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Neuro 2 > Neuro ICU > Flashcards

Neuro ICU Flashcards

1
Q

NSICU indications

A

CVA
Guillain-Barre Syndrome
Acquired TBI
Acquired SCI
Myasthenic Crisis
Seizures
Brain Tumors
Hydrocephalus
Multiple Sclerosis – less common
Parkinson’s Disease – less common
Amyotrophic Lateral Sclerosis – less common

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2
Q

STICU indications

A

TBI
SCI
polytrauma

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3
Q

neurosurgery
vs
neurology

A

NSGY: Consulted whenever diagnosis may warrant invasive interventions for the brain or spinal cord
Also with orthopedic injuries to SPINE
Neuro: Primary team when invasive interventions not warranted and/or when pt demo’ing significant fluctuations in neuro status

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4
Q

trauma vs ortho

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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5
Q

common precautions to check

A

OOB status
WB status
Bracing needs
spinal
cranial
seizure

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6
Q

seizure precautions

A

close monitoring, avoid rigorous activity

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7
Q

skin grafts can

A

range from no restrictions to no AROM to NWB

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8
Q

CBC lab values

A

Should be relatively stable, with some considerations for admitting diagnosis.

Ex: hemorrhage  decreased hgb/hct, increased platelets

If no further up/downtrend, usually okay to see

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9
Q

electrolyte panel lab values

A

Patients are very symptomatically sensitive to △s in Na after a neurological event
- Cognitive changes

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10
Q

kidney function lab values

A

BUN and Serum Creatinine generally stable unless relevant comorbidities present
If complications seen, tends to be more subacute/chronic stages of recovery

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11
Q

hypothyroid function lab values

A

Hypothyroidism: has been associated with signs of aortic or coronary atherosclerosis
Slowed cognitive function, ataxia, weakness, paresthesias, edema, bradycardia, CHF, HTN

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12
Q

hyperthyroid function lab values

A

Hyperthyroidism: associated with atrial fibrillation and cardioembolicstroke
Tremors, weakness/atrophy, tachycardia, arrhythmias, hypotension

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13
Q

acid base respiratory alkalosis lab values

A

Respiratory Alkalosis common sequelae of CVA (strokes)
Dizziness, paresthesias, chest pain, confusion, seizures

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14
Q

acid base respiratory acidosis lab values

A

Respiratory Acidosis common with prolonged ventilatory support and neuromuscular disease
Confusion, fatigue/somnolence, SOB

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15
Q

anti HTN
examples
AE

A

diuretics, ACEi BB, CC

hypotension!!!!
dizzy
lightheaded
fatigue
N&V

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16
Q

vasoconstrictors
examples
AE

A

midodrine

supine HTN!!!
HA
blurred vision
dizzy

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17
Q

seizure control or prophylaxis

examples
AE

A

Keppra

Agitation, aggressiveness, irritability, restlessness

Fatigue, apathy, depersonalization, depression

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18
Q

agitation
medications
AE

A

Precedex, Fentanyl, Propofol

Decreased arousal, drowsiness

Bradycardia vs tachycardia, hypotension vs hypertension, irregular heartbeat, edema

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19
Q

decreased arousal
meds
AE

A

amantadine

Blurred vision,nausea, loss of appetite, drowsiness,dizziness, lightheadedness

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20
Q

tone management
meds
AE

A

Baclofen, Dantrolene, Tizanidine

Hypotonia, weakness, drowswiness

21
Q

pain meds- narcotics
meds
AE

A

Hydrocodone, Hydromorphone, Codeine

Drowsiness, N&V, hypoxia

22
Q

RASS levels

+4
+3
+2
+1
0
-1
-2
-3
-4
-5

A

+4 combative
+3 very agitated
+2 agitated
+1 restlessness
0 alert & calm
-1 drowsy
-2 light sedation
-3 moderate sedation
-4 deep sedation
-5 unarousable

23
Q

common meds for agitation

A

Propofol – RASS = -4 or -5

Fentanyl - pause

Precedex – good to go

24
Q

What are some of the major considerations for initiation of mobility in the NS/STICU for patients with cardiovascular impairment?

