Neurological Emergencies

Transcription

1 Neurological Emergencies Sabreena Stratton MSN, RN, CCRN, CEN Understand basic anatomy of the brain Complete a focused assessment of a brain injured patient Treatment modalities for various head injuries Learning Objectives CEN Exam 10% is Neuro 15 questions 1

2 Neuro Anatomy Cranium Meninges: surround and protect Dura (separates Cerebrum from Cerebellum) aka: Supratentorial Arachnoid Pia Brain 3 lbs 20% CO & 02 consumption Ventricles-interconnected cavities Central Nervous System Cerebrum Left and right hemispheres lobes Corpus callosum Cerebellum Brainstem Central Nervous System Cranial Nerves Not consciously controlled Cerebral Blood Flow CSF Circle of Willis Internal Carotid Arteries Vertebral Arteries Venous drains through sinuses in dura into jugular veins 7-10ml/hr Protector Transport system Spinal Cord Spinal Canal from Brain Stem to L-1 and L-2 Cranial Nerves I. Olfactory II. Optic III. Oculomotor IV. Trochlear V. Trigeminal VI. Abducens VII. Facial VIII. Acoustic IX. Glossopharyngeal X. Vagus XI. Spinal Accessory XII. Hypoglossal Unconscious? III, IV, VI: pupils; eye movement V, VII: corneal, grimace IX, X: cough, gag Central Nervous System 2

3 31 Spinal Nerves dermatomes Autonomic Nervous System Sympathetic Fight or flight Parasympathetic Conserve energy Peripheral Nervous System Neuro Assessment What is the most reliable indicator of neurologic function?? Level Of Consciousness 3

4 Alert Verbal Painful Stimulus Unresponsive u Oriented x4, awake, following commands u Responds to voice; not fully oriented u Responds to painful stimulus u Unresponsive AVPU Level of Consciousness Central vs. Peripheral Stimulation?? Herniation Uncal: lateral shift of brainà ipsilateral dilated pupil Supratentorial: brain pushing downwardà Pinpoint: parasympathetic Dilated: sympathetic Pupils What percentage of the population have a normal finding of unequal pupils?? 4

5 Monro-Kellie Doctrine EARLY LATE Headache Nausea/Vomiting Amnesia LOC Drowsiness Fixed, dilated pupil Unresponsive Posturing Hypertension Altered Respirations Intracranial Pressure EARLY LATE Headache Nausea/Vomiting Amnesia LOC Drowsiness Fixed, dilated pupil Unresponsive Posturing Hypertension Altered Respirations Intracranial Pressure 5

6 Cushing s Reflex: Hypertension, widening pulse pressure, decreased heart rate Treatment?? Vitals Heart rate Increased: ICP Decreased: ICP (terminal), neurogenic shock, autonomic dysreflexia Blood pressure Increased: ICP, autonomic dysreflexia Decreased: ICP (terminal), neurogenic shock Respirations (abnormal): brain stem compression Temperature Increased: hypothalamic injury, neurogenic shock Decreased: neurogenic shock SENSORY Neuro Assessment Headache N/V Lethargy Chills Photophobia Nuchal Rigidity Brudzinski s Reflex Kernig s Reflex Meningitis Inflammation of the meningeal layers surrounding the brain and spinal cord ² Viralà gradual onset, less acute. ² Enterovir, herpesvirus ² Increased Protein, normal lglucose, clear CSF, leukocytes ² Bacterialà acute onset, fatal in 50% ² ² Streptococcus, neisseria, haemophilus, group B and Listeria Higher protein>200, decreased glucose, pruluent, leukocytes 1,000-20,000 ² Fungalà immune-compromised individuals ² ² Aspergillus, Candida Low Leukocytes <500, low glucose, >200 protein Treatment CT head before Lumbar Puncture 6

7 Decreased CBFà deprived 02 and glucoseà cellular ischemiaà cerebral infarction v 500,000 Americans suffer stroke annually with 20% mortality rate the first year v 50% caused by thrombosis vs. emobolic v 80-85% are ischemic v Symptoms vary on affected brain and can occur slowly as blood flow gradually decreases Stroke TIA vs. RIND vs. CI Treatment ABC s Intubation Manage SBP>220 Identification of Stroke Type Thromboemobolicà tpa Hemorrhagicà Surgical intervention and ICP manageent Stroke Neuro Trauma 7

