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Care of Critically Ill Patients with Neurologic Problems
Chapter 47 Care of Critically Ill Patients with Neurologic Problems
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Transient Ischemic Attack (TIA) Reversible Ischemic Neurologic Deficit (RIND)
Warning signs that cause transient focal neurologic dysfunction resulting from: a brief interruption in cerebral blood flow, possibly resulting from cerebral vasospasm or systemic arterial hypertension
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Stroke Impact Statistics -from AHA May 2012
About 795,000 Americans each year suffer a new or recurrent stroke A stroke occurs every 40 seconds Stroke kills more than 150,000 people a year It's the No th cause of death in the US--every 4 minutes someone dies of stroke About 40 percent of stroke deaths occur in males, and 60 percent in females
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Stroke Ischemic Hemorrhagic
The brain is unable to store oxygen or glucose and must receive a constant flow of blood to function Stroke represents a change in the normal blood supply to the brain: Ischemic—interruption in blood flow to the brain Hemorrhagic—bleeding within or around the brain Ischemic Hemorrhagic thrombotic embolic aneurysm AVM HTN
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Types of Strokes Ischemic stroke (most common)
a) Thrombotic stroke (clot) gradual occlusion - slow onset b) Embolic stroke (dislodged clot often from heart)- rapid onset Hemorrhagic stroke resulting from: ruptured aneurysm, arteriovenous malformation, or severe hypertension
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Assessment/Clinical Manifestations
Cognitive changes include: aphasia, alexia (inability to read), agraphia (inability to write) Motor changes include: hemiplegia, hemiparesis, hypotonia, flaccid paralysis, hypertonia. Agnosia (inability to recognize or interpret objects, people, sounds, smell), apraxia (impaired sequencing of movements) Sensory changes include: unilateral neglect syndrome, ptosis, retinal ischemia causing a brief episode of blindness, hemianopsia Psychosocial- emotional lability - unsteady or subject to quick change
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Non Surgical Management
Monitor for changes in LOC Thrombolytic therapy (clot buster) Endovascular therapy
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Fibrinolytic Therapy IV (systemic) thrombolytic therapy.
Retavase (rtPA) only drug approved for treatment of acute ischemic stroke Eligibility criteria: within hours of onset of stroke
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Endovascular Interventions
Intra-arterial thrombolysis using drug therapy and mechanical embolectomy (clot removal) 6 hour window from onset of symptoms Has advantage of a direct injection into thrombus
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Monitoring for Complications
Increased ICP (Greatest risk in first hrs from onset) Normal ICP is <15 FIRST sign is decrease in LOC -lethargy to coma ~behavior changes i.e: restless, irritable, confusion ~pupillary changes ~headache ~speech changes ~seizures ~nausea and vomiting ~abnormal posturing
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Cushings Triad
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Monitor for other complications
Hydrocephalus -may occur as a result of blood in the CSF. This prevents CSF from being reabsorbed. Vasospasms Rebleed or rupture (commonly seen in patient with aneurysm or AVM in 1-7 days)
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Drug Therapy Thrombolytic therapy
Anticoagulants (no longer best practice) ASA Antiepileptic drugs Calcium channel blockers Stool softeners Analgesics for pain Antianxiety drugs
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Other Non Surgical Interventions –
Carotid artery angioplasty with stenting (CAS)
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Management of Arteriovenous Malformations
Interventional therapy (most common) to occlude abnormal arteries or veins and prevent bleeding from the vascular lesion Gamma radiation to produce fibrous thickening of the endothelial lining to prevent further vessel enlargement
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AVM Treatment Embolization: Foam, plugs, coils, to occlude blood flow
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Management of Cerebral Aneurysms
Repair via craniotomy (clipped or clamped aneurysm to prevent blood from entering) Interventional radiology (no incision-coils to seal aneurysm) Most aneurysms resemble a balloon, with a narrow neck at its origin and a large expanding dome. Typically, a clip is placed across the neck of the aneurysm to prevent blood from entering the dome.