A

CV complications common
CVAs are commonly preceded by:
Diagnosed/undiagnosed HTN
A-Fib

TBI storming can lead to sever cardiovascular compromise that can linger post episode

SCI spinal shock accompanied by changes in BP (hyper  hypo)

Always investigate need for HR/BP parameters prior to initiating mobility

25
Q

What are some of the major considerations for initiation of mobility in the NS/STICU for patients with pulmonary impairment?

A

**Pulmonary: Vent/O2 settings **
Check in with RT:
How much support is the ventilator providing? How is the patient responding to these settings?

Is the patient undergoing/is there a plan for a Spontaneous Breathing Trial? - SBT

If on supplementary O2, has weaning trials begun? If not, can trials start with PT?

We can, and absolutely should, mobilize patients on the vent!!

26
Q

What are some of the major considerations for initiation of mobility in the NS/STICU for patients with SCIs?

A

**Spine stability **– spinal precautions

Spinal Shock
Above T6
Vitals most important
Initially = ↑ ↑ BP  ↓ BP, HR, hypothermia, venous stasis
Resolves usually within 24 hours to days
Sacral/anal reflexes come back 1st

Autonomic Dysreflexia
s/s
pounding HA due to ↑ ↑ BP
goose bumps
sweating – above NLI
bradycardia
skin blotching
RR
SIT THEM UP
NEVER LIE DOWN
Check cath
Check clothing
Check skin
Initiate emergency response if not resolved within 10 min

27
Q

transcranial doppler for TBIs

paramaters - contra for mob

A

**Transcranial Doppler (TCD): Measures mean blood flow velocity of arteries in neck & brain
>100-120 cm/s (centimeters per second) generally contraindicative for mobility **

28
Q

What are some of the major considerations for initiation of mobility in the NS/STICU for patients with TBIs?

A

Autonomic Storming
PT typically deferred until storming subsides
Can be consulted for bed-level positioning management

Vasospasm
Delayed event after SAH, peak 7-9 days after bleed
Symptoms: Often asymptomatic, can show △ neurological or mental status
If unchecked  secondary aneurysms or hemorrhaging
**Transcranial Doppler (TCD): Measures mean blood flow velocity of arteries in neck & brain
>100-120 cm/s (centimeters per second) generally contraindicative for mobility **
Always consult with NSGY, varies patient to patient

29
Q

What are some of the major considerations for initiation of mobility in the NS/STICU for patients with CVA?

BP parameters as well

A

tPA
Ischemic or thrombotic CVAs
No OOB for 24 hours post administration

Typical Hemodynamic Parameters
Ischemic Event:
Permissive HTN – they could allow this to try to break through an ischemic block
BP <220/110
Hemorrhagic Event:
BP <150/90

30
Q

What are some of the major considerations for initiation of mobility in the NS/STICU for patients with seizure?

A

Mobility clearance: no active seizures in past 24 hours
May have more flexibility with small, focal seizures that are stable – check with Neurology team
cEEG: OK to mobilize with MD clearance – mobility limited to in-room activities due to restrictions for EEG wires

31
Q

What are some of the major considerations for initiation of mobility in the NS/STICU for patients with shunt placement?

A

Starting parameters of shunt relatively universal
Patients will have variety of response to shunt
May need further adjustment by NSGY to see further improvements

OK to mobilize after surgery – monitor CLOSELY for S&S of ↑ ICP and/or hydrocephalus and shunt dysfunction
Hydrocephalus signs: Cognitive changes, urinary incontinence, shuffled/magnetic gait pattern

32
Q

What are some of the major considerations for initiation of mobility in the NS/STICU for patients with GBS placement?

