Increased ICP /Traumatic Brain Injury - Lecture Notes | NURS 372, Study notes of Health sciences

Download Increased ICP /Traumatic Brain Injury - Lecture Notes | NURS 372 and more Study notes Health sciences in PDF only on Docsity! Increased ICP/Traumatic Brain Injury A. Increased ICP = increased BP & decreased HR B. Etiology a. Cerebral edema : swelling b. Concussion: quick stop of firing neurons c. Contusion: bruising d. Hematoma e. Hydrocephalus f. Tumor g. Cerebral hypertension = Increased ICP C. Mechanism of Injury a. Initial/primary impact – coup b. Secondary impact – contrecoup c. ALWAYS get Cerebral Edema D. Subdural hematoma a. Tear in bridging veins between the brain & the dura matter & arachnoid membrane i. Usually blood is reabsorbed b. Acute: 24-48 hours c. Subacute: 2 days to 3 weeks later d. Chronic: 2-3 weeks after i. Slow bleed but blood is not reabsorbed ii. WORRY ABOUT ANTICOAGULANTS E. Epidural hematoma a. Interruption of middle meningeal artery – loss of consciousness, awake, coma b. A lot faster – brief loss of consciousness & go into a coma F. Intracerebral hematoma a. Tissue bleeding >50-100ml G. Assessment a. Neurologic examination i. Mental status (cognitive functioning) 1. If any Person/Place/Thing/ect. are off, they are disoriented ii. LOC (Glasgow coma scale) iii. Pupils iv. Cranial nerve function v. Cerebellar function (balance/coordination) vi. Reflexes vii. Motor and sensory function b. Glasgow Coma Scale i. Eyes 1. Open simultaneously, verbal command, pain (sternal rub) 2. NOTHING TO DO WITH PUPILS 3. Unilateral dilated pupils a. Cranial nerve III compression (90% ipsilateral (same side) to hematoma) b. Damage is on the same side as non reactive eye 4. Bilateral dilated pupils a. Midbrain injury 5. Irregular pupils a. Orbital trauma 6. Conjugate gaze deviation a. Frontal lobe lesion 7. Small/pinpoint pupils a. Pontine injury, opiate administration ii. PAPILLEDEMA: SIGN OF INCREASED ICP (swollen optic disc) iii. Best motor 1. Obeys commands, localizes pain (swat at where pain is being inflicted), flexion – withdrawal (not with purpose), flexion – abnormal (decorticate – usually brain injury in the cortex – hands to heart), extension (cerebellum, brain stem), no response iv. Verbal response 1. Oriented & converses, disoriented & converses, inappropriate words, incomprehensible sounds, no response v. Total 3-15 (15 norm) vi. U =Untestable (unconscious) vii. Abnormal motor 1. Flexion – decorticate (injury in cortex) a. Hands pulled to chest/heart 2. Extension – decerebrate a. Hands extended away from chest c. Changes in breathing patterns i. Normal ii. Cheyne-stokes iii. Cheyne-stokes variant – bilateral hemispheric lesion or metabolic cause iv. Central neurogenic hyperventilation (popular) – brainstem, between lower midbrain & upper pons v. Apneustic – mid or lower pons vi. Ataxic - medulla d. Cranial Nerves i. I – olfactory (smell) ii. II- optic (visual acuity) b. Head in alignment with body when positioning - increases jugular venous damage c. Posture! R. Care a. Avoid increased intrathoracic & intra-abdominal pressure i. Avoid Valsalva/isometric exercise ii. Minimize sneezing, coughing, blowing nose iii. Stool softeners b. IV therapy – hypertonic saline to decrease cerebral edema c. Decrease cerebral edema i. Mannitol – osmotic diuretic (filtered needle) 1. S.E. dehydration a. CHECK SERUM OSMOLALITY – 260-300 (high=dehydrated) & output d. Controlled hyperventilation – blow off pCO2, constricts arterioles to decrease blood flow to cerebral i. Caution: severe hypocapnia----ischemia e. Control metabolic rate i. Maintain normothermia, prevent seizures (Depakote/Dilantin), control blood sugar, neuromuscular blockers (Norcuron), sedatives (Diprivan/Propofol) 1. If seizure – Ativan ii. Barbiturate Coma 1. Pentobarbital (IV drip or loading dose then q 6 h)– depresses CNS, CV, & resp. systems 2. Need mechanical ventilation and total physical care - EEG 3. Drug holidays f. Therapeutic hypothermia i. </= 36 degrees Celsius ii. Within 24 hours iii. Rebound hyperemia, cerebral edema during rewarming S. Complications a. Diabetes insipidus i. ADH decreased in production and secretion -----diuresis ii. Fluid replacement with IV hypotonic solutions 1. Vasopressin – DDAVP – decreased urine output iii. Affects hypothalamus 1. STOP MANNITOL 2. STOP DIURETICS b. Herniation & Ventricular Shift i. Herniation: brain tissue is moved – WORST COMPLICATION c. Brain death (want positive signs) i. Cushings