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Clinical manifestations of Increased ICP
- Decreased LOC
- Pupillary changes....CN #3
- BP changes
- Pulse changes
- RR changes
- Increased temp
- Loss of motor fxn
How do pupils change with increased ICP?
- first occurs on ipsilateral side
- then constriction to dilation
- from sluggish to non reactive
- terminal.... is fixed bilateral pupils
BP changes with increased ICP
- initially systemic increase with widened pulse pressure
- as patient deteriorates BP will fail
Pulse and increased ICP
- increase with compensatory stage
- decreases and decompensating
- end becomes irregular and thready
Decorticate posturing....tells me what? Describe.
cerebral cortex isnt functioning, and diencephalon is in control
upper arms are tight to sides with elbows, wrists and fingers flexed...coming in to their core
Decerebrate posturing....tells me what? Describe.
only the brain stem is functioning
arms adducted and stiffly extended at the elbows with forearms pronated and wrists, hands and fingers flexed....to the outside
What are the feet doing with decerebrate and decorticate posturing?
they are extended
it is a late sign of ICP, due to interrupted blood flow
seen as blurred disc borders, distended veins, pulseless arteries
Changes I will see when a patient is starting to get in to trouble from increasing ICP
LOC-not patient needs more stimulation to display the same response
Motor- was a 5/5 and now is a 4/5
Pupils-they are now sluggish
BP, P, RR-no reliable changes
Changes I will see when a patient is in the late stages of increased ICP and it is not good.....
- LOC-not arrousable
- Motor signs-no response
- Pupils-one blown pupil, then both are fixed and dilated
- BP, P, RR-Cushings Triad
- Increased SBP
- Abnormal Respirations
What is the goal for measuring ICP?
keep it below 20
What does a Intraventricular catheter do? How?
directly measures ICP
it is placed in the right side of the brain, in to the right ventircle
Advantages and Disadvanges of Intraventricular catheter
advantage....accurate measurement of CSF
disadvantage....risk of infection
How do you monitor brain tissue oxygenation?
it's inserted in to ischemic brain tissue to directly measure brain tissue oxygen levels
What is a normal Licox monitor reading for oxygen?
First tier treatment for a person with increasing ICP
- Monitor ICP
- CT scan
- Maintain CPP at 70-100
In first tier therapy for a person with increased ICP how do I maintain CPP between 70-100?
- drain the ventricles
- osmotic therapy....minnitor
Second tier treatment for a person with increasing ICP
- Decompressive craniectomy
- High dose barbituates
- Aggressive hyperventilation
How do you position a person with increased ICP?
bed at 30 and head in neural position
How do you make sure the brain is being perfused with increased ICP?
- maintain fluid balance
- maintain SBP from 100-160
- maintain CPP >70
- reduce cerebral metabolism
How do you reduce cerebral metabolism?
- cool patient
- anti convulsants
What does hyperventilation do?
brief periods of hyperventilation may be useful in refractory intracranial hypertension
In a person with increased ICP, how do we prevent DVT's?
SCD's or TEDS....not Lovenox or Heparin.....bleeding problems???
2 nursing diagnoses for a person with increased ICP
ineffective cerebral tissue perfusion
ineffective airway clearance
Closed head injury
Open head injury
fracture with piercing of the skull
site of impact
brain bounces back and forth
gun shot wound
Primary head injury
stress within the brain from trauma
Secondary head injury
increase in ICP
Minor head injury vs. Major head injury....glasgow coma scale score and intervention
Minor 13-15, will observe and treat
Major <8, long critical care stay
What will I do to manage a person with head trauma
- #1 ABC
- cervical spine precautions
- monitor ICP
- max brain O2
- assess for other injuries
- seizure precautions
- monitor/manage temp
Linear skull fx
crack in the surface of the skull without bony displacement
Depressed skull fx
inward depression of bone fragments
Compound skull fx
depressed skull fx with laceration of the scalp, allowing for a communication pathway to intracranial cavity
bleeding with bony displacement of skull
will need surgery
Basilar skull fx
fracture at the base of the skull....this is complex cuz it is close to the brain stem
How do we treat linear, depressed and compound skull fx's?
- Monitor neuro status, LOC
- watch for signs if increased ICP
What will I see in a person with basilar skull fx?
change in HR, BP, RR....close to brain stem
- Raccoon eyes
- Otorrhea-leaking from ear
- Battle sign-blood by ears
How do I treat a person with a basilar skull fx?
- LAY PATIENT FLAT!!
- Manage HR, BP and RR
- Look at CSF if it is leaking for Halo sign
- Treat increased ICP
mild damage to the brain that affects gray matter....structural damage...minor head trauma
Patient presentation when they have a concussion
- brief loss of consciousness
- loss of reflexes
can have post concussion syndrome for up to 1 year or more
What do I monitor on a patient who has a concussion?
