Shocks/Seizures/Strokes/TBI Flashcards
Septic Shock
Distributive shock caused by widespread bacterial infection (Massive vasodilation, Loss of vessel tone)
= Persistent HYPOtension*** despite fluid resuscitation (massive vasodilation)
= High RR
= ARDs (SIRS casacade»_space; MODS)
Bacterial meningitis
- Sxs in adults / kids / neonates?
Inflammation of meninges caused by N.meningitis/Strep pneumoniae = increased ICP
DROPLET PRECAUTIONS
** SEIZURE**
ADULTS = Neck stiffness, (+) Brudzinski, (+) Kernig
KIDS = Rash, Neck stiffness
NEONATES = Poor feeding/suck, Bulging fontanelles
Dx via Lumbar puncture for CSF (Cloudy, high pressure @ puncture)
= Low serum glucose
= High WBC + serum protein
Anaphylaxis
Distributive shock response to allergen (Massive vasodilation, Loss of vessel tone)
= HYPOtension
= N/V
= Flushed, warm, dry
= Pruritus + Edema (wheezing)**
1st LINE tx: Adrenergics (epinephrine IM; q5min x3 dose)
- Antihistamines
- Leukotriene antagonists
- Glucocorticoids (stabilizes mast cells)
* *can mask infection** - Xolair (decreases IgE)
- Immunotherapy
- Support ABCs (ex. Ventolin nebulizers for bronchodilation)
Distributive Shock
MASSIVE peripheral vasodilation, loss of muscle tone (Anaphylaxis, Septic)
= High HR (but low in neurogenic shock)
= High JVP
= Warm peripheries
What is Neurogenic shock?
Caused by traumatic SCI or any Nerve injury
= Hypotension (Distributive Sxs - Massive vasodilation)
= Bradycardia**
= Hypothermia (initially warm/flushed, but then cold/clammy)
Hypovolemic Shock
Reduced blood volume (hemorrhage, dehydration)
= Low CO / BP / JVP
= Tachycardic
= Change in MS, Cold peripheries
Tx: increase BV in ECF
1. Colloid IV
2. Crystalloid IV
3. Whole blood; PRBCs
Cardiogenic Shock
What is the tx focus?
Unable to pump effectively (MI, trauma)
adequate blood volume
= Low CO / BP
= High JVP + Tachypnea
= Cold peripheries
Tx focus is to OPTIMIZE CO via:
= DECREASE WORKLOAD/BV via Diuretics
= VASODILATE via Direct Acting Vasodilators + Nitroglycerine
= BETTER CONTRACTILITY via P-inhibitors + Catecholamines
What is an intra-aortic balloon pump used for?
CARDIOGENIC SHOCK = increases CO and blood flow
(Inflates during diastole; deflates @systole)
What are obstructive shocks?
Tx?
When there is mechanical obstruction to blood flow through central circulation.
(cardiac tamponade, tension pneumothorax, PE)
= low CO, BP
= High RR?
Ischemic Stroke
No BF to brain caused by thrombus (Atherosclerosis) or Embolus (CAD/Angina - dislodges in brain)
Warning sign via “TIA”
= Undetected
= Lasts minutes to hours
= Resolves in 24 hrs w/ full functional recovery
Sxs = “BE FAST”
Pronator drift
Dx = CT scan w/o contrast to rule out hemorrhage (contraind.) and be able to tx with Thrombolytics
What is a special consideration for non-TPA pts undergoing Ischemic stroke?
What should the nurse do?
Permissive HTN b/c it can hyperperfuse the brain
Monitor BP
= Titrate CBB to correct extreme HTN > 220/120
= maintain SBP > 170 mmHg to persevere brain fx
Thrombolytic therapy
- Contraindications?
For Ischemic stroke
= Must be initiated < 4 hrs of Sx onset!!!
DO NOT GIVE TO Pts with:
- Hemorrhage/Active bleed
- Low platelets or HIGH INR/PT
- Uncontrollable HTN (> 185/110)
- Recent brain/spinal surgery
Concussion
A mild blow to the head = dizziness, headache, amnesia
= resolves fast
Contusion
Bruising to the brain tissue
= Focal Sxs
Diffuse Axonal Injury (DAI)
TBI via MVA = shearing of white matter
= Diffuse brain swelling (cerebral edema)
= COMA
Skull Fractures
Linear (along sutures), Depressed, Comminuted (fragments)
Battle sign + Raccoon eyes
If FRONTAL FRACTURE = check for CSF LEAKAGE***
Hematomas
- Types x 3
Closed TBI with blood buildup beneath skull
**Will increase ICP = monitor for altered LOC + Headache + N/V)
EPIDURAL = between skull + dura mater (arterial bleed)
SUBDURAL = dura + arachnoid (venous bleed)
INTRA-CEREBRAL = within tissues
Nursing interventions for TBI
- Stabilize neck + cervical spine
- GCS scoring (If < 8 = intubate)
- Monitor for ICP (headache, N/V, altered LOC)
- Maintain normothermia (temp)
- Check for CSF leakage!!
Cerebral Edema
Excess fluid in brain due to increased CSF production/blocked drainage/impaired resorption
= Cushing’s Triad (HTN - wide PP, Bradycardia, Bradypnea)
= Increased ICP (Decorticate/Decerebrate + Hyperthermia)
= Fixed pupil dilation (uni/bilateral)»_space; BRAIN STEM HERNIATION
Brain stem herniation (signs?)
Bilateral fixed pupil dilation!!!