triad – bradycardia, systolic pressure increase, irregular respirations ii. Oculocephalic Response: Doll’s Eyes – eyes don’t move when turn 1. Eyes move opposite direction of way the head is turning iii. Oculovestibular Response – water injected into ear canal – no eye response 1. Abnormal caloric iv. Corneal reflex – trigeminal (V) – 4x4 over eye – do they blink v. Cough & gag vi. Spontaneous respirations off the respirator T. Concussion a. Brief interruption of neuron transfers – can lose consciousness i. Grade 1: Transient confusion, no loss of consciousness, mental status abnormalities detected on exam resolve within 15 minutes ii. Grade 2: transient confusion, no loss of consciousness, S/Sx on exam last longer than 15 minutes iii. Grade 3: any loss of consciousness b. Retrograde amnesia from event (new info) c. S&S: increased ICP, incoordination (ataxia), photophobia, phonophobia d. Post concussion syndrome – headaches afterwards e. Chronic traumatic encephalopathy (CTE): progressive degenerative disease U. Skull Fractures a. Linear skull fracture i. Debride and irrigate wound if needed ii. Assess for infection b. Basilar skull fracture i. NEVER PUT ANYTHING INTO THE NOSE ii. Raccoons eyes iii. Battle sign – bleeding behind mastoid bone; bruise behind mirror iv. Otorrhea – ear – CS fluid leaking – clear yellow tinged v. Rhunorrhea – nose vi. Halo or ring sing vii. Minimize coughing, sneezing, valsalva maneuver, no nasal suctioning, no nasogastric tube, do not pack nose/ears if CSF leak c. Debrascile – something surgery d. CSF leak – cover w sterile, non-occlusive gauze i. W/ infection yellow/milky/smell ii. Culture e. Depressed i. Protective device ii. If >5mm then surgery iii. Acrylic cranioplasty within 24 hours Spinal Cord Injury: A. Mechanism a. Hyperflexion – coup i. Compression of spinal cord ii. Ruptured anterior ligament b. Hyperextension – contracoup i. Ruptured posterior ligaments ii. Forward dislocation c. Transection = worst! d. Compression fracture i. Compression of spinal cord ii. Fractured vertebrae e. Flexion-rotation i. Displacement of vertebrae B. Initial Priorities a. Airway (jaw thrust only) & spine immobilization b. Breathing & Oxygen c. Circulation and cardiovascular stability d. Logrolling – lift and turn pt as unit e. At bedside – track vital capacity – norm 15-20ml/kg C. S&S a. NG tube may be inserted to prevent aspiration b. Low venous return to the heart due to low muscle tone c. Cervical injury at or above C4: can/will respiratory arrest, need vent, track vital capacity (max exhale after max inhale) – 15-20 ml/kg = normal i. Make sure they have adequate breath d. Cervical injury below C4 level – go through diagram i. Diaphragmatic breathing if phrenic nerve functioning ii. Spinal cord edema and hemorrhage can cause respiratory insufficiency iii. Hypoventilation – high CO2 - INTUBATE iv. Paralysis of abdominal and intercostal muscles v. Pt cannot cough effectively – atelectasis/pneumonia e. Sensory i. C4: shoulders ii. C6: thumb iii. C7: middle finger iv. C8: little finger v. T4: nipples vi. T6: xiphoid M. Postural Hypotension a. Due to decreased venous return to heart upon sitting and standing – flaccid b. Elevate HOB 10’’ prior to OOB N. Weight Shifts a. Pressure releases – tilt chair backwards laterally, shift using arms b. DVT’s if not moving – warm enlarged calf i. Lovenox/compression boots O. Reflexes a. May see this as a return of function – but it is not b. Hyperactive, exaggerated responses, penile erections, spasms i. Spasms tx – baclofen, dantrium, zanaflex P. Spasticity a. Excessive muscular tone & exaggerated DTR b. Tx – heat, electrical stimulation, meds, surgery Q. Poikolothermia a. SNS interruption prevents peripheral temp sensations from reaching hypothalamus: decreases shivering/sweating b. Warm fluids/cooling blankets R. Dysreflexia a. When noctious stimuli happens – causes mass of sympathetic response b. Autonomic – lesions above T7 c. Noxious stimuli creates responses below lesion – vasoconstriction (cold/pale) - hypertension d. Baroreceptor stimulation - Reflex brady & vasodilation above lesion (flushed) – slowed HR i. High blood pressure – cause hemorrhagic stroke e. ELEVATE HOB STAT! - atropine S. Gastrointestinal System a. Cord injury above T5 – GI problems r/t hypomotility b. Cause paralytic ileus/gastric distention (NG tube) c. Metoclopramide (Reglan) used to treat delayed gastric emptying T. Bowel Management a. Upper motor – digital stim, Valsalva maneuver