1. Care of Critically Ill Patients with Neurologic Problems
Chapter 47
Care of Critically Ill Patients with Neurologic Problems

2. 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

3. 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

5. 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

6. 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

8. 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

9. Non Surgical Management
Monitor for changes in LOC
Thrombolytic therapy (clot buster)
Endovascular therapy

10. 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

11. 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

12. 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

13. Cushings Triad

14. 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)

15. Drug Therapy Thrombolytic therapy
Anticoagulants (no longer best practice) ASA
Antiepileptic drugs
Calcium channel blockers
Stool softeners
Analgesics for pain
Antianxiety drugs

16. Other Non Surgical Interventions –
Carotid artery angioplasty with stenting (CAS)

17. 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

18. AVM Treatment
Embolization:
Foam, plugs, coils, to occlude blood flow

19. 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.

20. Surgical Management
Endarterectomy (remove atherosclerotic plaque for stroke prevention)~less common today
Extracranial-intracranial bypass (craniotomy grafting arteries to re-establish blood flow)

21. Management of Intracranial Bleeding
Craniotomy:
to remove clots, and relieve intracranial pressure (ICP)

22. 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

23. 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

24. 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

25. Promoting Continence
Altered level of consciousness may cause incontinence or impaired innervation or an inability to communicate
Develop a bladder and bowel training program

26. 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

27. 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

28. 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

29. 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

30. 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

31. 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

32. 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

33. 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

34. Coup and Contrecoup Injury
Site of impact
Opposite
Site of impact

35. 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

36. 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

37. 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)

38. 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

39. Epidural Hematoma (Cont’d)

40. 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

41. Hemodynamic instability
Complications
Hydrocephalus
Brain herniation
Medical Emergency
nonreactive pupils
Hemodynamic instability

42. 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

43. Decorticate and Decerebrate Posturing

44. 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

45. 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)

46. Drug Therapy Glucocorticoids Mannitol, furosemide Opioids, naloxone
Neuromuscular blocking agents
Antiepileptic drugs
Acetaminophen and aspirin
Barbiturate coma

47. 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

48. 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

49. 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

50. 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

51. 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

52. Brain Tumor Clinical Manifestations
Headaches (usually more severe upon awakening)
Nausea and vomiting
Visual Symptoms
Seizures
Changes in mentation or personality
Chart page 1032

53. 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

54. Gamma Knife Selective radiation to not damage
surrounding healthy tissue

55. 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

56. Postoperative Complications
Increased ICP
Hematomas/intracranial hemorrhage
Hydrocephalus
Respiratory problems
Wound infection
Meningitis
Fluid and electrolyte imbalances

57. 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