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S6- Neuro 2 > Week 8- Neuro ICU > Flashcards

Week 8- Neuro ICU Flashcards

1
Q

PART 1

A

PART 1

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2
Q

What is an ICU?

A

“Intensive care, also known as critical care, is a multidisciplinary and interprofessional specialty dedicated to the comprehensive management of patients having, or at risk of developing, acute, life threatening organ dysfunction. Intensive care uses an array of technologies that provide support of failing organ systems, particularly the lungs, cardiovascular system, and kidneys”

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3
Q

Indications for Admission to ICU:

  • Threatened airway
  • All respiratory arrests
  • Respiratory rate >___ or < ___% on >50% oxygen
  • All cardiac arrests
  • Pulse rate ____ bpm
  • Systolic blood pressure < ___ mm Hg
  • Sudden fall in level of __________
  • Repeated/prolonged ___________
  • Rising arterial carbon dioxide tension with respiratory acidosis
  • Any patient giving cause for concern
A
  • RR >40 or <90% on >50% O2
  • Pulse <40 or >140 bpm
  • SBP <90mmHg
  • fall in level of consciousness (GCS score >2)
  • repeated/prolonged seizures
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4
Q

What are the 2 ‘Neuro” ICUs?

A
  • Neurosurgical ICU (NSICU)

- Surgical Trauma ICU (STICU)

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5
Q

Patients seen in NSICU.

A
  • CVA
  • Guillain-Barre Syndrome
  • Acquired TBI
  • Acquired SCI
  • Myasthenic Crisis
  • Seizures
  • Brain Tumors
  • Hydrocephalus
  • Multiple Sclerosis
  • Parkinson’s Disease
  • ALS
  • *(3 above not usually seen unless something else happens)
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6
Q

Patients seen in STICU.

A
  • TBI
  • SCI
  • Polytrauma
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7
Q

What are the (6) parts of an ICU chart review?

A
  1. ) MD Plan of Care
  2. ) Diagnostic Imaging
  3. ) Lab Values
  4. ) Medications
  5. ) Current Patient Status
  6. ) Lines, Drains, Tubes
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8
Q

Neurosurgery vs Neurology Team:

  • When is neurosurgery consulted?
  • When is neurology consulted?
A
  • Neurosurgery (NSGY) = Consulted whenever diagnosis may warrant invasive interventions for the brain or spinal cord. (Also with orthopedic injuries to SPINE)
  • Neurology = Primary team when invasive interventions not warranted and/or when pt demonstrating significant fluctuations in neuro status.
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9
Q

Trauma vs Ortho Team:

  • When is trauma consulted?
  • When is ortho consulted?
A
  • Trauma = Primary team when admitting diagnoses is a result of trauma. (Can be involved in surgical interventions)
  • Ortho = Consulted whenever orthopedic injury to EXTREMITIES. (Can be involved in surgical interventions.)
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10
Q

What are the major search points when reviewing prior MD notes and active orders? (5)

A
  • Reason for admission to ICU
  • PMHx and relevant interventions
  • HPI and relevant interventions
  • 24-hour plan
  • PRECAUTIONS
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11
Q

What are 3 common orthopedic precautions?

A
  • OOB status
  • WB status (TRIPLE CHECK ACCURACY)
  • Bracing needs (TRIPLE CHECK ACCURACY)
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12
Q

What are 4 common neurological precautions?

A
  • Spinal Precautions (No B/L/T)
  • Craniotomy Precautions (avoid activities that ↑ ICP)
  • Seizure Precautions (close monitoring, avoid rigorous activity)
  • Fall Precautions
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13
Q

What is 1 common hemodynamic precaution?

A

-BP restrictions

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14
Q

What is 1 common integumentary/plastics precaution?

A

-Skin grafts (can range from no restrictions to no AROM to NWB)

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15
Q

Common Neurological Diagnostic Imaging.

A
  • Brain/Spine CT Scan
  • Brain/Spine MRI
  • Chest X-Ray (CXR)
  • Lumbar Puncture (LP)
  • Ultrasound
  • Electroencephalogram (EEG) (Continuous versus spot check)
  • Transcranial Dopplers (TCDs)
  • Interventional Radiology (IR)
    • Angioplasty
    • Carotid Stenting
    • SAH Vasospasm Endovascular Treatment
    • Spinal Cord Embolization
    • Vertebroplasty
    • IVC Filter Placement
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16
Q

What is Interventional Radiology (IR)?

A

-Taking an x-ray/CT scan/MRI while doing something to the body.