b. Low motor – dig stim, suppositories, enema U. Neurogenic Bladder a. Bladder retraining, intermittent catheterization, external catheter, indwelling b. May need to relax muscles or to contract bladder (oxybutynin) TIA/Stroke: A. Causes: a. Carotid plaque with anteriogenic emboli b. Artery blocked by embolus c. Penetrating artery disease d. Intracranial atherosclerosis e. Flow-reducing carotid stenosis f. Arterial fibrillation g. Valve disease h. Emboli i. Aortic arch plaque j. Cardiogenic emboli B. Types a. Ischemic – do not have decreased LOC within first 24 hours i. Thrombotic – from injury to a blood vessel wall and formation of blood clot 1. HTN and diabetes main causes b/c accelerate atherosclerosis ii. Embolic – traveling clot, remains conscious but may have headache* iii. Lacunar – from occlusion of a small penetrating artery with a cavity in the place of the infarcted brain tissue (basal ganglia, thalamus, internal capsule, or pons) b. Hemorrhagic i. Intracerebral – ruptured cerebral aneurysm, HTN cause ii. Subarachnoid C. Prehospital Assessment a. Face – cranial nerve VII b. Arm – drift down c. Speech - strange d. Time – death of brain cells D. Transient Ischemic Attack a. Temporary focal loss of function d/t ischemia secondary to microemboli b. S&S: onset considered time from when last seen symptom free*, typically last less than 1 hour w/o visual evidence of infarction c. Other causes: hypoglycemia – could mask this d. Tx within 60 minutes E. ABCD risk assessment a. Points if age (>60), have HTN (>140/90), unilateral weakness, speech disturbance without weakness, diabetes, duration b. >6: *% risk of stroke within 2 days c. <4: 1% risk of stroke within 2 days F. Primary assessment a. Hx of current illness, past medical illnesses, family hx G. Secondary Assessment a. LOC, motor function, cognition, cranial nerve function, sensation, DTRs, proprioception, cerebellar function, stroke scale i. NIHSS – stroke scale – LOC (alert-reflex), LOC questions (month, age), LOC commands (eyes open, grips), best gaze (horizontal), visual fields (no vision loss – hemianopsia), facial palsy (Symmetric, complete), motor (Arm/leg), limb ataxia (absent present), sensory, best language (normal-global aphasia - COGNITIVE), dysarthria (norm-slurred - MOTOR), extinction (no abnorm-visual,tactile, auditory, spatial) , palmer drift (close eyes & one arm falls) H. Time Frames a. Within 10 minutes to ED b. 15 minutes in ED – stroke specialist c. 25 minutes – CT scan (PET – viability and function of tissue) d. 45 minutes – results read e. MAX – 60 minutes I. Diagnostics a. CT scan (ischemic vs. hemorrhagic) b. MRI (detailed) c. Transcranial Doppler (stenosis) d. Digital Substraction Angiography (dye for occlusions, plaque, malformation) e. PET (active brain activity – functionality of tissue) f. Echo (MI) J. Prevention a. Risk factor control – HTN, A-fib, smoking, lipids b. Drug therapy – antiplatelet (ASA, Ticlid, Plavix, Persantine) i. Anticoagulation – Coumdin w/ a fib c. LDL control - <100 (<70 if greater risks) d. Surgical i. Carotid Endarterectomy (CEA) – clamp above and below plaque area, take off plaque 1. Vagal side effects ii. Transluminal angioplasty with stenting K. CEA Post-op care a. Cranial nerve assessment i. VII – facial ii. X – swallowing, gag reflex, phonate (ah) iii. XI – shrug iv. XII – tongue movement b. Horners Syndrome from sympathetic nerve fiber edema/damage – ipsilateral eyelid ptosis, pupillary constriction, lack of facial sweating c. Pupils, Glasgow Coma Scale d. Bleeding – neck swelling, VS changes, resp difficulties e. Watch for bradycardia f. Maintain BP!!! – don’t cause ischemia i. Preswallow screen – alert/awake, sit upright?, cough, control saliva, lick both lips, breathe freely, clear voice ii. Swallow screen – 1 tsp water with spoon, 2nd tsp with spoon, 3rd tsp with spoon, 3oz/90ml water with cup 1. Failure: choking, coughing, throat clearing, gurgly, leaking from mouth iii. Impaired swallowing & risk for aspiration 1. Assess swallow/gag reflex 2. Elevate HOB 45-90 degrees 3. Select food easy to swallow 4. Remove unnecessary items from tray/table to reduce spills 5. Perform mouth care prior to eating 6. During meal: flex head forward during & for 30 minutes following feed, place food on unaffected side, double swallow 7. Mouth care after eating iv. Impaired mobility & risk for falls 1. Spasticity noted within 48 hours 2. Balance training, transferring bed to chair – have chair on strong