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1 Anatomy Neurological Review TCHP CCRN Review Lynelle Scullard MSN RN CCRN K CNRN Bones Lobes Vascular Cranial nerves Bones Parietal Temporal occipital Frontal Sphenoid Ethmoid Lobes Frontal Willed mvmt, personality, mentation Parietal Sensation, emotion Occipital Vision Temporal Hearing, language, smell Cerebellum coordination Brain stem Vital life functions Vascular Cranial nerves Circle of Willis Supplies 2/3 of the cerebrum Posterior communicating Posterior cerebral Anterior communicating Vertebral arteries Anterior cerebral 1

2 Cranial nerves Cranial nerves II optic III oculomotor IV trochlear VI abducens IX glossopharyngeal X vagus XI spinal accessory XII hypoglossal The eyes have it! SWALLOW Cranial nerves Physiology Blood What s left? I O olfactory V trigeminal t touch VII facial Monroe Kellie Hypothesis Skull is an enclosed box Skull is not expandable Contents: 80% brain 10% CSF 10% blood Brain % 10 VIII acoustic Any change in one of three above will require compensation of the other 2. CSF Physiology Blood Physiology Blood Monroe Kellie Hypothesis Hemorrhage or mass compresses brain tissue, raises ICP Brain 60% clot 20% Monroe Kellie Hypothesis Ventriculostomy removes CSF, giving the brain more room without limiting bloodflow. Craniotomy performs same function Brain 80% clot 10% 9 % 1 CSF CSF 2

3 ICP/CPP Cerebral Perfusion Pressure (CPP) Intra Cranial Pressure (ICP) Normal 0 15 Tissue death >20 MAP ICP=CPP Normal is mmhg Decompensation and/or tissue ischemia occurs < 60 mmhg One # always effect the other 2 MAP 80 ICP 12= CPP 68 MAP 80 ICP 20= CPP 60 CPP Autoregulation is maintained w/ CPP <50, hypoperfusion and ischemia >160 vascular dilation and severe increase in pressure ICP/CPP Signs and symptoms Decreasing LOC Nausea/ projectile vomiting Cushing's triad Hypertension with widening pulse pressure Bradycardia Respirations abnormal ICP/CPP ICP rising Pupillary changes Posturing ICP/CPP Waveforms P1 P2 P3 3

4 ICP waveforms ICP waveforms SjO2 Jugular bulb saturation Brain receives 20% C.O. SjO % <55% cerebral oligemia >70% cerebral hyperemia TiPO2 Oxygen in brain tissue Measures immediate surrounding tissue only normal <20 ischemia <5 high probability of brain death ICP measuring devices Ventriculostomy Draining Ventriculostomy Combo drain/sensor Monitoring only Intraparenchymal Bolts Measures ICP Allows for drainage of CSF Measured in cm H2O Drain closed for accurate readings Infection risk Difficult to place in swollen brain 4

5 Ventriculostomy Leveled at the nasion or EAC (level to lateral ventricle) Combo Ventriculostomy and Intraparenchymal sensor Ventriculostomy provides drainage Intraparenchymal sensor gives continuous ICP reading Truly accurate when ICP off to drain Placed in the non-injured side. Intraparenchymal sensor Continuous ICP readings Easy to place Low infection risk No drainage of CSF Intracranial bolts Epidural Subdural Subarachnoid Not within brain tissue Less invasive Unable to drain CSF Not accurate with high ICP s Traumatic Brain Injury Blunt Coup contracoup Forces brain against skull Creates shearing forces and multiple bleeds 5

6 Penetrating Includes open skull fx Open Skull fx Facial fx Closed Bones intact Basilar Black eyes Battle signs Bruise behind ears CSF leak Focal injuries Epidural hematoma Subdural hematoma ICH/IVH NO TUBES IN NOSE! Epidural hematoma Epidural Typically arterial talk and drop Middle menningeal artery Hematoma elliptical Good outcome if crani early 6

