Neurologic Emergencies PDF

Neurologic Emergencies Marichu Cazel A. Sara CMT, RN, MN Ast. Professor 1 Craniotomy What is this? A procedure to open the skull and expose the brain. Remember: You’ll only be responsible for patient’s care before surgery. Craniotomy Degree of Risks: Infection Hemorrhage Resp...

Neurologic Emergencies Marichu Cazel A. Sara CMT, RN, MN Ast. Professor 1 Craniotomy What is this? A procedure to open the skull and expose the brain. Remember: You’ll only be responsible for patient’s care before surgery. Craniotomy Degree of Risks: Infection Hemorrhage Respiratory compromise Increased ICP Craniotomy Nursing Considerations: Encourage patient and family to ask questions about the procedure. Explain that some patient’s head will be shaved before surgery. Patient may be transfered to ICU for close monitoring. Provide emotional support. Cerebral Aneurysm Repair Alternatively, coils may be inserted (percutaneously through the femoral artery) to occlude the aneurysm. This is to prevent rupture or rebleeding of cerebral aneurysm. COMMON DISORDERS ON NERVOUS SYSTEM TRAUMATIC BRAIN INJURY (TBI) Head trauma is categorized as: Blunt trauma (closed or open) - more common Penetrating trauma TRAUMATIC BRAIN INJURY (TBI) Penetrating Trauma: A foreign object in the scalp, skull, meninges or brain tissue exposes the cranial contents to the environment. TRAUMATIC BRAIN INJURY (TBI) Blunt Trauma: It typically a sudden acceleration or deceleration (or both) injury. Coup: the head hits an object injuring cranial tissues near the point of impact Countercoup: the force then pushes the brain against the opposite side of the skull, causing a second impact TRAUMATIC BRAIN INJURY (TBI) Diagnostic Tests: Head CT Scan/Cranial CT Scan - shows cranial fractures Cerebral Angiography - shows location of vascular disruption MRI - can assess axonal injuries Traumatic Brain Injury Supportive Care Measures: Close observation to detect neurologic changes Cleaning, debridement of wounds Diuretics (Mannitol/Hypertonic Saline) Analgesics Anticonvulsants Respiratory support for any patient with GCS score of 8 or less Traumatic Brain Injury Nursing Interventions: Be alert for rate changes or arrhythmias Maintain patent airway Avoid using NGT in any patient with potential midface trauma Check neurologic status including pupil size in every 15 minutes Maintain spinal immobilization until spine has been cleared Observe the patient closely for signs of hypoxia, hypotension, or increased ICP, such as headache, dizziness, irritability, anxiety, and such changes in be havior as agitation. Carefully monitor the patient for CSF leakage from the ears or nose. Traumatic Brain Injury Nursing Interventions: Elevate the head of the bed 30 degrees. Keep the nose and the navel in alignment. Position the patient to promote secretion drainage. If you detect CSF leakage from the nose, place a gauze pad under the nostrils. Don’t suction through the nose, but use the mouth. CSF leakage from the ear indicates the patient has a skull fracture and ruptured tympanic membrane. Increased Intracranial Pressure This refers to pressure produced by the contents within the skull. The skull contains three components: blood CSF brain tissue RANGE: 5-15 mmHg Increased Intracranial Pressure Causes: hemorrhage edema hydrocephalus space-occupying lesions infection metabolic disorders (hepatic encephalopathy) Increased Intracranial Pressure What to assess? Patient’s level of consciousness Pupils Motor responses Vital signs Increased Intracranial Pressure What to assess? EARLY SYMPTOMS: Headache Increased blood pressure Nausea and vomiting Motor changes on the side opposite to the lesion Change in LOS (restless, anxious, quiet, needs stimulation to be aroused) Increased Intracranial Pressure What to assess? FURTHER COMPROMISE: Hemiparesis Hemiplegia Increased Intracranial Pressure What to assess? SEVERE INCREASED ICP Absent doll’s eye reflex Bradycardia Systolic hypertension Widened