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17
Q

What are the biggest lab value considerations with Neuro ICU. (6)

A
  • CBC
  • Electrolyte Panel
  • Kidney Function
  • Endocrine Function
  • Thyroid Function
  • Acid-Base Disorders
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18
Q

CBC:

  • Should be relatively ________, with some considerations for admitting diagnosis (Ex: hemorrhage → decreased hgb/hct, increased platelets).
  • If no further up/downtrend, usually okay to see - check with RN for POC.

Electrolyte Panel:

  • Patients are very symptomatically sensitive to changes in ___ after a neurological event (→ cognitive changes).
  • Significant changes in CL, Ca, Mg, PO4, and K are _____ common post neurological insult.
A

-stable

  • Na
  • less common
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19
Q

Kidney Function:
-BUN and Serum Creatinine generally _______ unless relevant comorbidities present. (if complications seen, tends to be more subacute/chronic stages of recovery)

Endocrine Function:
-Helpful to review blood _______ prior to mobilization, common to see fluctuations. (hyper and hypoglycemia both lead to poor activity tolerance)

A
  • stable

- blood glucose

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20
Q

Thyroid Function:

  • Hypothyroidism: has been associated with signs of aortic or coronary __________.
  • Hyperthyroidism: associated with _________ and ________________

Acid-Base Disorders:

  • Respiratory ________ common sequelae of CVA.
  • Respiratory ________ common with prolonged vent support and neuromuscular disease.
A
  • atherosclerosis
  • a-fib and cardioembolic stroke
  • alkalosis
  • acidosis
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21
Q

PART 2

A

PART 2

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22
Q

Considerations for Initiation of Mobility in the NS/STICU. (6)

A

Patient Status

  • MD POC
  • Neurological Status (stable, fluctuating, declining)
  • Arousal, Cognition, Behavior
  • Common Meds for Agitation
  • Medically-Induced Paralysis
  • CV and Pulmonary Status
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23
Q

What are some things to take into consideration in regards to MD POC? (3)

A
  • Is there surgery planned in the next several days?
  • Is the patient undergoing any significant treatment protocols? (Ex: CXT, radiation, IVIg, Plasmaphoresis, Dialysis)
  • Are there any significant changes being made to the POC? (medication adjustments, progressive care vs comfort measures (CMO))
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24
Q
  • What is comfort measures (CMO)?

- Are they appropriate for PT at this point?

A
  • Means that the patient is dying.

- NO, focus will be on comfort via pain medication and guidance to passing.

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25
Q

What is a big consideration for patients initiation of mobility in 90% or more of patients in the ICU?

A

-Arousal, Cognition, Behavior

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26
Q

What are (5) outcome measures to evaluate arousal, cognition, and behavior?

A
  • Glasgow Coma Scale (GCS)
  • Coma Recovery Scale (CRS-R)
  • Agitated Behavior Scale (ABS)
  • Richmond Agitation & Sedation Scale (RASS)
  • Confusion Assessment Method (CAM)
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27
Q

-What outcome measure is where we start a review? Why?

A

-RASS, quick and dirty way of telling whether or not patient is appropriate for PT.

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28
Q

RASS Levels.

A 
\+4 = Combative (violent, immediate danger to staff)
\+3 = Very Agitated (pulls or removes tubes or catheters; aggressive)
\+2 = Agitated (frequent non-purposeful movement, fights ventilator)
\+1 = Anxious (apprehensive but movements not aggressive or vigorous)
0 = Alert and Calm
-1 = Drowsy (not fully alert, but has sustained awakening to voice (eye opening and contact >/=10s))
-2 = Light Sedation (briefly awakens to voice (eye opening and contact <10s))
-3 = Moderate Sedation (movement or eye-opening to voice (but no eye contact))
-4 = Deep Sedation (no response to voice, but movement or eye opening to physical stimulation)
-5 = Unarousable (no response to voice or physical stimulation)
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29
Q

What are the GREEN LIGHT RASS Levels?

A

+1, 0, -1, -2

30
Q

What are the YELLOW LIGHT RASS Levels?

A

+2, -3

31
Q

What are the RED LIGHT RASS Levels?

A

+4, +3, -4, -5

32
Q

What are the (3) common medications for agitation? List whether they are red, yellow, or green light.

A
  • Propofol (RED LIGHT)
  • Fentanyl (YELLOW LIGHT)
  • Precedex (GREEN LIGHT)
33
Q
  • What is Medically-Induced Paralysis?

