Class6_Thermoregulation_2024_StudentCopy(2) (1).pptx

Thermoregulation NRSG3301 C RY S TA L T R E I G E M N N P PRESENTATION CREATED BY C.TREIGE 2024 Concept(s) & Exemplar(s) Concept(s): Thermoregulation Exemplar(s): Malignant Hyperthermia Head Injuries...

Thermoregulation NRSG3301 C RY S TA L T R E I G E M N N P PRESENTATION CREATED BY C.TREIGE 2024 Concept(s) & Exemplar(s) Concept(s): Thermoregulation Exemplar(s): Malignant Hyperthermia Head Injuries This Photo by Unknown Author is licensed under CC BY-SA-NC PRESENTATION CREATED BY C.TREIGE 2024 Thermoregulation The body process that balances heat production and heat loss to maintain the body’s temperature (Gidden, 2021) ** As long as heat production & heat loss are properly balanced, body temp should remain constant. PRESENTATION CREATED BY C.TREIGE 2024 Key Terms Normothermia is the normal body temperature (ranges between 36.5C and 37.2C) Hypothermia is a body temperature below 36.2C Hyperpyrexia (exceptionally high fever) is an extremely high body temperature (above 41/41.5C) (Lewis, 2019) PRESENTATION CREATED BY C.TREIGE 2024 Key Terms Fever is a natural, adaptive response of the body, to physiological stress. An elevation in body temperature due to a change in the hypothetical set point (caused by inflammatory cytokines; hypothalamus is the “thermostat of the body”). Fever can be caused by a vast range of conditions, both infectious and non- infectious. This results in a controlled increase of the overall body temperature. This change in the set-point is mediated by the action of cellular messengers, known as pyrogens, on the hypothalamus. Pyrogens can either be endogenous (e.g.IL1, IL6, TNF ) or exogenous (e.g. bacterial/viral toxins). (Evolve, 2022) PRESENTATION CREATED BY C.TREIGE 2024 Key Terms This Photo by Unknown Author is licensed under CC BY-NC-ND Hyperthermia is a body temperature above 37.6 C (causes can be either drug induced, environmental, endocrine or neurogenic). It is caused by a failure of the body’s thermoregulatory (temperature control) apparatus - i.e. The body has an impaired ability to lose heat. Unlike fever, there is no involvement of the hypothalamus, and the hypothalamic set-point remains untouched. Hyperthermia can either be caused by excessive amounts of heat from the surroundings or due to an increase in the body’s internal heat production. For instance, hyperthermia could be caused by strenuous exercise in a hot environment or due to excess heat production in diseases such as pheochromocytoma (a rare form of tumor in the adrenal gland). In either case, the heat produced overruns the body’s heat-loss capacity and causes a sharp spike in temperature, which often leads to severe complications and serious organ damage (Evolve, 2022) PRESENTATION CREATED BY C.TREIGE 2024 Mechanism of Fever PRESENTATION CREATED BY C.TREIGE 2024 Hypothalamus PRESENTATION CREATED BY C.TREIGE 2024 Hyperthermia Causes Neurogenic – caused by damage to the hypothalamus Brain trauma Ischemic/hemorrhagic stroke Increased intracranial pressure Endocrine Thyroid storm (tachyarrhythmias *A.fib) Pheochromocytoma (severe hypertension) Adrenal crisis (hypotension, hyponatremia, hyperkalemia in Addison’s disease) PRESENTATION CREATED BY C.TREIGE 2024 Hyperthermia Environmental Exogenous warming – the outside temperature is high Endogenous warming – extreme sports *Usually a combination of both Drug-induced Hypersensitivity – classified by specific allergy type; inflammatory response to a drug; can occur with any drug esp. antibiotics Altered thermal regulation – anticholinergic agents which disturb hypothalamic function, sympathomimetics that disturb hypothalamic function, and increased muscle activity Idiosyncratic reactions – unpredictable, bizarre drug reactions that can occur irrespective of the dose of the drug given, (Malignant hyperthermia in response to general anesthesia) PRESENTATION CREATED BY C.TREIGE 2024 Hyperthermia Consequences Individuals will often display signs of neurological dysfunction Cognitive dysfunction Agitation Seizures Unsteadiness Disturbance of consciousness (lethargy to coma) (Lewis, 2023) PRESENTATION CREATED BY C.TREIGE 2024 Hyperthermia Interventions Remove excess clothing and blankets Provide external cool packs Provide a cooling blanket Hydrate with cool fluids (oral or intravenous) Administer antipyretic drug therapy This Photo by Unknown Author is licensed under CC BY-SA PRESENTATION CREATED BY C.TREIGE 2024 Exemplar: Malignant Hyperthermia Malignant hyperthermia (MH) is a rare, potentially fatal metabolic disease characterized by hyperthermia with rigidity of skeletal muscles that can affect genetically susceptible patients MH susceptibility