

93
Q

Alprazolam

A

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

94
Q

Dexmedetomidine

A

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

95
Q

Barbituates

A

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

96
Q

Phenobarbital

A

Category: Barbituates

Generic Name: Phenobarbital

Trade Name: Luminal

Reversal Agent: None

Used For: Anticonvulsant for seizures

97
Q

Sodium Pentothal

A

Category: Barbituates

Generic Name: Sodium Pentothal

Trade Name: Thiopental

Reversal Agent: None

Used For: Anesthesia

98
Q

Anesthetics Stages

A

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!)

99
Q

Diprivan (Propofol)

A

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

100
Q

Diprivan (Propofol) Side Effects

A

Hypotension

Respiratory depression

Pain on injection

101
Q

Diprivan (Propofol) Uses

A

Induction and maintenance of general anesthesia

Sedation for mechanically ventilated patients

Procedural sedation

102
Q

Narcotics (Opioids)

A

Opioid – derivative of naturally occurring drug mixture opium, derived from the Poppy

103
Q

Narcotics (Opioids) Overdose

A

Pinpoint pupils, coma, and respiratory depression

104
Q

Narcotics (Opioids) Reversal Agent

A

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!

105
Q

How are Common Narcotics Given

A

Can be given via a bolus or infusion;

106
Q

Morphine

A

Category: Narcotic

Generic Name: Morphine

Trade Name: N/A

Reversal Agent: Naloxone (Narcan) or Naltrexone (ReVia).

Used For: Can be aerosolized for palliative care

107
Q

Fentanyl

A

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)

108
Q

Oxycodone

A

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)

109
Q

Codeine

A

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)

110
Q

Meperidine

A

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)

111
Q

Oxycodone + acetaminophen

A

Percocet

112
Q

Narcotics (Opioids) Effects

A

Analgesia

Sedation

Decreases preload and afterload on the left ventricle

Antitussive qualities (cough supression)

113
Q

Narcotics (Opioids) Side Effects:

A

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

114
Q

Non Steroidal Anti-Inflammatory Drugs (NSAIDs)

A

Acetaminophen (e.g. Tylenol/acetaminophen) Salicylates (Aspirin/acetylsalicylic acid) Ibuprofen (e.g. Advil/ibuprofen)

115
Q

Acetaminophen

A

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

116
Q

Salicylates (Aspirin/acetylsalicylic acid)

A

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!

117
Q

Ibuprofen

A

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

118
Q

Haloperidol

A

Category: Anti-Psychotics

Generic Name: Haloperidol

Trade Name: Haldol

Reversal Agent: None

Used For: Control active psychotic symptons, delirium management

119
Q

Paralytics (Neuromuscular Blocking Agents – NMBAs)

A

= 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

120
Q

Non-depolarizing NMBAs

A

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

121
Q

Non-depolarizing NMBAs Side effects

A

Cardiovascular effects (tachycardia, vasoconstriction and hypertension). Pavulon the worst.

Have a tendency to release histamine

Need to provide ventilation!

122
Q

Non-depolarizing NMBAs Reversal Agent

A

Neostigmine-Neostigmine is a cholinesterase inhibitor (cholinesterase is the enzyme that breaks down AcH)

123
Q

Rocuronium

A

Category: Non Depolarizing Neuromuscular Blocking Agent

Generic Name: Rocuronium

Trade Name: Zemuron

Reversal Agent: Neostigmine (prostigmin)

Used For: Maintain Paralysis in ICU

124
Q

Pancuronium

A

Category: Non Depolarizing Neuromuscular Blocking Agent

Generic Name: Pancuronium

Trade Name: Pavulon

Reversal Agent: Neostigmine (prostigmin)

Used For: Maintain Paralysis in ICU

125
Q

Atracurium

A

Category: Non Depolarizing Neuromuscular Blocking Agent

Generic Name: Atracurium

Trade Name: Trecrium

Reversal Agent: Neostigmine (prostigmin)

Used For: Maintain Paralysis in ICU

126
Q

Tubocurarine

A

Category: Non Depolarizing Neuromuscular Blocking Agent

Generic Name: Tubocurarine

Trade Name: N/A

Reversal Agent: Neostigmine (prostigmin)

Used For: Maintain Paralysis in ICU

127
Q

Depolarizing NMBAs

A

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

128
Q

Depolarizing NMBAs Mechanism of Action

A

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

129
Q

Depolarizing NMBAs Side Effects

A

Tachycardia, hypertension

Histamine release (and thus brochospasm; hypotension)

Hyperkalemia

Increased ICP

Malignant hyperthermia (rarely)

Sensitivity to Succinycholine

Muscle pain and soreness

130
Q

Malignant hyperthermia

A

Is a genetic defect of muscle metabolis and potentiall fatal hypermetabolic state.