- Are these patients appropriate for PT?

A
  • Barbituate or Propofol-managed state that allows state of hibernation for brain to combat severe pressure dynamics.
  • Not appropriate for PT interventions.
34
Q

Cardiovascular Status:

  • CVA complications are common and often preceded by what 2 things?
  • TBI ________ can lead to severe CV compromise that can linger post episode.
  • SCI ________ ______ accompanied changes in BP (hyper → hypo).
  • ALWAYS investigate need for ___/___ parameters prior to initiating mobility.
A
  • CVA complications often preceded by diagnosed/undiagnosed HTN and A-Fib.
  • TBI storming
  • SCI spinal shock
  • HR/BP parameters
35
Q

Pulmonary Status:

  • Check in with RT:
    • How much vent support, patient response?
    • Spontaneous Breathing Trial?
    • If on O2, weaning trials? If not, can trials start w/ PT.
  • WE CAN AND SHOULD ________ patients on the vent.
A

-mobilize

36
Q

PART 3

A

PART 3

37
Q

Diagnostic-Specific Contraindications/Precautions to Mobility - Spinal Cord Injury (SCI):
-What are (3) contraindications/precautions to mobility in this population?

A
  • Spine stability
  • Spinal shock
  • Autonomic Dysreflexia
38
Q

Diagnostic-Specific Contraindications/Precautions to Mobility - Traumatic Brain Injury (TBI):

  • What are the 2 main contraindications/precautions to mobility in this population?
  • With autonomic storming, PT is typically deferred until storming subsides, what can PTs be consulted for at this level?
  • Transcranial Doppler (TCD) measures mean blood flow velocity of arteries in neck and brain. What level is typically contraindicative for mobility?
A
  • Autonomic Storming, Vasospasm
  • bed-level positioning
  • 100-120cm/s
39
Q

Diagnostic-Specific Contraindications/Precautions to Mobility - Stroke (CVA):

  • tPA no OOB for ___ hours post administration.
  • Stroke is the most common place we will see hemodynamic parameters. What are the parameter differences in regards to Ischemic Event vs Hemorrhagic Event?
A
  • 24 hours
  • Ischemic Event
    • Permissive HTN
    • BP <220/110 = MOBILITY
  • Hemorrhagic Event
    • BP < 150/90 = MOBILITY
40
Q

Diagnostic-Specific Contraindications/Precautions to Mobility - Seizures:

  • No active seizure in past ___ hours.
  • cEEG: OK to mobilize with MD clearance (limited to in-room activities due to EEG wires).
A

-24 hours

41
Q

Diagnostic-Specific Contraindications/Precautions to Mobility - Shunt Placement:

  • Starting parameters of shunt relatively universal.
  • OK to mobilize after surgery, monitor closely for S/Sx of ______ and/or _________.
  • What are the S/Sx of hydrocephalus?
A
  • ↑ ICP and/or hydrocephalus

- Cognitive changes, urinary incontinence, shuffled/magnetic gait pattern

42
Q

Diagnostic-Specific Contraindications/Precautions to Mobility - Autoimmune-Related (GBS, Myasthenic Crisis):
-Are patients okay to see if on IVIg/Plasmapheresis?

A

-Yes, if tolerated, pending medical stability. (best to try and see in AM or off days)

43
Q

General Contraindications for Initiation of PT in ICU Setting:

  • New administration of a _______/________ agent.
  • Multiple ________ being administered.
  • Change in ventilator setting to provide increased ventilator support.
  • ____-________ airway.
  • Active ____ bleed (consult with MD).
  • Elevated _____.
  • Agitation requiring increased sedative administration in the last 30 minutes.
A
  • pressor/antiarrhythmic agent
  • pressors
  • non-secured airway
  • active GI bleed
  • elevated ICP
44
Q

What does basic monitoring for ICU patients include? (7)

A
  • Heart rate
  • Blood pressure
  • Respiratory rate
  • Pulse oximetry
  • Hourly urine output
  • Temperature
  • Blood gases
45
Q

NSICU-Specific Monitoring - ICP:

  • ___% of patients with serious neurological injuries have ↑ICP.
  • Increased pressure can compress brain tissue, decrease perfusion to brain tissues or possible herniation.
  • Normal ICP = ___-___ mmHg
  • Abnormal ICP = >___ mmHg
A
  • 70%
  • Normal ICP = 5-10 mmHg
  • Abnormal ICP = >20 mmHg
46
Q

What are the (3) major ways we can monitor ICP? Which is the gold standard?

