Unit 13 ALOA Structural Coma Flashcards
What is the Monro-Kellie Hypothesis?
What should normal ICP be?
What is auto-regulation regarding this?
How can it be measured?
Pressure exerted by the combined volume of:
- Blood 80%
- Brain 10%
- Spinal fluid 10%
Normal ICP should be 5-15
A change in one of these volumes means a change in another
Can be measured by spinal tap.
What are the types of skull fractures?
Simple- small break, no interference
Comminuted- Complex
Depressed- Complex
Basilar- Life threatening
What are the symptoms of a Basilar fracture?
Where do they usually happen?
Rhinorrhea - bloody nose
Otorrhea - ear damage, CSF
Halo Sign- from CSF leak
Raccoon eyes
Battle’s sign - bruising behind ear/near ear
They usually happen near temporal regions.
What is Basilar Skull fracture collaborative management?
Neuro checks every hr w/VS
Prevent meningitis w/antibiotic prophylaxis
Nothing in the ears
No NGT or nasal suctioning
No blowing nose only wiping
Elevate HOB 30
May need surgery to lift bone
What is the number one cause of traumatic brain injuries?
Falls
What are the two types of traumatic brain injuries?
Closed - head suddenly and violently hits an object
Open - object pierces the skull and enters the brain
What are symptoms of a traumatic brain injury?
Headache
Dizziness
Balance issues
Sensitivity to noise and light
Sleep issues
Anxiety
What are the 2 stages of brain injury?
What is the main goal of brain injury?
Primary: occurs at time of injury, infarction, disruption of blood supply, hematoma
Secondary: Progression of initial injury which leads to cellular and toxic changes causing cerebral edema and increased ICP.
Main goal is to prevent secondary injury from occurring.
What are the types of closed head injuries?
Concussion:
-disturbance of neurological function caused by trauma
Contusion:
-Bruising of brain at site of impact
Laceration:
-Tearing of surface vessels
What are PT considerations with closed head injuries?
Avoid physically demanding activities/ gradually resume
Avoid straining
Avoid sustained electronic use
Avoid alcohol and nicotine
Only take prescribed meds
Allow frequent rest
What is the collaborative management of closed head injury?
Minor injury, PT will be sent home from ED
PT/family education to:
- call if change in behavior, speech, or vomiting
- cognitive/physical rest
Neurocognitive Testing (Impact test) –25 min computer test that measures attention, memory, responses, and reaction times
What are the type of Hematomas?
Epidural Hematoma:
- Extreme emergency!
- Associated w/skull fracture usually in temporal region
- Arterial bleed
Subdural Hematoma: (part of severe brain injury)
- Acute
- Subacute
- Chronic
Intracerebral Hemorrhage
Describe an Epidural Hematoma.
What is the treatment?
Blood collection between the skull and dura
PT may have brief loss of consciousness w/return of lucid state, as hematoma expands ICP will reduce LOC
An emergency situation!! FROM Arterial Bleed!!
Symptoms develop rapidly
Treatment:
- Reduce ICP
- Remove the clot
- Stop bleeding - (burr holes or craniotomy)
- Monitoring of VS
What is a subdural hematoma?
Associated w/ what?
Describe acute and subacute Subdural Hematoma and treatment.
Describe chronic Subdural Hematoma and treatment.
Collection of blood between the dura and the brain.
40-60% fatal
FROM veins!
Associated w/ skull fractures and contusions
Acute: symptoms develop over 24 - 48 hrs
Subacute: symptoms develop 48hrs- 2 weeks
Treatment for both: Immediate craniotomy and control ICP
Chronic:
-Develops over weeks to months
-Causative injury may be minor and forgotten
-Clinical signs and symptoms may fluctuate
Treatment: evacuation of the clot
What is Intracerebral hemorrhage?
What is the treatment?
Hemorrhage occurs into the substance of brain.
May be due to trauma or a non-traumatic cause.
Treatment:
- Supportive care
- Control ICP
- Administer fluids, electrolytes, and antihypertensive medications
- Craniotomy or Craniectomy to remove clot and control hemorrhage (may not be possible due to location)
What is the Secondary Injury (complication of primary injury) Cerebral Edema.
Brain swelling which leads to ICP.
What is the nursing care and prevention of secondary injury cerebral edema?
- HOB 30 degrees
- Log roll when turning
- Analgesics
- Stool softeners to prevent straining
- Prevent coughing/sneezing
- Prevent valsalva maneuvers
- Prevent pain
- Prevent hypoxemia and hypercapnia
- Avoid increased ICP (suctioning and turning can increase, be careful)
What is the treatment of the secondary injury, cerebral edema?
mannitol -osmotic diuretic
Hypertonic solution 2-3% normal saline
Control “neuro fever” w/antipyretics, cooling blankets, etc
Maintain or slightly increase systolic BP
What is hydrocephalus secondary injury?
What is the treatment?
Volume increase in CSF.
- Increased production in ventricles
- obstructed circulation
- decreased absorption
Treatment: Ventriculostomy (external ventricular drain)
What is the earliest indicators of ICP?