Treated with dantrolene

131
Q

Depolarizing NMBAs When are they Used

A

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).

132
Q

TBI PaCO2 and PaO2 Target

A

PacO2=35-40

PaO2-80-120

133
Q

Give 2 examples of drugs with a positive chronotropic effects.

A

Anything that stimulates B1 thus: epi, norepi, dopamine (moderate/cardiac dose), Dobutamine, Atropine

134
Q

List a drug that is a powerful α1 agonist.

A

Levophed, Phenylephrine and dopamine (high/pressor dose).

135
Q

Describe the effects of β2 stimulation.

A

Bronchodilation (for receptors in the lungs) and vasodilation (due to the receptors in the periphery)

136
Q

Describe the cautions associated with β1 stimulation.

A

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.

137
Q

Describe the effects of dopamine.

A

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

138
Q

Describe when a bolus of epinephrine is given.

A

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

139
Q

Describe how “inodilator” drugs work and why they are helpful in CHF patients.

A

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

140
Q

Central Nervous System

A

Brain and spinal cord

141
Q

PNS

A

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

142
Q

RASS Score of -1

A

Patient is awake with sustained eye opening and eye contact

143
Q

RASS Score of -2

A

Patient awakened with eye opening and eye contact, but not sustained

144
Q

Benefits from Pharmacological Therapies

A

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

145
Q

Goals of Pharmacology Therapy

A

Pt. comfort has to be the primary goal

Provide for agitation/anxiety free, amnesia, comfort

Trying to achieve a balance-TIGHT TITRATION

146
Q

Common Benzo’s Used for Anxiety and Hyponotic Effects

A

Midazolam (Versed)

Iorzepam (Ativan)

Diazepam (Valium)

Alprazolam (Xanax)

147
Q

True /False-Depolarizing succinylcholine is commonly used as a neuromuscular blocking agent in short medical procedures

A

True

148
Q

What is Normal ICP pressure?

A. <5mmHg

B. 5-10mmHg

C. 10-15mmHg

D. <15mmHg

A

C. 10-15mmHg

149
Q

What cranial nerve is responsible for stimulating a cough?

A. Glossopharyngeal
B. Vagus
C. Phrenic

D. Hypoglossal

A

B. Vagus

150
Q

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

A

E. B and C

151
Q

True/ False - Decorticate posturing is also known as extension

A

False

152
Q

Which medication causes respiratory depression when administered?

A. Proprofol

B. Dexmedatomidine

C. Diprivan

D. A&B

E. A&C

F. All of the above

A

E. A&C

153
Q

Delirium can indicate all of the following except

A. Liver Failure
B. Electrolyte Problems
C. Unrecognized Dementia

D. Brain Tumor

A

D. Brain Tumor

154
Q

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

A

C. Venous drainage is impeded and edema develops

155
Q

What does an increase in SjvO2 indicate?

A

Reduced cerebral metabolic rate due to hypothermia, sedatives, or brain death.

156
Q

What is the reversing agent for succinylcholine?

A

No reversal for succinylcholine.

157
Q

What is the goal of therapeutic hyperventilation?

A

Low-normal PaCO2 to vasoconstrict the cerebral arteries and reduce intracranial pressure.

158
Q

True/ False -Pancuronium is typically used as a neuromuscular blocking agent in short medical procedures

A

False

159
Q

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

A

C. Extra ventricular drain

160
Q

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

A

E. All of the above

161
Q

What is the goal temperature of therapeutic hypothermia?

A

32-34 degrees celsius.

162
Q

Indications for therapeutic hypothermia are?

A. Stroke

B. Brain injury

C. Pneumonia

D. Bronchiectasis

E. All of the above

F. A and B

A

F. A and B

163
Q

According to AHS TBI protocol what are the goals for PaO2, PaCO2, and ICP?

A

PaO2>80-120 mmHg, PaCO2 35-40 mmHg, ICP<20 mmHg

164
Q

What is the drug Luminal normally used for in modern medicine?

A. Neuromuscular blocking agent
B. Seizure control
C. Anti-inflammatory

D. Analgesic

A

B. Seizure control

165
Q

What is the generic name for Versed and Ativan?

A

Midazolam (Versed) Lorazepam (Ativan)

166
Q

What is the reversal agent for Zemuron, Pavulon, and Tracrium

A

Neostigmine

167
Q

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

A

F. A, B, and D

Final Review (27 decks)

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