7 Subdural hematoma SDH Usually venous Acute vs. chronic Usually requires crani Intracerebral hematoma Intraventricular hematoma Hematoma within cerebral tissue Clot remains and dissolves over time Non operative Poor outcome Diffuse injury DAI Diffuse Axonal Injury Shearing injury Coup contracoup with severe tearing of the axons. Gray matter denser than white, don t move together 7

8 DAI Damage to corpus collosum and reticular activating system Deep, immediate coma, often with negative CT (MRI) 3 H s Hypertension Hyperhydrosis Hyperthermia Management and Nursing Care A Airway Common problem for HI Secretions vs. function Management and Nursing Care B Breathing Tachypnea from hyperventilation to decrease CO2.. Lessen cerebral edema Apnea with impending brain death Or anything in between PaO2<60 poorer outcome, w/ hypotension 75% mortality rate CO2 ~35 Management and Nursing Care C Circulation MAP and CPP Normovolemia Mannitol, serum osmo <310 Hypertonic saline Pressors, vasodilators HOB up, midline Management and Nursing Care D Drain CSF Ventriculostomy Management and Nursing Care E Environment Stimulation control Sedation Spreading out nursing functions Family 8

9 Management and Nursing Care F Fever/metabolism Fever increases O2 consumption, lowers BP, raises HR, raises ICP. Brain temp up to 2 degrees higher than body temp. Extremely high caloric need Preferred temp 36 Non traumatic Brain Injury Ischemic Vascular hemorrhage Subarachnoid hemorrhage Ischemic Ischemic Plaque or clot 6 window to cell death TIA Transient ischemic attack Deficits last <24 hrs Diagnosis CT scan negative Based on symptoms and risk factors Treatment Anti hypertensives Supportive tpa tpa CT first to rule out hemorrhage Give within 3 hrs of onset of sx 6 hrs if given intra arterial per angio Rule outs for hemorrhage Get inserted what needs to be inserted 0.9 mg/kg (10% dose over 1 bolus Over 1 hour) Stroke monitoring posttpa VS and Neuro assessment Q15 x2h Q30 x6h Q1h x16h 9

10 Vascular hemorrhage Subarachnoid hemorrhage Hypertensive bleed Intraventricular Intracerebral SAH Bleeding into Subarachnoid space worst HA of my life Female 30 50y Aneurysm rupture On circle of Willis MCA Acomm Pcomm SAH Repair Clip Coil Crani? when SAH Management Vasospasms Nimodipine The 3 H s Hemodilution Hypervolemia Hypertension Arteriovenous malformation AVM Presents as CVA or SAH Crani or clip Secondary Brain Injury Systemic Intracranial Herniation Brain Death Usually avoidable! 10

11 Systemic Hypotension Hypoxia Anemia CO2 Hyperglycemia Hypotension and hypoxia are the most Powerful determinates of outcome. Intracranial Hi ICP Cerebral edema Mass effects Seizures Regional ischemia RN at the bedside Herniation Herniation Transtentorial /Uncal Central Wide pulse pressure with hi systolic Tachy Hi ICP Rapid resp Done when pt goes into automatic pilot Brain Death Absence of cranial reflexes Pupils Gag, cough Corneal Cold calorics Dolls eyes Other Neurological Insults Anoxia Infections Seizures Tumors 11

12 Anoxia Global tissue death from lack of O2 delivery Cardiac arrest Carbon monoxide poisoning Infectious Abscess Open head injury Sinus infection URI Poor outcome Infectious Meningitis Viral Rarely fatal Treatment is symptomatic Symptoms last 7-10 days Resp secretions Bacterial May be fatal Treatment is supportive Antibiotics a must! Break in dura, URI, strep Tumors Slow process slow neuro changes Often present with seizure. Spine Blunt Spinal injury 12

13 Penetrating Hyperextension Hyperflexion Axial rotational Spinal shock Temporary loss of sensation and/or function Neurogenic shock SNS unable to get signals thru injury, PNS takes over LOW BP, LOW HR Fluids prevent vasopressors 13