What is the latest sign of ICP?
Mental status changes
Cushing’s triad (arterial hypertension and widening PP, bradycardia, bradypnea)
What is the secondary injury Diabetes Insipidus and SIADH?
DI: Lacks antidiuretic hormone to there is urine, urine, urine! very diluted urine!
Syndrome of Inappropriate ADH(SIADH):
- too much ADH
- stops urine/holds onto fluid
Describe DI vs SIADH.
DI:
- Dilute urine
- High serum Na+
- High serum osmolarity
- Low urine gravity
- THIRSTY
- Rx: Vasopressin
SIADH: -Concentrated urine -Low serum Na+ -Low serum osamlarty -High urine gravity -Thirsty Rx: Hypertonic saline, fluid restriction
Describe the secondary injury brain herniation.
-Displacement of brain tissue into the spinal canal.
- Essentially brain pushed down onto brain stem.
- Often results in death
- Presents w/abnormal posturing, GCS 3-5
What are the clinical manifestations of ICP?
Decrease in GCS ALOA Headache Vomiting Abnormal speech Motor/sensory issues Change in cardiac rate/rhythm Change respiratory patterns
Any ICP over what is considered increased?
What flexions will ICP?
16
Neck and hip flexion
What is Cushing’s triad?
- Arterial hypertension with widening PP
- Bradycardia
- Bradypnea
What are nursing interventions for all brain injuries?
- Neuro assessment hourly
- Monitor for ICP
- Elevate HOB 30
- Maintain head in neutral position
- Log roll when turning
- Avoid straining, breath holding exercise, isometric exercise, and extreme hip flexion
- Alternate activity with rest periods
- Temp control
- Prevent or treat pain/seizures/agitation
- Strict fluid restrictions
- Limit environmental stimulus
What is a method to temporarily reduce ICP?
Intubation with mechanical ventilation:
- Hyperventilate to get PaCO2 between 35-30
- If suctioning, do NOT suction for more than 10 secs at a time, utilize hyper-oxygenation before and after procedure
What is the systolic BP goal for/during a brain injury?
120-140
What are medications for brain injury?
Diuretics:
- mannitol (osmotic diuretic)
- furosemide (loop diuretic)
Corticosteroids:
-dexamethasone (prevents further swelling)
Anticonvulsants:
-phenytoin (given through IV, monitor for heart block, mix only in NS)
Antihypertensives:
- Beta blockers
- Calcium channel blockers
- ACEis
Analgesics, Anesthetics, Sedatives:
- propranolol
- barbiturates
- pentobarbital
What is ICP monitoring?
What is there a high risk for?
What are the advantages?
- Burr hole in skull, continuous monitoring of ICP done with screw or bolt
- High risk for infection
Advantages:
- Pressure can be recognized and treated before clinical symptoms appear
- Allows drainage of CSF via 3 stopcock
- Cerebral perfusion pressure can be calculated and treatment adjusted
- Effects of nursing interventions on ICP can be monitored
How is cerebral perfusion pressure calculated?
What is the normal?
How is mean arterial pressure calculated?
What is the normal?
What should it be maintained above?
What does maintenance of CPP do?
MAP-ICP = CPP
Normal CPP 60-100
MAP= Systolic + Diastolic x 2 divided by 3
Normal is 70 -100
(should be maintained above 70-80)
Maintenance of CPP reduces mortality in severe head injury
What is associated w/ poor prognosis in head injuries?
Systemic hypotension is associated with poor prognosis in head injury
What are the risk factors of hemorrhagic stroke?
- Uncontrolled HTN
- Overtreatment w/ Anticoagulants
- Overweight/Obese
- High cholesterol
- Cardiovascular disease
- Diabetes
- Age 55 and older
- Smoking
- Heaving drinking
- Males and A.A’s more at risk
What are a couple causative factors of a hemorrhagic stroke?
- Aneurysm
- Arteriovenous malformation
What does a transcranial doppler do?
Assess blood flow through arteries in brain, therefor assessing for vasospasms
How can the following help decrease ICP? antipyretics docusate sodium lorazepam insulin
antipyretics: by decrease fever you decrease ICP
docusate sodium: prevents straining which helps lower ICP
lorazepam: decreases agitation which decreases ICP
insulin: controls BS which decrease ICP
What is triple H therapy and what is it for?
Hypervolemia
Hypertension
Hemodilation
Therapy used to prevent vasospasms after aneurysm subarachnoid hemorrhage; PT stays in ICU for 2 weeks.
What is nimodipine and what is it used for?
- A calcium channel blocker used to decrease vasospasms;
- take for 21 days on empty stomach.
What is subarachnoid hemorrhage?
Blood between pia and arachnoid membranes.
Causes: Head trauma, etc
S and S’s: Headache, dull pain, nausea, dizziness, unequal pupils
What are vasospasms?
Abnormal narrowing or constriction of arteries due to irritation by blood in the subarachnoid space.
(blood is putting pressure on the vessels which correlates with ICP)