has an inherited autosomal dominant pattern It is triggered by commonly administered anaesthetic drugs, particularly succinylcholine (Anectine), which is given during general anesthesia. The MH defect is hypermetabolism of skeletal muscle resulting from altered control of intracellular calcium, leading to muscle contracture, hyperthermia, hypoxemia, lactic acidosis, and hemodynamic and cardiac alterations that can result in cardiac arrest and death. (Giddens, 2019) PRESENTATION CREATED BY C.TREIGE 2024 Malignant Hyperthermia The first sign of MH is often severe masseter muscle rigidity (MMR) that occurs after the administration of succinylcholine and is noted by the anesthesiologist when trying to establish an airway. MMR should be considered an indication of MH, and treatment should be initiated immediately In classic MH, the initial signs are tachycardia, rapidly rising end-tidal C02, tachypnea and elevated body temperature (Riazi et al., 2018) Acidosis may be mild if the syndrome is recognized and treated promptly Rhabdomyolysis may appear several hours later Hyperkalemia, leading to cardiac arrhythmia and even arrest, is uncommon if the syndrome is detected and treated promptly but may develop with remarkable rapidity In survivors, normalization of edematous muscle and serum CK concentration occurs within ten to 15 days, but symptom resolution may take longer (Rosen PRESENTATION CREATED BY C.TREIGE 2024 Malignant Hyperthermia The diagnosis of MHS is established with in vitro muscle contracture testing by measuring the contracture responses of biopsied muscle samples to halothane and graded concentrations of caffeine. The diagnosis of MHS can also be established by identification of a pathogenic variant in CACNA1S, RYR1, or STAC3 on molecular genetic testing (Rosenberg et al., 2020) PRESENTATION CREATED BY C.TREIGE 2024 Malignant Hyperthermia Prevention of primary manifestations: Individuals with MHS should not be exposed to succinylcholine. Individuals undergoing general anesthetics that exceed 30 minutes in duration should have their temperature monitored using an electronic temperature probe. Individuals with MHS should carry proper identification as to their susceptibility (Rosenberg et al.,, 2020) ***Early diagnosis of an MH episode is essential*** Successful treatment of an acute episode of MH includes: discontinuation of potent inhalation agents and succinylcholine increase in minute ventilation to lower end-tidal CO2 administration of Dantrolene sodium intravenously cooling measures if body temperature is >38.5° C treatment of cardiac arrhythmias if needed (do not use calcium channel blockers as can cause fatal hyperkalemia if used with Dantrolene) monitoring blood gases, serum concentrations of electrolytes and CK, and coagulation profile treatment of metabolic abnormalities. PRESENTATION CREATED BY C.TREIGE 2024 HEAD INJURIES Any injury to the: Skull Scalp Brain PRESENTATION CREATED BY C.TREIGE 2024 Head Injury: Causes ◦ Motor vehicle accidents ◦ Falls ◦ Assaults ◦ Sports-related injuries ◦ Recreational accidents PRESENTATION CREATED BY C.TREIGE 2024 Head Trauma High potential for poor outcome Deaths occur at three points in time after injury: ◦ Immediately after the injury ◦ Within 2 hours after the injury ◦ 3 weeks after the injury This Photo by Unknown Author is licensed under CC BY-NC PRESENTATION CREATED BY C.TREIGE 2024 Head Trauma Scalp lacerations ◦ The most minor type of head trauma ◦ Scalp is highly vascular → profuse bleeding. ◦ Major complication is infection. ◦ After hemostasis is achieved and the wound is irrigated, scalp lacerations are typically closed with surgical staples under local anesthesia. Sutures may be preferred over staples for large, gaping wounds and to provide hemostasis for wounds with brisk bleeding (UTD, 2021) PRESENTATION CREATED BY C.TREIGE 2024 Skull Bones PRESENTATION CREATED BY C.TREIGE 2024 Skull Fractures Skull fracture. A skull fracture is a break in the skull bone. There are four major types of skull fractures, including the following: ◦ Linear skull fractures. This is the most common type of skull fracture. In a linear fracture, there is a break in the bone, but it does not move the bone. These patients may be observed in the hospital for a brief amount of time, and can usually resume normal activities in a few days. Usually, no interventions are necessary. ◦ Depressed skull fractures. This type of fracture may be seen with or without a cut in the scalp. In this fracture, part of the skull is actually sunken in from the trauma. This type of skull fracture may require surgical intervention, depending on the severity, to help correct the deformity. ◦ Diastatic skull fractures. These