14 Management Immobilization Restore blood supply Steroids Spinal cord syndromes Anterior cord syndrome Often flexion injury Motor function lost Most sensation intact Spinal cord syndromes Central cord syndrome Hemorrhage and edema in central cord Weakness is much greater in upper extremities Spinal cord syndromes Brown Sequard syndrome Transection or lesion to half of spinal cord Paralysis on same side Loss of pain and temp sensation on opposite Complications Questions??? DVT/PE Autonomic dysreflexia T6 or higher Stimulus causes SNS to fire. HTN brady Full bladder, BM, stimulation to skin, pain 14

15 Practice questions 1. A patient has been restless during the night. Now there is a sudden increase in the patient s systolic pressure, a decrease in diastolic pressure, and a slowing of her pulse. What is this reflex called? a. Battle s sign b. Cushing s triad c. Kerning s sign d. Chvostek s sign 2. Nursing measures to maximize ICP include which of the following? 3. A patient is admitted with a spinal cord injury from a knife wound to the back. He exhibits ipsilateral paralysis, and contralateral loss of pain and temperature sensation below the level of the lesion. These findings describe which of the following? a. Turn the patient every hour b. Routine suctioning every hour c. Maintain head in neutral position d. Maintain PCO2 below 25 mmhg a. Complete cord injury b. Anterior cord syndrome c. Brown-Sequard syndrome d. Central cord syndrome 4. All of the following are symptoms of a basilar skull fracture but one. Which one is NOT? 5. A 28 y.o. Male is admitted to the intensive care unit with a diagnosis of closed head injury. The nurse should be aware of which potential complications? a. Rhinorrhea and otorrhea b. Battle s signs and raccoon eyes c. Tinnitus, nystagmus, and hearing difficulty d. Loss of conscious and dilated pupils a. Hypotension b. Respiratory alkalosis c. Tremors d. Cerebral edema 15

16 6. Cerebral perfusion pressure is calculated according to which of the following formulas? 7. This patients current vital signs are: BP 180/90, ICP 15, P 140, RR 20. What is this patient's CPP? a. MAP-ICP b. SPB-ICP c. ICP + cerebral blood flow d. MAP+ICP a. 90 b. 105 c. 120 d. cannot be calculated 8. A fixed and dilated pupil indicates compression of which cranial nerve? 9. Which is a common complication of a ruptured intracranial aneurysm? a. I b. II c. III d. IV a. Hypotension due to hypovolemia b. Cardiac dysrhythmias c. Acid-base disturbances d. Vasospasm of cerebral arteries 10. Which artery of the brain is responsible for anterior cerebral circulation? 11. An injury directly below the point of head trauma with a concomitant laceration at the opposite pole of impact is called a a. External carotid b. Internal carotid c. Basilar d. Vertebral A. diffuse axonal injury B. Coup contrecoup injury C. Hematoma D. Concussion 16

17 12. An 18yo patient is admitted to the ICU after sustaining closed head trauma. The critical care nurse observes otorrhea. Which nursing intervention is appropriate at this time? A. Apply pressure to the area B. Apply gentle suction C. Assess the drainage for the presence of glucose D. Pack the ear firmly with sterile dressings 13. The critical care nurse anticipates which of the following interventions for a patient within the first 24 hrs after a cerebral event caused by an embolus? A. Head of bed flat B. Anticoagulation therapy C. Out of bed in chair 1 hour 3 times a day D. Epidural catheter to monitor intracranial dynamics References Blackmore, A. Developing, Implementing, and Evaluating a Nurse Driven Rapid Reversal Protocol for Patients With Traumatic Intracerebral Hemorrhage in the Presence of Preinjury Warfarin; Journal of Trauma Nursing. 23(3): , May/June 2016 Han, J. Impact of Intracranial Pressure Monitoring on Prognosis of Patients With Severe Traumatic Brain Injury: A PRISMA Systematic Review and Meta Analysis; Medicine. 95(7):e2827, February Davis, C. Update: Stroke guidelines; Nursing Management. 47(2):24 33, February Walters, B. Guidelines for the Management of Acute Cervical Spine and Spinal Cord Injuries: 2013 Update; Neurosurgery. 60 (Supplement 1):82 91, August