Week 12 - Acute neuological/neurosurgical patients: Cerebral haemorrhage, tumours,TBI Flashcards
Describe the aims of the ax of acute neurological patients (8)
- Describe activity limitations
- establish the presence/absence of impairment
- establish baseline (objective measures) for monitoring improvement
- Determine likelihood of secondary impairment
- Ascertain degree to which patient can actively participate in therapy
- Determine a plan for intervention
- Recommend the most appropriate form of mobility (including level of assistance and equipment required)
- Work with multidisciplinary team to plan for transfer to rehabilitation/discharge
outline the guidelines for intervention for common impairments in acute neurological patients (3)
- Graded mobilization - gradual increase amount and intensity of activities performed
- follow medical/surgical instructions in medical record, aiming to commence graded mobilization as soon as medically stable
- Follow acute stroke - aim for frequent but short bouts of out of bed activity (24-48 hours post)
Outline methods of preventing secondary impairments (contracture, pain, swelling and pressure areas) in acute neurological patients (5)
- Passive positioning in neutral positions through the day - day/night, casting/splint for severe
- loading bone and cartilage
- Electrical stimulation to prevent swelling in the hand/feet
- Frequent positioning changes to prevent pressure areas
- Task-related training that involves active stretching during the lengthening phase of action (monitor ROM)
Discuss the factors influencing the timing and amount of activity training performed (6)
Timing:
- ICP stable
- Drains removed
- BP <220/110 and >90/60
- No uncontrolled atrial fibrillation
- PEG or nasogastric feed ceased
- Read surgeon’s instructions
What is the % of brain injury patients with shoulder pain on admission?
56%
What are ways to prevent shoulder pain or injury? (3)
- Wearing arm sling when up walking around
- E-Stim
- Stickers and signs to be cautious of arm
What are ways to prevent pressure areas? (2)
- Frequently change position (turn to side, tilt table, SOOB)
- utilise pressure care devices
What is an important factor to monitor when implementing graded mobilization?
Monitor clinical signs of increased ICP as they may be present but not monitored
What is an important factor to consider when first getting patient up and out of bed?
Gradually monitoring blood pressure (different degrees) as postural hypotension is common and can cause patient to faint
What are some considerations to prepare a person for rehabilitation? (4)
RAFI
- Establish attitude of active participation
- Educate families and friends
- Promote involvement in physiotherapy
- Be realistic about recovery time frame (encourage but vague)
What % of total O2 consumption is by brain?
20%
What % of resting cardiac output is to brain?
15%
What factors affecting cerebral blood flow? (3)
- Intracranial pressure
- Local constriction and dilation of cerebral arterioles
- Mean arterial pressure at brain level
Define Cerebral pefusion pressure (CPP) and the equation used for it
- Net pressure gradient causing blood flow to the brain
- CPP = MAP - ICP
What is the normal range of CPP
70-90 mm Hg
Define Intracranial pressure
Pressure within the intracranial compartment
What happens when CPP drops <40?
Ischaemia
What happens when CPP >90
Damage to blood vessels -> cerebral oedema -> brain injury
When wanting to reduce risk of 2nd deg brain injury following TBI what levels is CPP often maintained at?
50-70 mm Hg
What is the formula to find MAP?
DBP + 1/3 (SBP - DBP)
What are the 2 main methods of regulating blood flow?
- Autoregulation (Based on MAP)
2. Chemicals - PaCO2, PaO2
What range of MAP is auto-regulation effective?
MAP between 60-160 mmHg
How does the respiratory system have a direct effect on cerebral blood flow and secondary brain injury?
- Increase in CO2 -> vasodilation -> ICP
- Low CO2 -> vasoconstriction = ischaemia
- Increase in O2 -> vasoconstriction
- decrease in O2 -> vasodilation (<60 mmHg)
What is risk of Pneumonia due to respiratory consequences in TBI?
60%
Risk of ARDS (acute respiratory distress syndrome)
10-30%
What are the goals of physiotherapists for patients with acute TBI? (3)
- Respiratory impairments (gas, secretion)
- Other body systems (ie. musculoskeletal)
- Prevent 2nd deg brain injury
What are the effects of physiotherapy techniques on ICP?
Effect the blood flow and oxygenation of the brain such as:
- Increasing ICP
- CPP usually maintained at adequate level due to increased MAP
What are the general principles for physiotherapy Mx of patients with acute TBI in ICU?
consider (MWL):
Weight risks vs. benefit
liaise with medical team
Prepare (LMP):
- liaise with nursing staff
- medication prior to / during tx
- prep patients for intervention (meds, hyper-oxygenation if necessary)
Timing:
- CPP optimal stable range
- with other interventions - avoid quick succession
Modifications:
- Keep short and frequent
- Modify to reduce risk
Monitor:
1. Monitoring continually (ICP, CPP, HR, RR, MAP/BP/rhythm, PaO2, PaCO2, ETCO2)
Which physiotherapy techniques shown to cause increased ICP (5)
- MHI
- Suctioning
- Vibration
- positioning/cervical flexion or ext.
- early mobilization
What is the semi phallus position and what are the benefits?
- 30 deg head up tilt
- used to maintain good CPP, max effective ventilation and minimize aspiration in non-intubated patients
What are the effects of exercise on ICP? (3)
- Passive ROM - no significant change in ICP or CPP
- Active limb movement - no significant change in ICP or CPP but significant O2 consumption
- Resisted exercises causing valsalva manoeuvre - significant increase in ICP due to reduced venous return from head
