CC Neuro Trauma

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kbryant86
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278619
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CC Neuro Trauma
Updated:
2014-07-11 11:50:46
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CC Final exam
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CC Neuro Final exam
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  1. 5 levels of conciousness
    • alert
    • lethargic
    • obtunded
    • stuporous
    • comatose
  2. lethargic
    vs
    obtunded
    vs
    stuporous
    L= drowsy but verbal arousal/tactile stiumulation

    O= verbal AND tactile needed response but fall asleep again easily

    S= tactile stimulous needed for any response
  3. noxious stimulation techniques
    • sternal rub
    • supraorbital pressure
    • trapezius pinch
    • mandibular pinch

    these all illicit central stimulation
  4. 4 H's that need to be stabalized before we can conduct official neuro exam
    • HypoTN
    • Hypoxia
    • Hypoglycemia
    • Hypotrhermia
  5. Glascow Coma Scale
     and levels of brain injury
    • <8 = severe
    • 9-12 = moderate
    • 13-15 = mild
  6. periph strength scale review
    0-5
    • 0 no movement
    • 1 flicker or trace amount
    • 2 can move but not against gravity
    • 3 against gravity but not resistance
    • 4 weak, but can overcome gravity and mild resistance
    • 5 normal
  7. posturing
    decoticate= hands up, damage above brain stem

    decerebrate= worse, hands down, damage to brain stem
  8. 2nd best indicator of neuro trauma
    Pupil size, reaction, and equality
  9. dolls eye exam
    + finding is good, brain stem intact, eyes move opposite direction of head movement (continue to watch you)

    - finding is bad, brain death possible, eyes remained fixed and do not adjust when head is moved
  10. cushings triad
    vital sign assessment

    • Inc SBP
    • Dec HR
    • Dec RR

    these indicate INC ICP
  11. all drugs, sedation, bld sugar meds need to be COMPLETELY out of the system before we assess for Brain Death
  12. brain death assess:
    EEG
    vs
    Evoked potentials
    EEG= look at brain waves

    Evoke= give shocks to illicit response
  13. Transcranial doppler
    evaluation of verebral bld flow
  14. caloric test
    • ice h20 against tempanic membrane (ear)
    • watch eye response

    nl= eyes jerk toward side with h20

    abnl= no response OR single eye jerks on opposide side/direction
  15. apnea test
    • hyperO2
    • d/c vent and watch for 10 minutes
    • at 10, draw ABG's and reconnect vent
    • if no respers in to min AND pCO2 is >60, brain death indicated
  16. 3 things within the cranium and their %'s
    • brain 80%
    • CSF 10
    • blood 10
  17. normal ICP

    Tx threshold
    0-15 mmHg

    Tx threshold >20 mmHg
  18. Cerebral Perfusion Pressure
    O2 delevery to the brain

    • nl= 50-70, safe up to 150
    • MAP - ICP = CPP

    lower CPP is what we worry about
  19. bld flow dec by 50% following a TBI w/n the first 24 hours

    DO NOT compromise bld flow during this time
  20. autoregulation w/n the brain
    the cerebral bld vessels respond to changes with the cranium
  21. metabolic autoreg: CO2
    CO2 levels cx brain vessels to constrict/dilate which Inc or Dec ICP, affecting CPP

    Hypocapnea (d/t hypervent) cx's constriction -> cerebral ischemia

    Hypercapnea -> dilation -> Inc ICP

    goal is 35-45 CO2 and 100% O2
  22. Dec CO2
    vs
    Inc CO2 affects on cerebral vessels
    Small CO2 = Small vessels (constriction)

    Large CO2 = large vessels
  23. pressure autoreg:
    Inc BP -> vaso constrict (which is good if Inc ICP)

    Dec BP -> dilation (good for cerebral perfusion)
  24. 4 primary factors that affect cerebral perfusion
    • perfusion pressure
    • vascular resistance
    • O2 or glucose supply
    • metabolic demand
  25. how perfusion pressure affects CPP
    • BP
    • ICP
  26. how Vascular Resistance affects CPP
    • vasospasm
    • thrombosis
    • Cerebral edema
    • hypocapnea
  27. how O2 or glucose supply affects CPP
    • hypoxia
    • anemia
    • hypoglycemia
    • CO
  28. how metabloic demand affects CPP
    • fever
    • seizures
    • agitation
  29. Brain tissue oxygenation (PbtO2)

    nl
    how is balance maintained?
    nl= 20-35 mmHg

    • maintained by balancing:
    • CPP >50
    • ICP <20
  30. ICP should be monitored in severe TBI's with one of these two things
    • abnl CT
    • OR
    • nl CT with >2 risk factors