pulse pressure Hyperthermia Pupils fixed and dilated Increased Intracranial Pressure Treatment: osmotic diuresis with mannitol hypertonic saline Increased Intracranial Pressure Nursing Interventions: Institute cardiac monitoring and be alert for cardiac changes or arrhythmias. Closely monitor vital signs and neurologic status, including LOC and pupil size. Maintain a patent airway. Monitor oxygenation and ventilation.. Elevate the head of the bed 30 degrees (appropriate for most patients). Increased Intracranial Pressure Nursing Interventions: AVOID: Avoid extreme hip, knee, and neck flexion because these actions increase ICP. Minimize procedures that might increase ICP, such as suctioning.  Seizures This is an abnormal electrical discharge of neurons in the brain. PRIMARY SEIZURE idiopathic, occurring without any apparent structural changes in the brain SECONDARY SEIZURE characterized by structural changes Seizures Complications: Hypoxia or anoxia Traumatic injury Aspiration Neuronal damage Depression Anxiety Seizures Neurons in the brain = hyperexcitable Electrical current spreads to surrounding cells, which fire in return. Areas: single area of brain - partial seizure both sides of brain - generalized seizure cortical, subcortical and brainstem areas Seizures Hallmark of seizure disorder: Recurring seizures (generalized or partial) Drugs: phenytoin carbamazepine phenobarbital primidone Seizures Nursing Interventions: Ensure patient safety. Protect patient’s airway by positioning. Never place anything in patient’s mouth. Administer supplemental oxygen as needed. Obtain blood glucose level. Initiate IV access. Seizures Types of Seizures: Partial seizure - from localized (focal) area of the brain simple partial - do not alter consciousness (repetitive jerking) complex partial - altered consciousness (glassy state, lip-smacking, chewing, unintelligible speech) Generalized seizure - involves loss of consciousness Absence seizures (petit mal seizures) - rolling eyes, blank stare, common in children Myoclonic seizures - muscle jerks especially in the morning Clonic seizures - bilateral rhythmic jerking movements Tonic seizures - increase in bilateral muscle tone Tonic-clonic seizures - body stiffness (tonic), relaxed (clonic); postictal phase (confused) Atonic seizures - general loss of postural tone and temporary loss of consciousness Status Epilepticus Stopping the seizure quickly is the immediate treatment of choice. IV drugs are always used Make sure the patient is safe from convulsion trauma First-Line Therapy: Diazepam (Valium) Given IV in incremental doses Provides 30-40 minutes seizure-free Lorazepam (Ativan) Longer duration of action Tonic-clonic Seizures Nursing Interventions: Do not restrain the patient during seizure Place patient in lying position, loosen tight clothing put something soft under his head Clear area of hard objects Don’t force anything into patient’s mouth Turn patient or patient’s head tp sode After seizure, orient him to time and place and inform he had a seizure SPINAL CORD INJURY Spinal injuries include fractures, subluxations, and dislocations of the vertebral column. Injuries to the 5th, 6th, or 7th cervical; 12th thoracic; and 1st, 4th, and 5th lumbar vertebrae are most common. SPINAL CORD INJURY Nursing Assessment: muscle spasms and back or neck pain that worsens with movement point tenderness (pain) on spinal palpation pain that radiates to other areas, such as the arms or legs sensory loss pain, edema, guarding, tenderness over the spine and spinal area loss of bulbocavernous reflex neck pain induced by coughing loss of rectal tone sensation of hot water or electric shock running down patient’s back diaphragmatic breathing SPINAL CORD INJURY Nursing Intervention: Stabilize the spine: use cervical collar, backboard if there’s helmet, remove as possible as per facility protocol (at least 2 will help) check patient’s airway, respiratory rate evaluate patient’s LOC administer supplemental oxygen as indicated prepare to administer fluids if patient becomes hypotensive  STROKE This is also known as a brain attack, is a sudden impairment of cerebral circulation in one or more blood vessels. Stroke interrupts or diminishes blood supply to the brain and causes serious damage to brain tissues. STROKE Cause: thrombosis embolism hemorrhage A stroke in the left cerebral hemisphere produces symptoms on the right side of the body; in the right hemisphere, symptoms appear on the left side.  