- neuro status
- signs of deterioration
- signs of increased ICP
- pupil changes
wake patient up q 2hours and ask them a question they need to think about to answer. Not something easy, like what is your name
Teach the family when a person has a concussion....
- stay with patient
- assess pupils and LOC
- check q2h
- take Tylenol....but not aspirin
- no sedatives
- no alcohol for 48 hrs
What a contusion? and how do I treat them?
a bruising of the brain, may be at the site (coup)or contra coup (opposite side) of the injury
- ABC management
- control bleeding
- watch for increase in ICP
Brain laceration and how do I treat them?
actual tearing of brain tissues....considered major head trauma
- can NOT repair surgically...prognosis is poor.
- Manage ABC's, control bleeding and watch ICP
If a person has a brain laceration, how will they present?
- loss of neuro fxn
- cerebral edema
- increased ICP
Diffuse Axonal Injury (DAI)....and how will I treat?
widespread axonal damage occurring after a brain injury...seen as little dots in CT scan. Major head trauma
usually been in a car accident
Manage ABC and watch ICP
What will a person with Diffuse Axonal Injury present to me like?
- decreased LOC
- increased ICP
secondary injury caused by vascular damage by shearing force of trauma
Epidural Hematoma vs. Subdural Hematoma
epidural....bleeding between the skull and dura matera
subdural.....venous bleeding in to the space beneath the dura and above the arachnoid from the tearing of bridging veins or a laceration of brain tissues
If a person has an arterial hematoma, they will....
pass out, come back around, then pass out again
Acute, sub acute and chronic subdural hematomas
- acute-happened within 48 hrs
- sub acute- 48 hrs to 2 weeks
- chronic-2 weeks to months
How will a person present that has an epidural/subdural hematoma?
- possible LOC decrease
- possible seizures
- symptoms of increased ICP
Which type of hematoma is a medical emergency requiring surgery?"
How do we manage a person with a hematoma?
- Manage ABC's
- control bleeding and watch ICP
If no problems....may observe and make sure not on anti coagulants
Intracerebral hematoma....and how do I manage?
bleeding within cerebral tissues
FOCUS on controlling ICP and bleeding...possible surgery
bleeding in to the subarachnoid spaced
caused by aneurysms
How much is a massive brain bleed?
loss of 30-50mL
What is a mycotic subarachnoid hematoma?
a microorganism wears at the wall of a vessel...making it weak and creating a tear, allowing for bleeding
How do we treat a subarachnoid hematoma/aneurysm?
- control bleeding
- watch ICP
- manage vasospasm
Describe H therapy after a clip has been done to a person who had an aneurysm?
- Hypertensives....bp needs to be higher to increase tissue perfusion
- Hypervolemic....give lots of fluids
S/S of a person has a vasospasm in the brain?
waxing and waining.....
What are aneurysm precautions for a person with an aneurysm, prior to surgery?
- dim lights
- limit visitors
- decrease stimulation
- elevate HOB
- avoid valsalva
- give sedatives/analgesics
Definition of brain death
irreversible cessation of all functions of the entire brain, including the brain stem
Criteria for clinical determination of brain death
- Clinical/neuro image of proof of dx -trauma/hemmorhage CT/MRI
- Exclusion of conditions that may confound clinical assessment of brain death (acute metabolic or endocrine problems....get normal labs)
- Confirmation of the absence of drug intoxication or poisoning
- Core body temp >32...must be warm
Cardinal findings in brain death
- absence of cerebral responsiveness
- absense of cerebral motor responses to pain in all extremeties
- absence of brain stem reflexes and apnea
Give examples of absence of brain stem reflexes
- no gag
- no cough
- no corneal reflex
- negative dolls eyes
- negative occulovestibular reflex
- wont be breathing above ventilator set rate
Confirmatory tests for the determination of brain death
- EEG....30 min. of nothing
- Transcranial doppler...dr. does
- somatosensory and brain stem auditory evoked
Misconception about brain death....
- it is no reversible
- time of death is determined and stated as the time they were determined brain dead
Who can consent to the donation of organs?
Spouse is the 1st....if no spouse, then adult kids
How do people with brain tumors feel in the am, and as the day goes on?
wake up with a headache, but feel better as they walk around because venous return is decreasing because of gravity
Fatal brin tumors?
all intercranial tumors, even benign ones are potentially fatal
- from local destruction and compression of brain tissues
- progressive increase in ICP can cause herniation
Life expectancy of a person with a glioma brain tumor
S/S of brain tumors
- change in mental status...tired, confused
What is the most important treatment for a person with a brain tumor?
early dx and treatment!!!
What do burr holes do?
meant for evacuation of extra cerebral clot or in prep for craniotomy
suck out clot
surgical opening of the skull to provide acfcess to the brain in order to remove a tumor, aneurysm or clot
portion of the skull is removed to relieve cerebral edema