    vent caths are most accurate tool
  31. ventricular drains
    • gold std for ICP monitoring
    • invasive
    • difficult to place
    • draingage of CSF to Tx inc ICP
  32. subarachnoid screw
    • bolt placed in subarach
    • lower rate of infection
    • easier to place
    • CSF sampling ONLY
    • less accurate
  33. Epidural monitoring
    • low risk infect
    • easy place
    • NO csf access
    • low accuracy
  34. parenchymal monitoring
    • low infect
    • easy place
    • NO csf access
    • low accuracy, can drift d/t no recalibration option
  35. ABC ICP waveforms
    A.weful= large mountainous wavefore

    B.ad= prominant peaks and troughs

    C.ommon= small, frequent waves. What we want
  36. ICP waveforms tell us about brain compliance

    need to look at more than #'s and waveforms though
  37. 4 types of head injury forces
    • acceleration (hit by moving object)
    • deceleration (head is moving, falls)
    • rotational (car/sports injury's)
    • penetrating (gun)
  38. why is the CT the gold std for dx head injuries?
    Diffuse injuries do not show up on a CT but Focal injuries do.

    so we rule out focal with a CT
  39. primary head injuries
    1-3
    happen at the time of impact

    • diffuse (all over, not localized)
    • focal
    • intracranial hemorrhages
  40. types of diffuse Head Injury (HI)
    • concussion
    • Difues axonal Injury (DAI)
  41. concussion
    Sx
    Tx

    post-concussive syndrome
    • diffuse
    • mild, temporary, REVERSIBLE
    • Sx= brief LOC, N/V, mem loss, confusion, dizzy, photophobia
    • Tx= observation

    post-conc= small % of Sx persist for up to 1 yr, usually HA, mem loss
  42. Diffuse Axonal Injury (DAI)
    Sx
    Tx
    • severe, Permanent shearing of axons  :(
    • dx with CT
    • Sx= acute and prolonged coma, Cushings tirad, posturing, INC temp
    • Tx= medical managment, control ICP and maintain CPP
  43. Focal injuries
    • specific area of brain
    • Pupil and motor respnse for Sx

    pupil is on SAME SIDE as injury

    motor is on OPPOSITE SIDE of injury
  44. 2 types of focal injuries
    • contusion
    • skull fracture
  45. contusion
    • bruising and swelling
    • coup or contracoup r/t to location of injury and/or bounce back of brain
    • can be temporal or parietal

    damage to midbrain, HIGH risk for epidural hematoma b/c temporal bone easily fractured
  46. contusion:
    Sx
    Tx
    sx= contalateral motor and ipsilateral pupil changes, altered LOC

    Tx medical management
  47. skull fractures:
    linear
    depressed
    liner= non-displaced bone, minor

    depressed= compression of brain, dura, bone missing
  48. Basilar skull fractures
    3 classic signs:
    • raccoon's eyes = periorbital brusing
    • battle's sign = mastoid bruising behind ear
    • CSF leakage = usually via ear or nose (look for halo on gauze)
  49. intracranial hemorrhage types
    1-4
    • epidural
    • subdural
    • intracerebral
    • subarachnoid
  50. epidural hematoma

    Sx
    Tx
    • ARTERIAL bleed
    • (E is close to A)
    • b/w skull and Dura layer

    • Sx= dec LOC followed by lucid period, then coma. Pupil and motor changes
    • Tx= surgery. good prgonosis
  51. subdural hematoma

    Sx
    Tx
    • Venous Bld
    • (S is close to V)
    • b/t dura and arachnoid (below dura mater)

    • Sx= gradual dec LOC, acute, subacute, or chroni onset. motor and pupil changes
    • Tx= surgery. prognosis is 30-60% mortality r/t REbld risk
  52. intra cerebral hematoma

    sx
    tx
    • most often from stroke
    • bld collection w/n brain tissue

    • Sx= depends on location and size
    • Tx= medical, always control ICP and optomize CPP
  53. Subarachnoid hemat (SAH)

    Sx
    Dx
    Tx
    usually an Aneurysm

    Sx= Thundering HA (worst ever!), photophobia, dec LOC, N/V, nuchal rigidity

    Dx= CT, Lumbar Puncture (bld in CSF), angioplasty

    Tx= clip it off
  54. SAH complications
    • high risk 30-60yrs
    • high rik for arterial vasospasms (70% of all cases)
    • peaks around 5-14 days