8 Protects brain from injury acting as a cushion Extensive vascular supply with poor vasoconstrictive properties Direct pressure, wound care, staples, tdap Scalp Lacerations Clinical presentation affected by: type of fracture area involved damage to underlying structures S/S Combative Racoon Eyes Battle s Sign Heotympanum CSF leak Skull Fractures Ø Bruising on the surface of the brain Ø Accelerationdeceleration injuries Ø S/S include: Ø N/V, LOC, Vision Changes, weakness, speech difficulty Ø Management: Ø Prservation of neuro function Ø Pain control Ø Adequate hydration Cerebral Contusions 8

9 u Bleeding b/w skull and dura mater u Middle Meningeal Artery involvement >50% mortality rate u 50% don t have skull fracture u Unconsciousà lucidityà uncon sciousness u Surgical intervention u Outcome is directly related to the neuro status prior to surgery (should try to maintain a low ICP) Epidural Hematoma Subdural Hematoma Bleeding into subdural space between the dura mater and arachnoid Occur more frequently than other intracranial injuries ACUTE disipation of energy rupturing bridging veins S/S: LOC, hemiparresis, fixed, dilated pupils Surgical intervention w/i 4 hours SUBACUTE 48hrs-2 weeks post injury S/S: progressive decline in LOC Brain compensates Surgical intervention with little or no lasting deficit CHRONIC 2weeks-months Difficult to ascertain cause Tolerate initally by elderly d/t atrophy Surgical intervention Burr holes Subdural drains IPH vs. IVH 9

10 Concussion Results from a direct blow to the head or from an acceleration or deceleration injury in which the brain collides with the inside of the skull Result of blunt trauma causing shearing and disruption of neuronal structures Severity depends on degree of injury and severity of damage from secondary injury Symptoms can resolve over several days or could be permanent posturing Early CT scans may be unremarkable Serial exams will show areas of edema and microvascular hemorrhage Diffuse Axonal Injury A patient who sustained traumatic brain injury in an MVC 1 hour prior to coming to ED by ambulance. He is combative, not opening his eyes, and groaning when his open ankle fracture is moved GCSà 8 What is the patients GCS? 10

11 A patient has survived a TBI and was discharged with a basilar skull fracture. He presents back to the ED from a rehab center with an elevated temperature. Although the POC is multifactorial, the most important aspect will center on identifying A. Deep vein thrombosis, a frequently neglected complication of immobility B. Meningitis, a potential complication of basilar skull fractures C. Hypothalamic dysfunction or storming a potentially lethal febrile syndrome after head trauma D. Foreign bodies still embedded in the skull base, a common source of infection Questions WHICH OF THE FOLLOWING BLOOD PRESSURE CHANGES IS ASSOCIATED WITH INCREASED INTRACRANIAL PRESSURE? A. Widening pulse pressure B. Decrease in systolic pressure C. Increase in diastolic pressure D. Declining mean arterial pressure Discharge teaching would be considered effective if the caregiver of a concussed patient A. Keeps the patient awake all night B. Withholds fluids for 12 hours when the patient is nauseated C. Seeks assistance when the patient develops lethargy D. Calls the emergency department when the patient is unable to remember 11

12 WHICH OF THE FOLLOWING STATEMENTS ABOUT SUBDURAL HEMORRHAGE IS TRUE? A. It results from a thrombosed artery B. It results from a tear in the middle meningeal artery C. It may initiate a rapid or slow onset of symptoms D. It occurs between the skull and the dura A patient who sustains a head injury has increased pressure on the left oculomotor nerve. Assessment of the left eye is most likely to reveal A. Conjunctival edema B. Ptosis of the eyelid C. Dilation of the pupil D. Ciliary spasm of the eyelid Bacterial Meningitis is most strongly suggested by a fever and? A. Confusion B. Slurred speech C. Nuchal Rigidity D. Lateral Nystagmus 12

13 Which of the following assessment findings are associated with a skull fracture and would indicate the need for further intervention? A. Rhinorrhea and headache or dizziness B. Decreasing level of consciousness and restlessness C. Early evidence of periorbital ecchymosis and photophobia D. Otorrhea, nausea and vomiting Chicarelli, M. (n.d.). This is your brain with a side of bacon: Concepts and treatment of brain trauma [Unpublished powerpoint slides]. Howard, P. K., & Steinmann, R. A. (Eds). (2010). Sheehy s emergency nursing principles and practice (6 th ed.). St Louis: Mosby/Elsevier. McReynolds, S. M. (n.d.). Neurological emergencies [Unpublished Powerpoint slides]. Urden. L. D., Stacy, K. M., & Lough, M. E Thelan s critical care nursing diagnosis and management (5 th ed.). St. Louis: Mosby/Elsevier. References 13