A

Medical Management
IVIg, Plasmapheresis
Lengthy administrations
Patients often exhausted after treatment
OKAY TO SEE, if tolerated, pending medical stability
Best to try to see first thing in AM or on days off

33
Q

contra indi of PT in ICU

A

New administration of a pressor agent or antiarrhythmic agent
Multiple pressors being administered
Change in ventilator setting to provide increased ventilator support
Non-secured airway
Active GI bleed (consult with MD)
Elevated ICP
Agitation requiring increased sedative administration in the last 30 minutes

34
Q

importance of ICP monitoring

normal ICP and abnormal

A

Increased pressure can compress brain tissue, decrease perfusion to brain tissues or possible herniation
**
Normal ICP = 5-10 mm Hg
Abnormal ICP + > 20 mm Hg**

35
Q

ICP monitoring intraventricular catheter
what
where
requires
used for

A

Most accurate monitoring method (Gold Standard), but can be difficult to place when emergent
Catheter inserted into lateral ventricle via ventriculostomy
Requires Neurosurgery/Neurology clearance for PT

Can be used to drain fluid out through the catheter
 Extraventricular Drain (EVD)

36
Q

ICP monitoring subdural bolt

what

A

**hard stop for PT

Immediate monitoring **
Screw inserted into subdural space
VERY easily dislodged with movement - mobility typically strictly contraindicated

37
Q

ICP monitoring implantable microtransducers
what
when is it used

A

Intraparenchymal most common
Least invasive
Very expensive, generally cannot be recalibrated once in situ  can be less accurate
Used in situations where EVD placement is unsuccessful or when CSF drainage not necessary
Generally not appropriate to mobilize until removed

38
Q

NSICU ICP monitoring device

A

EVD - extra ventricular drain

39
Q

EVD icp monitoring
what

A

Uses gravity-positioned drain to clear excess CSF from brain
Drain will be progressively raised, decreasing rate of draining, while patient is closely monitored for adverse symptoms
Once progressed to NSGY goal, clamp trials will start. If well tolerated, drain will be removed.

40
Q

EVD why clamp

A

Clamped versus unclamped drain
When unclamped, actively draining fluid
Patients cannot mobilize when drain is unclamped
When clamped, safe to mobilize and participate in full with close monitoring
Need NSGY clearance for clamping
Most common adverse S&S: decreased arousal, drowsiness, LOC

pt should first tolerate 30 mins of EVD clamped at rest prior to mobilization!!!!!

41
Q

What does the evidence say about early mobilization in the NSICU for individuals with a stroke?

A

improved QOL, motor function, walking and ADLs

42
Q

What does the evidence say about early mobilization in the NSICU for individuals with a EVDs?

A

Significant increase in mobility, decrease in hospital LOS and # of days requiring restraints, improved discharge disposition, decreased tracheostomy placement

43
Q

What does the evidence say about early mobilization in the NSICU for individuals with a TBI/ABI?

A

Moderate – Severe TBI: Limited research on early mobilization
Disorders of Consciousness: Significant improvement in CRS-R scores when implementation of verticalization protocols (tilt table, ERIGO) within 2 weeks of injury
better OMs
Additional benefits found with reduction of exercise-induced complications such as syncope or orthostasis

44
Q

What does the evidence say about early mobilization in the NSICU for individuals with a SCI?

A

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

45
Q

What does the evidence say about early mobilization in the NSICU for individuals with a vented?

A

Safe, effective, and feasible
Improve muscle strength, ability to wean from vent use, decrease hospital LOS, decreased 1 year mortality rate

PT can be extremely helpful during Spontaneous Awakening Trials (SATs) and Spontaneous Breathing Trials (SBT)
Command following and respiration sitting EOB&raquo_space;> Supine

46
Q

components of EGRESS test

A

Sit to Stand x 3
Marching x 3
Advancing step and return step of each foot
As soon as appropriate – ambulate!

47
Q

What is the function of the FSS-ICU, and what are its MCD and MCIDs?

A

Rolling, supine > sit, EOB sitting, sit > stand, walking
MCD: 2.0-5.0 points
MCID at ICU admission: 3 points

48
Q

What is the function of the PFIT?

A

Sit to stand assistance, marching cadence, quadriceps strength

Strong predictive validity comparing PFIT score on awakening and discharge home rates

49
Q

what to do if you see a lower RASS level

A

just try inc HOB

Neuro 2 (9 decks)

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