are fractures that occur along the suture lines in the skull. The sutures are the areas between the bones in the head that fuse when we are children. In this type of fracture, the normal suture lines are widened. These fractures are more often seen in newborns and older infants. ◦ Basilar skull fracture. This is the most serious type of skull fracture, and involves a break in the bone at the base of the skull. Patients with this type of fracture frequently have bruises around their eyes and a bruise behind their ear. They may also have clear fluid draining from their nose or ears due to a tear in part of the covering of the brain. These patients usually require close observation in the hospital. PRESENTATION CREATED BY C.TREIGE 2024 (John Hopkins, 2023) Skull Fractures PRESENTATION CREATED BY C.TREIGE 2024 BASILAR SKULL FRACTURE Anterior basilar skull fractures are associated with the “racoon eyes” sign, which refers to consequent bruising around the eyes. Additionally, these fractures can cause CSF to leak out through the ears or nose, resulting in the classic “halo” sign The Battle sign consists of a crescent-shaped bruise that appears behind one or both ears, just over the mastoid process. Battle sign and hemotympanum indicate a basil skull fracture May not show immediately DO NOT INSERT NG TUBE if suspected (Lewis, 2019) PRESENTATION CREATED BY C.TREIGE 2024 Basilar Skull Fracture Halo Sign PRESENTATION CREATED BY C.TREIGE 2024 Le Forte Fractures Le Fort fractures are fractures of the midface, which collectively involve separation of all or a portion of the midface from the skull base. In order to be separated from the skull base, the pterygoid plates of the sphenoid bone need to be involved as these connect the midface to the sphenoid bone dorsally. The Le Fort classification system attempts to distinguish according to the plane of injury (UTD, 2024) PRESENTATION CREATED BY C.TREIGE 2024 Le Forte Fractures PRESENTATION CREATED BY C.TREIGE 2024 Brain Anatomy PRESENTATION CREATED BY C.TREIGE 2024 Brain Anatomy Monro-Kellie doctrine, the contents of the cranium – which are the brain parenchyma, blood, and cerebrospinal fluid (CSF) – are constant/fixed (Amin-Hanjani & Smith, 2022) The brain parenchyma makes up 80% of that volume, the CSF makes up 10%, and the blood volume makes up 10% Any increase in the volume of one component necessitates a decrease of the other components through compensatory mechanisms, an increase in intracranial pressure (ICP), or both (Amin-Hanjani & Smith, 2022) The normal value for ICP is 5-15 mmHg; a value above 20 mmHg requires prompt recognition and treatment (Benson, Carr, Cutsforth-Gregory, Johnson & Madhavan, 2022) Major causes of increased intracranial pressure include intracranial mass, cerebral edema, increased CSF production, decreased CSF absorption, obstructive hydrocephalus, obstruction of venous outflow, and idiopathic intracranial hypertension (pseudo tumor cerebri) (Amin-Hanjani & Smith, 2022) PRESENTATION CREATED BY C.TREIGE 2024 Cushing’s Triad Refers to a set of signs that are indicative of increased intracranial pressure (ICP) Consists of bradycardia (also known as a low heart rate), irregular respirations, and a widened pulse pressure. A widened pulse pressure occurs when there is a large difference between the systolic BP, (the BP when the heart is contracting) and the diastolic BP (the blood pressure when the heart is relaxing). When ICP >MAP brain can no longer receive enough oxygen (MAP = mean arterial pressure= [2(DBP)+SBP]/3 (normal 70-100mmhg) ***Cushing’s triad is a medical emergency and medical attention is required. (AUSMED,2024) PRESENTATION CREATED BY C.TREIGE 2024 Traumatic Brain Injury Traumatic Brain Injury (TBI) is a disruption in the normal function of the brain that can be caused by a blow, bump or jolt to the head, the head suddenly and violently hitting an object or when an object pierces the skull and enters brain tissue. Observing one of the following clinical signs constitutes alteration in the normal brain function: Loss of or decreased consciousness Loss of memory for events before or after the event (amnesia) Focal neurological deficits such as muscle weakness, loss of vision, change in speech Alteration in mental state such as disorientation, slow thinking or difficulty concentrating Symptoms of a TBI can be mild, moderate, or severe, depending on the extent of damage to the brain. Mild cases may result in a brief change in mental state or consciousness. Severe cases may result in extended periods of unconsciousness, coma, or even death (AANS, 2023) PRESENTATION CREATED BY C.TREIGE 2024 Concussion A concussion is a form of a traumatic brain injury that