Shocks/Seizures/Strokes/TBI

Question 1

Septic Shock

Answer 1

Distributive shock caused by widespread bacterial infection (Massive vasodilation, Loss of vessel tone)
= Persistent HYPOtension*** despite fluid resuscitation (massive vasodilation)
= High RR
= ARDs (SIRS casacade&raquo_space; MODS)

Question 2

Bacterial meningitis

• Sxs in adults / kids / neonates?

Answer 2

Inflammation of meninges caused by N.meningitis/Strep pneumoniae = increased ICP

DROPLET PRECAUTIONS
** SEIZURE**

ADULTS = Neck stiffness, (+) Brudzinski, (+) Kernig
KIDS = Rash, Neck stiffness
NEONATES = Poor feeding/suck, Bulging fontanelles

Dx via Lumbar puncture for CSF (Cloudy, high pressure @ puncture)
= Low serum glucose
= High WBC + serum protein

Question 3

Anaphylaxis

Answer 3

Distributive shock response to allergen (Massive vasodilation, Loss of vessel tone)
= HYPOtension
= N/V
= Flushed, warm, dry
= Pruritus + Edema (wheezing)**

1st LINE tx: Adrenergics (epinephrine IM; q5min x3 dose)

2. Antihistamines
3. Leukotriene antagonists
4. Glucocorticoids (stabilizes mast cells)
   * *can mask infection**
5. Xolair (decreases IgE)
6. Immunotherapy
7. Support ABCs (ex. Ventolin nebulizers for bronchodilation)

Question 4

Distributive Shock

Answer 4

MASSIVE peripheral vasodilation, loss of muscle tone (Anaphylaxis, Septic)

= High HR (but low in neurogenic shock)
= High JVP
= Warm peripheries

Question 5

What is Neurogenic shock?

Answer 5

Caused by traumatic SCI or any Nerve injury
= Hypotension (Distributive Sxs - Massive vasodilation)
= Bradycardia**
= Hypothermia (initially warm/flushed, but then cold/clammy)

Question 6

Hypovolemic Shock

Answer 6

Reduced blood volume (hemorrhage, dehydration)

= Low CO / BP / JVP
= Tachycardic
= Change in MS, Cold peripheries

Tx: increase BV in ECF
1. Colloid IV
2. Crystalloid IV
3. Whole blood; PRBCs

Question 7

Cardiogenic Shock

What is the tx focus?

Answer 7

Unable to pump effectively (MI, trauma)
adequate blood volume
= Low CO / BP
= High JVP + Tachypnea
= Cold peripheries

Tx focus is to OPTIMIZE CO via:

= DECREASE WORKLOAD/BV via Diuretics
= VASODILATE via Direct Acting Vasodilators + Nitroglycerine
= BETTER CONTRACTILITY via P-inhibitors + Catecholamines

Question 8

What is an intra-aortic balloon pump used for?

Answer 8

CARDIOGENIC SHOCK = increases CO and blood flow
(Inflates during diastole; deflates @systole)

Question 9

What are obstructive shocks?

Tx?

Answer 9

When there is mechanical obstruction to blood flow through central circulation.
(cardiac tamponade, tension pneumothorax, PE)
= low CO, BP
= High RR?

Question 10

Ischemic Stroke

Answer 10

No BF to brain caused by thrombus (Atherosclerosis) or Embolus (CAD/Angina - dislodges in brain)

Warning sign via “TIA”
= Undetected
= Lasts minutes to hours
= Resolves in 24 hrs w/ full functional recovery

Sxs = “BE FAST”
Pronator drift

Dx = CT scan w/o contrast to rule out hemorrhage (contraind.) and be able to tx with Thrombolytics

Question 11

What is a special consideration for non-TPA pts undergoing Ischemic stroke?

What should the nurse do?

Answer 11

Permissive HTN b/c it can hyperperfuse the brain

Monitor BP
= Titrate CBB to correct extreme HTN > 220/120
= maintain SBP > 170 mmHg to persevere brain fx

Question 12

Thrombolytic therapy
- Contraindications?