The GOAL of treatment: Fibrinolytic Therapy (thrombolytics) within 60 minutes of ED arrival. 1. Fibrinolytic 3. Benzodiazepines - seizure activity 2. Aspirin (antiplatelet) 4. Antihypertensives to prevent recurrent ischemic stroke 5. Anticonvulsants Give thrombolytic therapy when: Pt’s age is 18 years old and above Acute ischemic stroke Onset of symptoms less than 3 hours before treatment begins Do not give thrombolytic therapy when: Subarachnoid hemorrhage happens Recent head trauma (within 3 months) Uncontrolled hypertension during the treatment Active bleeding Platelet count less than 100,000/mL Had heparin administration Blood glucose less than 50 mg/dL Nursing Intervention: Secure and maintain the patient’s airway Monitor oxygen saturation levels Assess for signs and symptoms of bleeding for pts receiving fibrinolytic therapy every 15-30 minutes If patient had TIA, administer antiplatelet as ordered. If there are signs of progression, give anticoagulants (heparin). Maintain communication with the patient. Subarachnoid Hemorrhage Bleeding that occurs into the subarachnoid space. CSF occupies this space. This is associated with aneurysm rupture. The most common form of aneurysm is berry aneurysm, saclike outpouching of an artery. Nursing Intervention: Secure and maintain the patient’s airway Monitor oxygen saturation levels Assess for signs and symptoms of bleeding for pts receiving fibrinolytic therapy every 15-30 minutes If patient had TIA, administer antiplatelet as ordered. If there are signs of progression, give anticoagulants (heparin). Maintain communication with the patient. Remember: Aneurysm rupture usually occurs abruptly without warning. sudden, severe headache nausea and projectile vomiting altered LOC meningeal irritation hemiparesis, hemisensory defects, dysphagia, vision defects diplopia, ptosis, dilated pupil Diagnostic Tests: Cerebral angiography - to identify site of bleeding CT scan reveals hemorrhage Lumbar puncture and analysis of CSF Transcranial Doppler studies How it’s treated? Five Grades for SAH severity: Grade 1 - Minimal Bleeding 1. Oxygenation and ventilation The patient is alert, no neurologic deficit, slight headache and 2. Reduce the risk of rebleeding nuchal rigidity. (attempt to repair aneurysm) Grade 2 - Mild Bleeding The patient is alert, mild to severe headache and nuchal rigidity, may have third nerve palsy. Nursing Assessment: Grade 3 - Moderate Bleeding 1. Headache The patient is confused, drowsy, nuchal rigidity and mild focal 2. Intermittent nausea and vomiting deficit. Grade 4 - Severe Bleeding 3. Nuchal rigidity The patient is stuporous, nuchal rigidity, mild to severe hemiparesis. 4. Photophobia Grade 5 - Moribund 5. Back and leg stiffness The patient is in deep coma or decerebrate. Be Alert For: Nursing Interventions: Decreased LOC Establish and maintain a patent airway Unilateral enlarged pupil Anticipate the need for supplemental oxygen/mechanical Worsening hemiparesis or motor deficit ventilatory support Increased blood pressure Initiate cardiac monitoring and be alert for cardiac changes and Slowed pulse rate arrhythmias Renewed or worsened nuchal rigidity Position patient: prevent aspiration and upper airway Seizures Renewed or persistent vomiting obstruction Worsening headache Limit stimulation - to minimize risk of rebleeding and avoid Increased confusion increased ICP Monitor LOC and vital signs frequently Avoid rectal temperature measurement Accurately record intake and output