EMERGENCY
Can be caused by cerebral edema
Epilepsy
Chronic recurrent seizures that last <5 min each
Status Epilepticus
EMERGENCY
Recurrent seizures that LASTS > 5 MIN + CONTINUOUS/NO RECOVERY PERIOD
Tonic-Clonic seizure (Grand mal)
Generalized seizure (both hemi)
“Pre-seizure aura” = blurred vision, tinnitus, nausea
= Sudden contraction + jerking mvts in limbs
= Muscle rigidity, Incontinence
= LOC + Postictal
Absence Seizure (petit mal)
Generalized seizure (both hemi) - usually CHILDREN
= Brief staring episodes
= Automatisms (lip smack, finger rolling)
= NO Postictal
Myoclonic Seizure
Generalized seizure (both hemi)
= Jerking movements in limbs
= No LOC or Postictal
Atonic/Akinetic Seizure
Generalized seizure (both hemi)
DROP ATTACK = sudden loss of all muscle control
Simple Partial Seizure
Focal/Partial seizure (one hemi)
= Awareness during seizure
= No postical
= Involuntary motor (head turn)
= Sensory disturbance (smell/taste)
Complex Partial Seizure
Focal/Partial seizure (one hemi)
= Altered LOC
= Automatisms
= Postictal phase
What is the Postictal phase in seizures?
Drowsiness, slowed speech, confusion
Febrile Seizure
Seizures only caused by high fever in children ages 6 m to age 5 (temp > 38)
*Benign = no chronic damage
SIMPLE
= once in 24 hrs, lasts < 10 min
= Brief postictal phase
COMPLEX
= Multiple times in 24 hrs, lasts >10 min
= just give ANTIPYRETICS (no Ibuprofen for kids < 6 m.)
NO TEPID SPONGING (cold water baths)!!
Signs of high ICP?
Altered LOC, Vomit, Headache
Hydrocephalus
- Kids vs Infants?
- Tx?
Increased ICP in brain = N/V, Altered LOC, Headache
Kids
= Cushing’s triad (HTN, Bradycardia, Bradypnea)
Infants
= High-pitched shrill cry
= Poor feeding
= Bulging anterior fontanelle + wide suture gap (rapid increase in head circumference)
= Sunset eyes
Kids
= Cushing’s triad (HTN, Bradycardia, Bradypnea)
Tx = VP shunts (into pericardium) - lay flat for first 24 hrs, then side
Dantrolene & Baclofen
Muscle relaxant - MS, Cerebral Palsy, Stroke, SCI (Spasticity)
Dantrolene
= for Neuroleptic malignant syndrome
= s/e of Hepatotoxicity
Ethosuximide
Succinimides (Anticonvulsants) - block Ca from entering thalamus/decreases NM excitability
= Absence seizures
= Do not d/c rapidly or else causes seizure
Phenytoin, Fosphenytoin, Carbamazepine*, Valproic acid
Hydantoins (Anticonvulsant) - blocks Na channels to induce calming effect on neurons
PhenyTOIN & Fosphenytoin (prodrug)
= TERATOGENICITY, lowers effectiveness of oral contraceptives
= Lethargy, Ataxia, Nystagmus/Diplopia, Purple Glove Syndrome
= Need to monitor blood work
= Need for folic acid supplements
(Phenytoin-like)
- Valproic acid
- Carbamazepine (also for trigeminal neuralgia; Risk of Hyperpyrexia, HTN)
Thiamine IV
For chronic ETOH abuse (Wernicke’s Encephalopathy)
Autonomic dysreflexia
SCI T6 and above (noxious “pain” stimuli from either distended bladder / fecal impaction / constrictive clothing)
= Severe HTN
= Bradycardia
= Throbbing headache (vasodilation)
= Nausea (vasodilation)
= Diaphoretic (vasodilation)
What to monitor for post-Craniotomy pts?
= Turn onto non-operated side.
= Polyuria (damage to hypothalamus/pituitary gland)
= Assess site drainage/dressing for HALO SIGN
**Pain = give SA opioids so it doesn’t get confused with complications coming from the craniotomy
Autonomic CVS instability
Gullain Barre Syndrome
= Reflexive tachycardia + Orthostatic hypotension + Dysrhythmia
Anticonvulsants
- Indications
- Nurse actions?
For seizures
Monitor for:
= Toxicity (Nausea/Ataxia/Lethargy/Nystagmus)
= Do not change dose rapidly!
Phenobarbital
- Antidote?
Lorzepam, Diazepam*, Clonazepam
“-BARBITAL” = Barbituates (Anticonvulsants) - enhances GABA effects
For status epilepticus
High risk of toxicity when taken w/ Phenytoins, CNS depressants (lorazepam)
= Activated Charcoal or NaHOC3
“-PAM” = Benzodiazepines (Anticonvulsants) - same MOA
OD tx = Flumazenil
Diazepam can also be for muscle spasms (muscle relaxant)
Succinylcholine
Rapid + brief muscle relaxant given during SURGERY or INTUBATION
= Must have ventilation support
= Give sedative beforehand
Benzotropine
Anticholinergic - Parkinson Disease’s EXTRAPYRAMIDAL DISORDERS
Take with food!!
Carbidopa/Levodopa
Dopamine Agonists - Parkinson Disease
= Orthostatic hypotension, Harmless urine discoloration
TOXICITY = Spasmodic winking, Muscle twitch
SumaTRIPTAN
“-triptan” (Serotonin Agonist; Migraine)
Contraind. in pts with Uncontrolled HTN + CAD because it constricts cranial BVs