    Sx= vision changes, hemiparesis, seizures, aphasia, dec LOC
  55. vasospasm Dx and Tx
    • Dx= Transcranial doppler
    • Tx= Ca blocker to prevent spasms
    • Double HH therapy
  56. HH therapy
    • HTN= induce HTN to keep vessels open with vasopressors
    •  =goal is >200 SBP

    • Hemodilution= dec bld viscosity with IV crystaloids and colloids
    •  = goal is Hct of 30%
  57. Secondary head injuries

    6 types of changes seen in 2nd injuries
    • progression of initial injury d/t cellular and toxic changes
    • what happens as a result of initial injury

    • hypoxia
    • hypercapnea
    • hypoTN
    • sustained HTN
    • cerebral edema (most common cx)
    • herniation
  58. cerebral edema
    peaks 3-5 days after injury
  59. herniation

    uncal
    vs
    central
    temporal lobe forced into tentorial notch (brain stem) which compresses brain stem

    • un=unilateral --> focal injury
    • central= Bilateral --> diffuse injury
  60. Uncal herniation Sx
    • fixed, blown pupil
    • comatose
    • loss of cranial nv and motor response
    • cushings triad
    • (-) dolls eyes
    • C-V collapse, death
  61. nsng: patient goals:
    control icp
    • ICP <20
    • stable of inproving neurons
  62. nsng: patient goals:
    Perfusion/O2 delivery:
    CPP
    SpO2
    PaO2
    PaCO2
    SBP
    MAP
    • CPP= 50-70, avoid <50
    • SO2= 100%
    • PO2= >100-150
    • cO2= 35-45
    • sbp= >90
    • MAP= >70-90
  63. ER phase
    • ABCD's
    • airway and protect spine
    • OG tube ONLY (NEVER INTER THE NOSE WITH A TBI)
    • ETT for GCS <9
  64. ER phase: circulation
    • goal is euvolemia and perfusion
    • labs values similar to perfusion/o2 delivery goals
    • Arterial lines are best for fluid and labs
    • Central Line for CVP (6-8)
  65. ER phase: Disability (D of ABCD)
    thorough neuro checks and brain CT scan w/n 15 minutes to give a good baseline
  66. what to do with ealy sx of herniation?
    give Mannitol rescure dose of 0.25-1.0 Gm/kg

    • Mannitol= osmotic diuretic (hypertonic)
    •  =raise tonicity of bld
    •  =pulls fluid into vasc space and out via kidney
  67. goal of therapeutic hypothermia
    • save the brain
    • dec metab and O2 demand
  68. nursing priorities:
    cx's of inc ICP to assess for
    1-7
    • fever** (Tx aggressivly, even if only 1 degree over)
    • hypoxemia
    • agitation
    • pain
    • shivering
    • vent asynchrony
    • seizures
  69. supportive nsng interventions:
    positioning
    space out care
    bld pressure control
    p= elevate HOB, head and neck alignment

    s= space out b/c everything we do to them will increase ICP

    bp= Tx HTN to avoid ICP
  70. supportive nsng interventions:
    normothermia
    vent manipulation
    pulmonary hygeine
    n= b/c fever inc metab and oO2 demand

    v= no PEEP >5, hyperO2 is OK

    • Pulm= Suct. only as needed and hyperO2
    •  =prophylact anti-bios w/ intubation
    •  =early trach to dec vent days
    •  =early extubate does NOT inc pneumonia
  71. supportive nsng interventions:
    fluid managment
    DVT proph
    seizure control
    nutrition support
    • f= giuded by CVP and or of indicates of fluid status
    •  =ASSESS for AHD imbalance

    D= SCD's, Heparin drip as proph

    s= anti-convulsants

    n= begin within 7 days
  72. Mannitol
    vs
    Hypertonic saline
  73. nsing priority: ICU phase:
    resistant ICP: 1st tier
    after we have tried other Tx

    • drain CSF via vent cath
    • osmotic therapy, but watch for dehydration
  74. nsing priority: ICU phase:
    resistant ICP: 2nd tier
    • sedation with high dose barbiturates
    • NO PROPOFOL in high dose or longer than 48hrs
    • Hypervent for more than 24 hrs b/c dec CO2 =vasocontriction
    • craniectomy
    • organ donotion
  75. complication of ADH imbalance
    • Diabetes Insipides
    • more urine out than bld level
    • inc Na in bld and dec u. gravity

    • SIAHD decreases UO
    • dec Na in bld and inc Na in urine
  76. DI Tx

    SIADH Tx
    D= hypotonic solutions, replace ADH with vbasopressin or DDAVP

    • S= fluid restriction
    • hypertonic fluids

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