A
  • Intraventricular Catheter (gold standard)
  • Subdural Bolt (“ICP Bolt”)
  • Implantable Microtransducer Sensors
47
Q

Intraventricular Catheter:

  • Most accurate monitoring method (gold standard), but can be difficult to place when emergent.
  • Catheter inserted into _______ ventricle via ventriculostomy.
  • Do these patients require clearance for PT?
  • Can be used to drain fluid out through the catheter (________ Drain)
A
  • lateral ventricle
  • Yes, requires neurosurgery/neurology clearance.
  • Extraventricular Drain (EVD)
48
Q

Subdural Bolt (“ICP Bolt”):

  • _______ monitoring.
  • Screw inserted into subdural space.
  • Does this dislodge easily? Is mobility indicated with these patients?
A
  • Immediate monitoring

- VERY easily dislodged with movement, therefore typically contraindicated.

49
Q

Implantable Microtransducer Sensors:

  • Intraparenchymal, epidural
  • ______ invasive but generally expensive and cannot be recalibrated into in situ.
  • In what situations is this used?
  • Is mobility indicated in these patients?
A
  • Least invasive
  • Used where EVD placement is unsuccessful or when CSF drainage not necessary.
  • Generally not appropriate to mobilize until removed.
50
Q

Extraventricular Drain (EVD):

  • What is the purpose of an EVD?
  • Drain will be progressively raised, what does this do?
  • Once patients are progressed to NSGY goal, ______ trials will start. If well tolerated, drain will be removed.
  • What is the difference between clamped and unclamped drain?
  • Patients should first tolerate ____ minutes of EVD clamped at rest prior to mobilization.
A
  • Purpose is to use gravity-positioned drain to clear excess CSF from brain.
  • Decreases rate of draining, while patient is closely monitored for adverse S/Sx.
  • clamp trials
  • When unclamped, patients CANNOT mobilize. When clamped it is SAFE TO MOBILIZE and participate in full with close monitoring.
  • 30 minutes
51
Q

PART 4

A

PART 4

52
Q

Is early mobilization after a neurological event safe?

A

YES, not only can it be safe, but can also impact recovery.

53
Q

Consequences of Immobility.

A
  • Respiratory (poor lung expansion, weak cough, secretions, pneumonia)
  • GI (aspiration, GERD, poor appetite, malnutrition, constipation,vomiting)
  • GU (difficulty voiding, incontinence, UTI)
  • Endocrine (glucose intolerance, increased fat stores, disturbed Na-water balance)
  • Cardiovascular (venous stasis, OH, increased risk for embolism)
  • Musculoskeletal (atrophy, weakness/deconditioning, osteoporosis, contractures)
  • Neuro (reduced motor control, delirium, cognitive/behavioral dysfunction, sleep dysfunction)
  • Skin (pressure ulcers)
54
Q

List some common barriers to mobility in NS/STICU.

A
  • Spinal instability
  • Autonomic storming
  • tPA
  • Bedrest associated with endovascular intervention
  • Increased ICP
  • Vasospasm
  • Hemodynamic instability
  • Femoral sheaths (A-lines)
  • Increased ventilatory support
  • Active seizures
  • Treatment interventions (IVIg, Plasma, Dialysis, CXT/RT, IR)
55
Q

Early Mobilization - Acute CVA:

  • What did the AVERT Trial conclude?
  • What did the HeadPoST Trial conclude?

-What are some important considerations for this?

A
  • AVERT = Early mobilization of acute CVA (<24h of onset) results in improved QOL, motor function, walking, and ADLs.
  • HeadPoST = Keeping patients flat for 24h did not offer any added improvements or additional safety benefits than those allowed to sit up.

-severity/type of CVA, interventions required, hemodynamic parameters, neuroimaging

56
Q

Early Mobilization - EVD:

  • What has research concluded about early mobilizations with EVDs?
  • Are there any adverse events with early mobility?

-What are some important considerations for this?

A
  • Significant increase in mobility, decrease in hospital LOS and # of days requiring restraints, improved discharge disposition, decreased tracheostomy placement.
  • No adverse effects

-severity/type of CVA, interventions required, hemodynamic parameters, neuroimaging

57
Q

Why should we be careful with early mobility if a patient has their drain raised?

A
  • There is a chance they aren’t going to feel well and can’t tolerate.
  • Monitor for ICP S/Sx
58
Q

Early Mobilization - TBI/ABI:

  • Limited research on early mobilization post TBI/ABI.
  • Disorders of Consciousness: Significant improvement in CRS-R scores when implementation of verticalization protocols (tilt table, ERIGO) within __ weeks of injury.

