acute Intracranial Problems Flashcards by Brendon Allen

3 types of non compressible contents in skull

Brain tissue
CSF
Blood

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Monro-kellie doctrine

The sum of volumes of brain, CSF and intracranial blood is constant

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Normal ICP
Increased ICP definition
Risk for what with increased ICP

Normal: 5-15
Increased icp: >20 mmHg for >5mins
Risk for herniation with increased ICP

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Primary vs secondary injury

Primary:
Blunt force

Secondary:
Swelling
Ischemia
Hypoxia
(Things that are caused by primary)

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Causes of increased ICP

Increased brain volume

Increased CSF

Increased cerebral blood volume

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What causes increased brain volume

Edema
Hypo osmolality
Increased capillary permeability

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What causes increased CSF

Hydrocephalus
Excess production of CSF

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What causes increased cerebral blood volume

Ineffective ventilation

Hypoxia

Hypercapnia (vasodilation) too much CO2

Hypocapnia (vasoconstriction too little CO2

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Normal CO2 range

35-45

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Early signs of increased ICP

Restlessness, agitation, change in behavior (sign of change in LOC)

HA (worst HA in your life)
Visual disturbances
N/V
Vitals change
Seizures

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Late sign of increased ICP

Significant change in LOC

Fixed, dilated or unequal pupils

(Cushings triad):
1.HTN w/ widening pulse pressure (systolic and diastolic get further
2. Brady cardia
3. Irregular breathing patterns (cheyne-stokes or agonal breathing)

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Clinical manifestations of increased ICP

Change in LOC (due to impared cerebral blood flow 🔽 O2)
-subtle symptoms (difficult to around, flat effect(their normal then no response), disoriented)
-severe coma:no response to pain, non pupil, gag or cough reflexes

Ocular signs:
Sluggish, non-reactive, difference in size
(ipsilateral dilation is a late sign): same side as injury

Motor:
🔽 in function
Hemiparesis or hemiplegia
Decorticate posturing
Decerebrate posturing

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Decerebrate vs decorticate

Decerebrate (away from core)
Damage to upper brain stem

Decorticate (to the core)
Damage to one or both corticospinal tracts

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Glasgow coma scale
Eyes
Best motor response
Best verbal response

Eyes:
4 spontaneous
3 to verbal command
2 to pain
1 no response

Best motor response
6 obey
5 localizes pain
4 flexion-withdrawl
3 decorticate
2 decerebrate
1 no response

Best verbal response
5 oriented and converses
4 disoriented and converses
3 inappropriate words
2 incomprehensible sounds
1 no response

Score 3-15

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Increased ICP complications

Inadequate cerebral perfusion:
CPP <60 (cerebral perfusion pressure
50=ischemia and neuro damage
30=ischemia uncompatible w/life

Cerbral herniation:
Through open skull fracture
Downward
Laterally

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increased ICP diagnostic test

CT: asap, check for bleed (no contrast)
MRI: tissue changes and ischemia
ABG: CO2 or hypoventilation
EEG: check for seizures
Cerebral angiography: blockages in brain
ICP measurement devices: measure pressures
Transcranial doppler: like a CT

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ICP labs

BMP: Na (may increase)
Coags

Test if you have SIADH or DI:
Urine specific gravity
Serum osmolality

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Management of ICP`
-figure out what
-nutirition
-meds for what
-support what
-normal valures

Figure out cause: infection, trauma

Nutrition: tube feed or parenteral

Med for ulcer prevention

Support VS:
Meds to control BP (want MAP 50-70)
Control temp
Ventilation:
-PO2 >80
-CO2 35-45
CO2 >45 (causes cerebral vessel to dilate increasing ICP)
CO2 <35 (vasoconstriction trouble getting O2 to tissue)

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ICP meds and fluids
-control metaboic demands with what meds

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ALL fluids in NS NO D5W!!!

Mannitol
Hypertonic saline (doesnt cross BBB & drawls fluid out)
Corticosteroids : with abscesses or tumors

Control metabolic demands:
-sedatives
-pain meds
-antipyretics
-seziure meds: pentobarbital coma if increased ICP refractory to other TX: must be on ventilator and in ICU
- 🔽 enviornmental stimuli

Mannitol
What it does
Dose
Se
Pt must have

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🔽 brain water content
Dose: 0.5-1g/kg over 15 mins

Se: HOTN, dehydration, electrolyte disturbances

Pt must have adequate intravascular volume prior to infusion:
UOP, BP, HR, quality of pulse, skin turger.