happens when the brain is shaken within the skull. Concussion is also known as mild traumatic brain injury (mTBI) but it does not typically result in structural brain injury identified on diagnostic imaging such as CT or MRI scans. The term mild does not diminish the impacts that concussion can have on your health and activities of daily living (ADLs) While the majority of people recover within one month, in some cases symptoms resolve more slowly or may persist longer than expected. Prompt medical assessment and management can help diagnose concussions and ensure patients are provided with proper education and guidance as well as treatment as needed (Brain Injury Canada, 2023) PRESENTATION CREATED BY C.TREIGE 2024 Concussion Symptoms Headache/migraine Seizure Dizziness and balance problems Problems with smell/taste Foggy-feeling Nausea Difficulty remembering and focusing Fatigue Slower information processing Sleep disturbance Trouble thinking clearly or finding your words Vision changes Difficulty making decisions or plans Sensitivity to light or noise Behavioural changes like depression, anxiety, irritability, aggression, or impulsivity Ringing in the ears (Brain Injury Canada, 2023) PRESENTATION CREATED BY C.TREIGE 2024 Concussion Symptoms Post-concussive symptoms can be physical, cognitive, emotional or sleep-related. Physical symptoms the patient may describe include: headache, dizziness, nausea, feeling unsteady, feeling “dinged” or “stunned” or “dazed”, feeling like their “bell was rung”, seeing stars or other visual disturbances, tinnitus, double vision, simply “not feeling right”. Physical signs of concussion include: loss of consciousness or impaired consciousness, poor coordination, balance or gait difficulties, easy distractibility and poor concentration, slowness answering questions and following directions, vomiting, looking “glassy eyed”, photophobia, slurred speech, personality or behaviour changes (including inappropriate playing behaviour such as skating or running in the wrong direction) and significantly decreased performance or playing ability. Cognitive symptoms include: confusion, amnesia, disorientation, poor concentration, and memory disturbance. Emotional symptoms include: feeling of depression, being nervous or anxious, and moodiness/irritability. Sleep disturbance: drowsiness, insomnia PRESENTATION CREATED BY C.TREIGE 2024 Concussion Management See Document on Moodle Brain Injury Awareness NS: Concussion Management PRESENTATION CREATED BY C.TREIGE 2024 Post-Concussion Syndrome New symptoms may develop, or individuals may continue to be bothered by symptoms from the injury, such as: Change in ability to think, concentrate, or remember. Headaches or blurry vision. Change in sleep patterns, such as not being able to sleep or sleeping all the time. Change in personality such as becoming angry or anxious for no clear reason. Lack of interest in usual activities. Dizziness, light-headedness, or unsteadiness that makes standing or walking difficult. (BC Guidelines, 2023) PRESENTATION CREATED BY C.TREIGE 2024 Brain Layer Anatomy PRESENTATION CREATED BY C.TREIGE 2024 Head Injuries Intracranial hematoma (ICH). There are several types of ICH, or blood clots, in or around the brain. The different types are classified by their location in the brain. These can range from mild head injuries to quite serious and potentially life-threatening injuries. ◦ Epidural hematoma. Epidural hematomas occur when a blood clot forms underneath the skull, but on top of the dura, the tough covering that surrounds the brain. They usually come from a tear in an artery that runs just under the skull called the middle meningeal artery. Epidural hematomas are usually associated with a skull fracture. Headache, impaired consciousness within hours, sometimes with a lucid interval. Herniation typically causing contralateral hemiparesis and ipsilateral pupillary dilation. ◦ Subdural hematoma. Subdural hematomas occur when a blood clot forms underneath the skull and underneath the dura, but outside of the brain. These can form from a tear in the veins that go from the brain to the dura, or from a cut on the brain itself. They are sometimes, but not always, associated with a skull fracture. Clinical manifestations: acute neurologic dysfunction, which may be focal, nonfocal, or both. With small hematomas, normal function possible (John Hopkins, 2023) PRESENTATION CREATED BY C.TREIGE 2024 Head Injuries con’t Contusion or intracerebral hematoma. A contusion is a bruise to the brain itself. A contusion causes bleeding and swelling inside of the brain around the area where the head was struck. Contusions may occur with skull fractures or other blood