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Surgical Management Endarterectomy (remove atherosclerotic plaque for stroke prevention)~less common today Extracranial-intracranial bypass (craniotomy grafting arteries to re-establish blood flow)
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Management of Intracranial Bleeding
Craniotomy: to remove clots, and relieve intracranial pressure (ICP)
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Impaired Swallowing- Prevent aspiration
Interventions include: Assessment of patient’s ability to swallow. (Ask patient to swallow as you place fingers on each side of adams apple to note larynx movement) Patient positioning to facilitate the process of swallowing before feeding Appropriate diet for the patient, including semisoft foods and fluids Aspiration precautions
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Improving Mobility and Promoting Self-Care
Interventions include: Range-of-motion exercises for the involved extremities Change of patient’s position frequently Prevention of complications of immobility i.e pneumonia, atelectasis, and pressure ulcers Therapy focused on patient performance of ADLs
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Promote Effective Communication
Language or speech problems is usually the result of damage to the dominant hemisphere Dysarthria (slurred speech) Expressive aphasia, the result of damage in (Broca’s ) area of the frontal lobe Receptive (Wernicke’s or sensory) aphasia, due to injury in the temporoparietal area
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Promoting Continence Altered level of consciousness may cause incontinence or impaired innervation or an inability to communicate Develop a bladder and bowel training program
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Managing Sensory Perception
Interventions include: Right hemisphere damage typically causing difficulty in the performance of visual-perceptual, or spatial-perceptual tasks. Difficulty with: ADLs Ambulation Left hemispheric damage generally causing memory deficits and changes in the ability to carry out simple tasks *need reorientation
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Preventing Unilateral Neglect
This syndrome is most commonly seen with right cerebral stroke Teach patient to: Observe safety measures Touch and use both sides of the body Use scanning technique of turning the head from side to side to expand the visual field
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Traumatic Brain Injury
Head injury occurs as a result of : a) blow or jolt to the head, or b) as a result of penetration of the head by a foreign object such as a bullet Frontal and temporal lobes most frequently involved
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Primary Brain Injury- occurs at the time of injury- occurs from force within the tissue - open or closed Open head injury occurs when there is a skull fracture or when the skull is pierced by a penetrating object; the integrity of the brain and the dura is violated, and exposure to outside contaminants occurs Closed head injury is the result of blunt trauma; the integrity of the skull is not violated
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Open Head Injury- types of fractures
Linear fracture—simple clean break; the impacted area of bone bends inward, and the area around it bends outward Depressed fracture—bone is pressed inward into the brain tissue to at least the thickness of the skull
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Open Head Injury (Cont’d)
Comminuted fracture -involves fragmentation of the bone, with depression of bone into brain tissue Open fracture - scalp is lacerated, creating a direct opening to brain tissue
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Basilar Skull Fracture
Occurs at the base of the skull Usually extends into the anterior, middle, or posterior fossa and results in cerebrospinal fluid leakage from the nose or ears Potential for hemorrhage, damage to cranial nerves, and infection Battles sign
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Types of Closed Head Injuries
Mild concussion Diffuse axonal injury (high speed acceleration/deceleration i.e.: MVC Contusion (coup and contrecoup injury) Laceration of the brain
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Coup and Contrecoup Injury
Site of impact Opposite Site of impact
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Types of Force Injuries
Acceleration injury is caused by an external force contacting the head, suddenly placing the head in motion Deceleration injury occurs when the moving head is suddenly stopped or hits a stationary object These forces may result in shearing, straining and distortion of brain tissue > hemorrhage around blood vessels in the brain
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Acceleration-Deceleration Injury
Acceleration injury is caused by an external force contacting the head, suddenly placing the head in motion Deceleration injury occurs when the moving head is suddenly stopped or hits a stationary object
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Secondary Brain Injury-any process that occurs after the initial injury, that worsens the outcome
Most common responses are hypotension, hypoxia, ischemia, and cerebral edema Increased ICP-leading cause of death from head trauma 3 types of Hemorrhage: -Epidural -Subdural -Intracerebral Keep CPP >70 (MAP-ICP)