Mannitol nursing implications
Assess and labs
Use what to infuse

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Serum osmo 2 hrs after dose
BUN & creatinine
Neuro assessment Q1

Must use a filter to infuse (crystalizes)
Assess med prior to infusion for these crystals

Hypertonic saline
What it does (decreases what, increases what, prevents what)
Goal
How to administer and where
Assess what

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🔽 cerebral water content
Increases MAP & CPP
Prevents hypernatremia

Goal:
Serum Na 145-155
Serum osmo <320

Administer as continuous infusion or single bolus dose
Must administer via central line
Assess lungs and CXR (risk of pulmonary edema)

Nursing management
ABC
Neuro
Fluid and electrolytes
Seizure precautions

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ABC:
Pt awake enough to protect airway
Must have adequate BP (MAP) for perfusion

Neuro:
GCS
Pupil
Motor
Reflexes: corneal reflex, cough and gag

Fluid & electrolyte: SIADH and DI

Seizure precaution

Nursing actions to manage ICP

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HOB 30 degrees (venous drainage)
Head midline with body (C-collar check fit)
Pre-oxygenate prior to suctionng
Space nursing activities out
Avoid excess stimulation

TBI Traumatic brain injury Predictors of poor outcomes

GCS <8 Older Associated hematoma Posturing Hypoxemia Hypercapnia

TBI patho -what it is -words to classify it -skull fx types -risk of

Damage to scalp, skull meninges and brain Open or closed Acceleration-deceleration (coup contracoup) Skull fractuir: -Linear fx: assess CSF leak, halo test, raccoon eyes, battle signs -depressed fx: injury to skull and possible dura If dura torn: brain exposed to environment Risk for seizure

TBI Concussion Contusion

Concussion: Mechanical force to skill May lose consciousness Memory problems Long term effects later with repeated blows to head Contusion: Coup and contracoup injury Bleeding and bruising of brian

TBI Penetrating injury Scalp laceration

Penetrating injury: Low or high velocity force Scalp laceration: Clean, debride, assess for Fx Bleeding Avulsion (tendon or ligament come off bone)

Hematomas: Epidural Subdural Intracerebral

Epidural: Blood between skull and dura (associated wit artery, blood accumulates fast) Subdural: blood accumulates below dura and above arachnoid covering of brain (Venous bleeds slower) Intercerebral: Hematoma within the brain tissue

Diffuse axonal injury

Acceleration-deceleration mechanism Shearing of axons Cerebral edema: injury to cells/neurons Pt remains unconscious Lasting effects and requires pt/ot

Secondary brain injury

Related to initial trauma: Increased capaillary permeability Increased cerebral edema 🔽 perfusion Hypoxia Infection

Surgical interventions for ICP

Craniectomy: remove bone flap on affected side Evacuate hematoma May leave bone off and allow brain to swell Cranioplasty: replace bone later

Post of care for ICP

Assess ICP, VS, CSF leak mechanical ventilation if needed If EVD (external ventricular drain) monitor output

Nursing management: head injury

assessment like ICP Assess: ABC Neuro status Q1 GCS

Brain tumors types Primary Secondary Benign Malignant

Primary lesion: originates in brain Secondary: Metastasis: outside of brain comes to brain Benign: slower growing Malignant: faster more dangerous

Brain tumor CM

HA N/V Seixures Cognitive changes Weakness Aphasia (slurred speech)

Brain tumor diagnostic studies

CT MRI EEG History

Brain tumor tx Sx Procedures Other kinds How it is adminsitered

Sx: Craniotomy Burr hole: drill holes to release pressure Shunt: drain into ventricles of the brain allow us to move CSF elsewhere Radiation chemo -meds that cross BBB -Ommaya reservoir:intrathcal admin: *Can administrate chemo and abx into csf

Meningitis What it is Types and their types

Inflammation of meningeal tissue Bacterial: more deadly: -streptococcus pneuoniae -neisseria meningitis Viral: -HIV, HSV -abx given until confirmed then supportive, manage s/s

Bacterial meningitis and viral miningitis CM Similar ones

Fever Iritability Severe HA Nuchal rigidity Photophobia

Bacterial meningitis CM seperate

Tachycardia N/V Seizures Signs of elevated ICP Decreased LOC Petechial rash (Viral could have but theyll be milder)

Meningitis nuchal rigidity test

Brudzinski’s neck sign: Flex neck causes flex in hip&knee Kernigs sign: Hip flexed and plain when straightening leg out

Meningitis diagnostic test 1st then 2nd Do what before ABX What is expected in bacterial sample vs viral

1st: CT (see if it is safe to get it0 2nd: CSF via lumbar puncture only after CT scan (Prevent herniation if too much fluid off too fast) Culture before abx: Bacterial: sample csf: low glucose, high protein, WBCs (cloudy CSF) and culture will grow Viral: sample csf: Normal glucose, High protein, negative culture, less wbcs

Bacterial meningitis tx Meds Monitor Isolation

Meds: -ABX IV -Corticosteroids (drexomethazone) -Manage fever (because ⬆️ BMR = ⬆️ O2 demand) Anticonvulsants (prevent seizures) Monitor: F&E Neuro status Safety precautions: (pad rails, O2, suction, fall precautions) Isolation: Droplet

Viral meningitis tx

No isolation Start abx until dx confirmed, then DC Antiviral: herpes or influenza the cause Anticonvulsants Usually just let it run its course

Bacterial meningitis prevention

Vaccination Handwashing Abx for contacts if your not vaccinated

Viral meingitis prevention

Reduce direct contact Handwashing Enteroviruses spread in stools too

acute Intracranial Problems Flashcards

(47 cards)