Answer 12

For Ischemic stroke
= Must be initiated < 4 hrs of Sx onset!!!

DO NOT GIVE TO Pts with:
- Hemorrhage/Active bleed
- Low platelets or HIGH INR/PT
- Uncontrollable HTN (> 185/110)
- Recent brain/spinal surgery

Question 13

Concussion

Answer 13

A mild blow to the head = dizziness, headache, amnesia

= resolves fast

Question 14

Contusion

Answer 14

Bruising to the brain tissue
= Focal Sxs

Question 15

Diffuse Axonal Injury (DAI)

Answer 15

TBI via MVA = shearing of white matter
= Diffuse brain swelling (cerebral edema)
= COMA

Question 16

Skull Fractures

Answer 16

Linear (along sutures), Depressed, Comminuted (fragments)

Battle sign + Raccoon eyes

If FRONTAL FRACTURE = check for CSF LEAKAGE***

Question 17

Hematomas
- Types x 3

Answer 17

Closed TBI with blood buildup beneath skull

**Will increase ICP = monitor for altered LOC + Headache + N/V)

EPIDURAL = between skull + dura mater (arterial bleed)
SUBDURAL = dura + arachnoid (venous bleed)
INTRA-CEREBRAL = within tissues

Question 18

Nursing interventions for TBI

Answer 18

1. Stabilize neck + cervical spine
2. GCS scoring (If < 8 = intubate)
3. Monitor for ICP (headache, N/V, altered LOC)
4. Maintain normothermia (temp)
5. Check for CSF leakage!!

Question 19

Cerebral Edema

Answer 19

Excess fluid in brain due to increased CSF production/blocked drainage/impaired resorption

= Cushing’s Triad (HTN - wide PP, Bradycardia, Bradypnea)
= Increased ICP (Decorticate/Decerebrate + Hyperthermia)
= Fixed pupil dilation (uni/bilateral)&raquo_space; BRAIN STEM HERNIATION

Question 20

Brain stem herniation (signs?)

Answer 20

Bilateral fixed pupil dilation!!!
EMERGENCY
Can be caused by cerebral edema

Question 21

Epilepsy

Answer 21

Chronic recurrent seizures that last <5 min each

Question 22

Status Epilepticus

Answer 22

EMERGENCY

Recurrent seizures that LASTS > 5 MIN + CONTINUOUS/NO RECOVERY PERIOD

Question 23

Tonic-Clonic seizure (Grand mal)

Answer 23

Generalized seizure (both hemi)

“Pre-seizure aura” = blurred vision, tinnitus, nausea
= Sudden contraction + jerking mvts in limbs
= Muscle rigidity, Incontinence
= LOC + Postictal

Question 24

Absence Seizure (petit mal)

Answer 24

Generalized seizure (both hemi) - usually CHILDREN

= Brief staring episodes
= Automatisms (lip smack, finger rolling)
= NO Postictal

Question 25

Myoclonic Seizure

Answer 25

Generalized seizure (both hemi) = Jerking movements in limbs = No LOC or Postictal

Question 26

Atonic/Akinetic Seizure

Answer 26

Generalized seizure (both hemi) DROP ATTACK = sudden loss of all muscle control

Question 27

Simple Partial Seizure

Answer 27

Focal/Partial seizure (one hemi) = Awareness during seizure = No postical = Involuntary motor (head turn) = Sensory disturbance (smell/taste)

Question 28

Complex Partial Seizure

Answer 28

Focal/Partial seizure (one hemi) = Altered LOC = Automatisms = Postictal phase

Question 29

What is the Postictal phase in seizures?

Answer 29

Drowsiness, slowed speech, confusion

Question 30

Febrile Seizure

Answer 30

Seizures only caused by high fever in children ages 6 m to age 5 (temp > 38) *Benign = no chronic damage SIMPLE = once in 24 hrs, lasts < 10 min = Brief postictal phase COMPLEX = Multiple times in 24 hrs, lasts >10 min = just give ANTIPYRETICS (no Ibuprofen for kids < 6 m.) NO TEPID SPONGING (cold water baths)!!