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Epidural Hematoma Neurologic emergency with potentially catastrophic ICP elevation Arterial bleeding into space between the dura and inner table of skull Temporal bone fractures, middle meningeal artery Momentary unconsciousness follows lucid interval within minutes of injury
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Epidural Hematoma (Cont’d)
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Subdural Hematoma Venous bleeding into the space beneath dura and above arachnoid Most commonly from a tearing of the bridging veins within the cerebral hemispheres, or from a laceration of brain tissue Bleeding occurs more slowly, and symptoms mirror those of epidural hematoma Highest Mortality
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Hemodynamic instability
Complications Hydrocephalus Brain herniation Medical Emergency nonreactive pupils Hemodynamic instability
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Physical Assessment/Clinical Manifestations
ABCs Assessment of vital signs to prevent and detect increased ICP- Late classic sign= Cushings Triad -HTN, bradycardia, widened pulse pressure Pupillary changes Motor Responses a. decebrate b. decorticate c. ataxia (loss of balance) d. nuchal rigidity
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Decorticate and Decerebrate Posturing
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Nonsurgical Management
Preventing and Detecting ICP Pulmonary ventilation and management of oxygen and carbon dioxide levels Suctioning Chest physiotherapy and frequent turning (watch ICP response) Positioning r/t ICP and CPP
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Brain Death Criteria Glasgow coma scale 3 Apnea No pupilary response
No cough and gag reflex No corneal reflex No oculocephalic reflex (dolls eyes) No oculovestibular reflex (ice water)
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Drug Therapy Glucocorticoids Mannitol, furosemide Opioids, naloxone
Neuromuscular blocking agents Antiepileptic drugs Acetaminophen and aspirin Barbiturate coma
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Surgical Management ICP monitoring devices:
Intraventricular catheter (IVC) Subarachnoid screw or bolt Epidural /subdural catheter Fiberoptic transducer catheter Craniotomy may be performed in extreme instances of elevated ICP
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Brain Tumors – account for <2% of all cancer deaths ~21,000 annual diagnosed ~2/3 of patients die from this disorder Brain tumors can arise anywhere within the brain structures: Primary tumors ~ originate within CNS –rarely metastize Secondary tumors ~ result from metastasis in other parts of the body glioblastoma
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Complications of Cerebral Tumors:
cerebral edema/brain tissue inflammation increased ICP neurologic deficits Hydrocephalus r/t obstruction of CSF flow pituitary dysfunction- SIADH/DI>severe fluid and electrolyte imbalance
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Classifications of Tumors
Tumors are classified as benign, malignant or metastatic Tumor’s location places it in a class of supratentorial or infratentorial r/t cerebral hemisphere Tumor’s cellular or anatomic origins ~2 types of cells, neurons, and neuroglial cells
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Types of Tumors Gliomas—malignant
Meningiomas—arise from the coverings of the brain- most common benign Pituitary tumors- adenoma most common Acoustic neuromas—arise from the sheath of Schwann cells – surrounds cranial nerves Metastatic or secondary tumors- spread from lung, breast, colon, pancreas, or kidney
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Brain Tumor Clinical Manifestations
Headaches (usually more severe upon awakening) Nausea and vomiting Visual Symptoms Seizures Changes in mentation or personality Chart page 1032
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Nonsurgical Management- goal is to decrease tumor size, improve quality of life, and survival time
Radiation therapy Chemotherapy Analgesics Dexamethasone (no effects on ICP) Phenytoin (Dilantin) Protonix – (Proton Pump Inhibitor) Stereotactic radiosurgery- accelerated xrays, implanted isotope seeds in the tumor
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Gamma Knife Selective radiation to not damage
surrounding healthy tissue
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Surgical Management Craniotomy more often used
Postoperative care—positioning, monitoring the dressing, monitoring laboratory values, ventilating the patient Drug therapy—antiepileptic drugs, proton pump inhibitors, histamine blockers, corticosteroids, analgesics, acetaminophen, prophylactic antibiotics
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Postoperative Complications
Increased ICP Hematomas/intracranial hemorrhage Hydrocephalus Respiratory problems Wound infection Meningitis Fluid and electrolyte imbalances
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Brain Abscess Organisms from the ear, sinus, or mastoid enters the brain traveling through the cerebral veins. They become lodged in the vessel and causes a localized infection. Streptococci is the most common organism Clinical picture-slow onset- headache, fever, and neuro deficits Treatment includes antibiotics, antiepileptic drugs, and surgical drain
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