side 3. Walking with assistive devices v. Musculoskeletal system – trochanter roll at hip to prevent external rotation, hand cones to prevent contractures, arm support with slings preventing shoulder displacement, splints vi. Communication deficits – left hemisphere – language skills 1. Dysarthria – difficulty in muscle control of speech – only motor 2. Dysphasia – difficulty with comprehension or language use – fluent/non 3. Aphasia – total loss of comprehension and language use a. Expressive – Broca (use wrong words to describe an object), Receptive – Wernickes (they make sense, but cannot comprehend what is said to them), Global 4. Treat pt as adult, one idea at a time, talk slowly and clearly with normal volume and tone, simple words, allow pt time to speak, encourage gestures, writing, and drawing vii. Incontinence 1. Bladder retraining – catheterization avoided 2. Adequate fluid intake (800-1900) 3. Schedule toileting every 2 hours with bedpan, commode, or bathroom 4. Void with direct command 5. Keep continence record for 3 days S. Cerebral Aneurysm a. Sx: localized headache, N/V, nuchal rigidity (stiff neck), blurred/double vision, photophobia, cranial nerve/motor deficits, LOC b. Normovolemia – look at INO over time – keeping flow going through vessels c. Metabolites cause vasoconstriction d. Meds – Mannitol, Nimodipine – cc blocker – dilates vessels (up to 14 days- vasospasms e. Complications of SAH: rebleeding – first 24 hours highest risk, bp management i. Cerebral vasospasm – manage bp, oral nimodipine ii. Hydrocephalus – blood in CSF in ventricles – CSF doesn’t circulate from brain to spinal cord well f. Aneurysm coil T. Hemorrhagic stroke surgery a. Craniotomy b. ventriculostomy Neuromuscular Diseases: A. Multiple Sclerosis a. Demyelination of nerve fibers (progressive – affects younger patients) (females 15-50) b. Unknown etiology – immunization, genetics, environment c. Weakness/paralysis of limbs, trunk, head, lower extremity, numbness and tingling anywhere (ONE extremity), visual disturbances, hearing disturbances, depending on where neuron is interrupted that is where you will have symptoms i. Diplopia – double vision ii. Scanning speech – look for words on wall iii. Spasticity – lose control of opposite muscle d. Sensory, balance, visual, motor –“multiple” – weakness or sensations i. Numbness/tingling 1. Loss of temp sensation ii. Blurred vision iii. Vertigo/tinnitus iv. Loss of hearing v. Chronic neuropathic pain 1. Barber’s syndrome – sharp intermittent shooting pain down spine with forward flexion of the head (electrical tingling) vi. Bladder dysfunction e. Cerebellar: dizziness, vertigo, loss of balance (falls/devices), dysphagia f. Emotional: anger, depression, euphoria g. EARLY: loss of myelin sheaths – no nerve damage/loss of function h. LATE: loss of myelin sheaths, nerve damage, loss of function, loss of eye sight, spasticity i. Meds: i. steroids to slow inflammation down, at preventive stage – prednisone (inflammation) ii. Immnomodulators (makes symptoms less when they do occur and less frequently) 1. Betaseron – prevents reoccurances/limit severity iii. Immunosupressants are if the immunomodulators are working 1. Novantrone (chemo – heavy duty) iv. Cholinergics – urecholine v. Anticholinergics – Ditropan vi. Muschle relaxants (spasticity) - Valium j. Incontinence – spastic or flaccid bladder – different types of meds to help with that i. Self catheterization k. Mobility is issue – need assistive devices – adapted clothes l. Surgical i. Neurectomy ii. Rhizotomy iii. Cordotomy iv. Dorsal column electrical stimulation – short circuit & use implant v. Intrathecal baclofen pump – spinal infusion for pain vi. PT m. PREGNANCY??? n. Death by complications B. Myasthenia Gravis a. Autoimmune disease of the neuromuscular junction (face & upper extremities) b. Antibodies destroy Ach receptor – no effective nerve impulse transmission (tumors in thymus gland) c. Facial-droopy, sleepy, ptosis. Large percentage with ocular involvement, diplopia, difficulty from eyelids drooping down, moves down to airway as far as fatigue – trouble swallowing (worry about choking – dysphagia) i. No sensory loss ii. Reflexes are normal d. Myasthenia crisis: acute exacerbation: infection, surgery, emotional distress, OD e. Exacerbations i. Antibiotics (gent, strept, tobr), beta blockers, procainamide, Dilantin, psychotropics (valium/Ativan) f. Complications: aspiration, respiratory insufficiency, respiratory infection