Question 31

Signs of high ICP?

Answer 31

Altered LOC, Vomit, Headache

Question 32

Hydrocephalus - Kids vs Infants? - Tx?

Answer 32

Increased ICP in brain = N/V, Altered LOC, Headache Kids = Cushing's triad (HTN, Bradycardia, Bradypnea) Infants = High-pitched shrill cry = Poor feeding = Bulging anterior fontanelle + wide suture gap (rapid increase in head circumference) = Sunset eyes Kids = Cushing's triad (HTN, Bradycardia, Bradypnea) Tx = VP shunts (into pericardium) - lay flat for first 24 hrs, then side

Question 33

Dantrolene & Baclofen

Answer 33

Muscle relaxant - MS, Cerebral Palsy, Stroke, SCI (Spasticity) Dantrolene = for Neuroleptic malignant syndrome = s/e of Hepatotoxicity

Question 34

Ethosuximide

Answer 34

Succinimides (Anticonvulsants) - block Ca from entering thalamus/decreases NM excitability = Absence seizures = Do not d/c rapidly or else causes seizure

Question 35

Phenytoin, Fosphenytoin, Carbamazepine*, Valproic acid

Answer 35

Hydantoins (Anticonvulsant) - blocks Na channels to induce calming effect on neurons PhenyTOIN & Fosphenytoin (prodrug) = TERATOGENICITY, lowers effectiveness of oral contraceptives = Lethargy, Ataxia, Nystagmus/Diplopia, Purple Glove Syndrome = Need to monitor blood work = Need for folic acid supplements (Phenytoin-like) - Valproic acid - Carbamazepine (also for trigeminal neuralgia; Risk of Hyperpyrexia, HTN)

Question 36

Thiamine IV

Answer 36

For chronic ETOH abuse (Wernicke's Encephalopathy)

Question 37

Autonomic dysreflexia

Answer 37

SCI T6 and above (noxious "pain" stimuli from either distended bladder / fecal impaction / constrictive clothing) = Severe HTN = Bradycardia = Throbbing headache (vasodilation) = Nausea (vasodilation) = Diaphoretic (vasodilation)

Question 38

What to monitor for post-Craniotomy pts?

Answer 38

= Turn onto non-operated side. = Polyuria (damage to hypothalamus/pituitary gland) = Assess site drainage/dressing for HALO SIGN **Pain = give SA opioids so it doesn't get confused with complications coming from the craniotomy

Question 39

Autonomic CVS instability

Answer 39

Gullain Barre Syndrome = Reflexive tachycardia + Orthostatic hypotension + Dysrhythmia

Question 40

Anticonvulsants - Indications - Nurse actions?

Answer 40

For seizures Monitor for: = Toxicity (Nausea/Ataxia/Lethargy/Nystagmus) = Do not change dose rapidly!

Question 41

Phenobarbital - Antidote? Lorzepam, Diazepam*, Clonazepam

Answer 41

"-BARBITAL" = Barbituates (Anticonvulsants) - enhances GABA effects For status epilepticus High risk of toxicity when taken w/ Phenytoins, CNS depressants (lorazepam) = Activated Charcoal or NaHOC3 "-PAM" = Benzodiazepines (Anticonvulsants) - same MOA OD tx = Flumazenil Diazepam can also be for muscle spasms (muscle relaxant)

Question 42

Succinylcholine

Answer 42

Rapid + brief muscle relaxant given during SURGERY or INTUBATION = Must have ventilation support = Give sedative beforehand

Question 43

Benzotropine

Answer 43

Anticholinergic - Parkinson Disease's EXTRAPYRAMIDAL DISORDERS Take with food!!

Question 44

Carbidopa/Levodopa

Answer 44

Dopamine Agonists - Parkinson Disease = Orthostatic hypotension, Harmless urine discoloration TOXICITY = Spasmodic winking, Muscle twitch

Question 45

SumaTRIPTAN

Answer 45

"-triptan" (Serotonin Agonist; Migraine) Contraind. in pts with Uncontrolled HTN + CAD because it constricts cranial BVs