-What are some important considerations for this?

A
  • 2 weeks

- Severity of injury, acute complications, ICP parameters, behavioral status

59
Q

Early Mobilization - SCI:

  • Emerging evidence on prevention of the chronic complications of SCI including respiratory compromise, bladder dysfunction, Charcot joints, and pressure sores.
  • Additional support for role in prevention of atelectasis and PNA, contractures, HO.
  • ______ tolerance is a big issue post SCI.

-What are some important considerations for this?

A
  • pain tolerance
  • Presence of fractures, orthopedic restrictions, autonomic dysreflexia, spinal shock, orthotics, pain tolerance, comorbidities
60
Q

Vent Myth Questions:

  • Can you move/touch someone on a vent?
  • Is the patient dying?
  • Will they always need a ventilator?
  • Is the patient always paralyzed?
  • Are these patients always unable to speak?
  • Can this patient be ambulating?
A
  • Yes
  • No
  • No
  • No
  • No
  • Yes
61
Q

What are the improvements we can see with mobilizing patients on vent support?

A
  • Improved muscle strength
  • Ability to wean from vent use
  • Decreased hospital LOS
  • Decreased 1 year mortality rate
62
Q
  • PT can be EXTREMELY helpful for _________ ________ Trials and ___________ _________ Trials.
  • Command following/respiration sitting EOB > Supine
A

-Spontaneous Awakening Trials (SATs) and Spontaneous Breathing Trials (SBTs)

63
Q

Why is it helpful to touch base with RT prior to session with vent patients?

A
  • Current parameters, vent POC, patient’s tolerance
  • Can we try progressing vent dependence during session?
  • Does the patient’s vent dependence need to be regressed during session?
64
Q

General Tips for Mobilizing Patients In NS/STICU:

  • Stepwise progression of patient positioning to ensure appropriate neurological, hemodynamic, and pulmonary response to activity/upright.
  • HOB _____ → _____ position → ___ → Bedside Chair
  • What is the EGRESS Test?
A
  • HOB elevated → chair position → EOB → Bedside Chair
  • 3 step process that evaluates a patient’s mobility to perform sit to stand x3, march in place x3, and step forward and back. Patients must successfully complete all three steps to ambulate independently.
65
Q

What are 2 specific ICU Outcome Measures?

A
  • Functional Status Score for ICU Patients (FSS-ICU)

- Physical Function in Intensive Care Test (PFIT)

66
Q

FSS-ICU:

  • 5 item performance based measure (0-35). What are the 5 items?
  • MCD = ___-___ points
  • MCID at ICU admission = ___ points
  • Excellent inter-rater and intra-rater reliability, internal consistency.
  • Predictive validity: For each 1pt increase at ICU discharge, LOS decreased by 0.27 days and odds of discharge home increased by 11%.
A
  • rolling, supine → sit, EOB sitting, sit → stand, walking
  • MCD = 2-5 points
  • MCID = 3 points
67
Q

PFIT:

  • What are the 3 things looked at with PFIT?
  • Qualitative metrics not as well studied (Strong predictive validity comparing PFIT score on awakening and discharge home rates).
A

-sit to stand assistance, marching cadence, quadricep strength

68
Q

General Tips for Mobilizing Patients in NS/STICU:

  • Do not be intimidated by moderately low RASS scores (RASS -2 to -3: May be able to improve arousal levels by simply sitting up!)
  • Do not be intimidated by multiple restraints
  • Recruit your village (Co-treating with PT, OT, RT, RN, CNA)
  • Be confident in your role
  • ASK QUESTIONS!!
A

1

69
Q

What are the (7) indications for activity cessation?

A
  • Increased lethargy/change in mental status
  • Change in neurological status
  • Elevated ICP
  • Line/Tube/Drain malfunctions
  • Hemodynamic instability
  • Pulmonary instability
  • Acute pain, severe HA
70
Q

What are the 2 major things that must be done to get a patient off of mechanical ventilation? Describe each.

A

Spontaneous Awakening Trial (SAT)
-Done when a patient has been weaned off of medication and is not medically stable. The point is that they will not be safe for us to see how they can do breathing if they are not awake.

Spontaneous Breathing Trial (SBT)
-Start weaning settings of vent so the patient does more and more work. Usually done over the course of the day. Looking for ability to keep O2 up without too much work having to be done.

S6- Neuro 2 (18 decks)

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