clots such as a subdural or epidural hematoma. Bleeding that occurs inside the brain itself (also called intraparenchymal hemorrhage) can sometimes occur spontaneously. When trauma is not the cause, the most common causes are long-standing, high blood pressure in older adults, bleeding disorders in either children or adults, or the use of medications that cause blood thinning or certain illicit drugs (John Hopkins, 2023) PRESENTATION CREATED BY C.TREIGE 2024 Brain Herniation Bleeding or swelling in the brain can increase pressure within the skull. The pressure may force the brain sideways and downward in the skull through small openings in the relatively rigid sheets of tissue that separate the brain into compartments. The result is brain herniation. These dividers are extensions of the outer layer of tissue covering the brain (the dura mater.) Herniation compresses brain tissue and thus damages it (Merck, 2023) The Monro-Kellie doctrine or hypothesis states that the sum of volumes of brain, cerebrospinal fluid (CSF) and intracerebral blood is constant. An increase in one should cause a reciprocal decrease in either one or both of the remaining two (Merck, 2023) Signs of herniation may include: dilated pupils, headache, drowsiness, difficulty concentrating, high blood pressure or blood pressure that's too low, loss of reflexes or increased reflexes, seizures, shortness of breath or rapid breathing (Merck, 2023) PRESENTATION CREATED BY C.TREIGE 2024 Posturing in Brain Injury PRESENTATION CREATED BY C.TREIGE 2024 Subdural Hematoma Acute: This is the most dangerous type of subdural hematoma. Symptoms are severe and appear immediately after a head injury, often within minutes to hours. Pressure on the brain increases quickly as the blood pools. If not diagnosed and treated quickly, pt. may loose consciousness, become paralyzed or die. ( 6 hours but no focal deficits or motor posturing PRESENTATION CREATED BY C.TREIGE 2024 Diffuse Axonal Injury (DAI) PRESENTATION CREATED BY C.TREIGE 2024 Types of Brain Hemorrhage PRESENTATION CREATED BY C.TREIGE 2024 Subarachnoid Hemorrhage A subarachnoid hemorrhage means that there is bleeding in the space that surrounds the brain. Most often, it occurs when a weak area in a blood vessel (aneurysm) on the surface of the brain bursts and leaks. The blood then builds up around the brain and inside the skull increasing pressure on the brain. A subarachnoid hemorrhage may occur as a complication of a type of stroke called a hemorrhagic stroke, or bleeding inside the brain. This is different from an ischemic stroke, which is caused by a blood clot (UTD, 2024) PRESENTATION CREATED BY C.TREIGE 2024 Subarachnoid Hemorrhage Common symptoms of a Trouble speaking subarachnoid hemorrhage include: Drooping eyelid Loss of consciousness Confusion and trouble concentrating Double vision Sensitivity to light Nausea or vomiting Neck stiffness Severe headache — the worst Seizures headache pain you've ever had that feels different from other headaches (UTD, 2024) PRESENTATION CREATED BY C.TREIGE 2024 Diagnostic Studies and Collaborative Care CT scan ◦ Best diagnostic test to determine craniocerebral trauma MRI Transcranial Doppler studies Cervical spine x-ray Glasgow Coma Scale (GCS) KNOW! PRESENTATION CREATED BY C.TREIGE 2024 49 Glasgow Coma Scale PRESENTATION CREATED BY C.TREIGE 2024 Lifespan Considerations PRESENTATION CREATED BY C.TREIGE 2024 Diagnostic Studies and Collaborative Care (Cont.) Treatment principles ◦ Prevent secondary injury ◦ Timely diagnosis ◦ Surgery if necessary ◦ Craniotomy - A craniotomy is the temporary removal of bone during another procedure. The bone is replaced before the surgery is complete. ◦ Craniectomy - A craniectomy is the removal of bone, commonly in an emergency situation. The bone is not immediately replaced ◦ Cranioplasty - The surgical repair of skull fractures or deformities. These fractures and deformities can happen as the result of a neurosurgical operation that required access to the brain, a traumatic accident, or a birth defect ◦ Burr-hole approach - Burr holes are small holes (the size of a dime) that a neurosurgeon makes in the skull. Burr holes can be used to relieve pressure on the brain when fluid, such as blood, builds up and starts to compress brain tissue. A layer of thin tissues called meninges surround and help protect the brain PRESENTATION CREATED BY C.TREIGE 2024 52 Burr Holes PRESENTATION CREATED BY C.TREIGE 2024 Nursing Management Nursing assessment ◦ Glasgow Coma Scale score ◦ Neurological status ◦ Presence of CSF leak PRESENTATION CREATED BY C.TREIGE 2024 54 Questions This Photo by Unknown Author is licensed under CC BY PRESENTATION CREATED BY C.TREIGE 2024