1
45: NEUROLOGIC PROBLEMS
p p
MONITORING FOR INCREASED INTRACRANIAL PRESSURE
p p p p
• MostpatpriskpforpincreasedpICPpresultingpfrompedemapduringpthepfirstp72phr.pafterponsetpofpap
stroke
• Mayphavepworseningpneuropchangespstartingpwithinp24-
48pafterptheirpendovascularpprocedurepfrompincreasedpICP
• Assessptheseppt.pQp1-4phr.
CHART 45-6 KEY FEATURES
p p p
• DecreasedpLOCp(lethargyptopcoma)
• Behaviorpchanges:prestlessness,p irritability,pandpconfusion
• HA
• N/Vp(maypbepprojectile)
• Changepinpspeechppattern/slurredpspeech:
o Aphasia
• Changepinpsensorimotorpstatus:
o Pupillarypchanges:pdilatedpandpnonreactivep(“brownppupils”)porpconstrictedpand
pnonreactive
o Cranialpnervepdysfunction
o Ataxia
• Seizuresp(usuallypwithinpfirstp24phr.pafterpstroke)
• Cushing’sptriad:
o SeverepHTN
o Widenedppulseppressure
o Bradycardia
• Abnormalpposturing:
o Decerebrate
o Decorticate
>> INTERVENTIONS
p
• ForpincreasedpICPpexperiencingpapstroke:
o ElevatepHOBp–psittingpthempuppispverypimportant
o O2ptherapyp(forpO2p<p94%)
o Maintainpheadpinpmidline,pneutralppositionp–
ppromotespvenouspdrainagepfrompthepbrain
1
, 2
o Avoidpsuddenpandpacutephipporpneckpflexionpduringppositioning
o AvoidpthepclusteringpofpRNpproceduresp–pcanpelevatepICPpevenpmore
▪ Notpforpneuroppt.
o Hyperoxygenatepbeforepandpafterpsuctioning
o Providepairwaypmanagementptoppreventpunnecessarypsuctioningpandpcoughingp
thatpcanpincreasepICP
o Maintainpquietpenvironmentpifppt.phaspapHA
o Keepptheproomplightsplowptopaccommodatepandpphotophobia
o MTpBP,pheartprhythm,pO2psat,pbloodpglucose,pandpbodyptempptoppreventpsecondaryp
brainpinjurypandppromoteppositivepoutcomespafterpstroke
▪ MDpusuallyplikepBPptopbepslightlypelevatedpafterpapstrokep(SBPp=p140-150)
• CRITICALpRESCUE!!p–pBepalertpforpS/SpofpincreasedpICPpinpthepheadpinjurypandpreportpany
neuropdeteriorationptopthepMDporpRapidpResponsepTeampimmediately!
o Thep1stp signpofpincreasedpICPpispapdecliningpLOC
2
, 3
TRAUMATIC BRAIN INJURY (TBI)
p p p
>>>pPATHO
• Canpleadptoptemporarypandppermanentpim
pairmentpinpcognition,pmobility,psensorypp
erception,pandppsychosocialpfunction
• Directpinjury:pblowpdirectlyptopthephead
• Indirectpinjury:pforcepappliedptopanotherpbo
dyppartpwithpapreboundpeffectptopthepbrain
• Sheared:preboundporprotatedponpthepbrain
pstem
• Bruised:pcontusionpofpthepbrain
• Torn:placerationpofpthepbrainpaspitpmovesp
acrosspthepinnerpsurfacepofpthepcranial
• Accelerationpinjury:pcausedpbypnpexternalpforcepcontactingpthephead,psuddenlypplacingp
thepheadpinpmotion
• Decelerationpinjury:poccurspwhenpthepmovingpheadpispsuddenlypstoppedporphitspap
stationarypobject
•
PRIMARY BRAIN INJURY
p p
• Occurspatptheptimepofpinjuryp--pDivespandphitsphead
• Canpbepfocalporpdiffuse
o Focal:pconfinedptopapspecificpareapofpthepbrainpandpcausesplocalizedpdamagepthat
canpoftenpbepdetectedpwithpapCTpscanporpMRI
o Diffuse:pdamagepthroughoutpmanypareaspofpthepbrain
▪ UsuallyptoopsmallptopdetectpwithpCTpscanpatpfirstpbutpcnpworsenptopap
detectablepsize
▪ MRIpcanpseepmicroscopicpinjuries
• Classifiedpaspopenporpclosed
o Open:pwhenpthepskullpispfracturedporppiercedpbypappenetratingpobject
o Closed:pthepintegritypofpthepskullpstayspintact
• Furtherpdefinedpaspmild,pmoderate,porpseverep–
pusuallypdeterminedpbypthepGlasgowpcomapscalepimmediatelypafterpresuscitation,ppresen
cepofpbrainpdamagepshownpinpCTpscanporpMRI,pestimationpofpforcepofptheptrauma,pandpS/S
3
, 4
SECONDARY BRAIN INJURY
p p
• Anypprocessespthatpoccurpafterpthepinitialpinjurypandpworsenporpnegativelypinfluenceppt.
poutcomes.
o Increasedpswellingpdueptopprimarypbrainpinjury
• Resultpformpphysiologic,pvascular,pandpbiochemicalpeventspthatparepanpextensionpofpthep
primarypinjury.
o Mostpcommonpsecondarypinjuriespresultpfromphypotensionpandphypoxia,p
intracranialpHTN,pandpcerebralpedema.
o DamageptopthepbrainptissuepoccurspprimarilypbecausepthepdeliverypofpO2pandpgluc
oseptopthepbrainpispinterruptedpfrompcerebralpedemapandpincreasingppressure.
> HYPOTENSIONpANDpHYPOXIA
• Hypotensionp=pMAPp<p70
o r/tpshockporpclotpformation
• Hypoxemiap=pPaO2p<p80
o r/tpresp.pfailure,pasphyxiation,porplosspofpairwaypandpimpairedpventilation
o leadsptopdecreasedpcognition
• Theseprestrictpthepflowpofpbloodptopvulnerablepbrainptissue
> INCREASEDpINTRACRANIALp PRESSURE
• NormalplevelpofpICPp=p10p–p15pmmpHg
• ApsustainedpICPpofp20pispdetrimentalptopthepbrainpbecausepneuronspbeginptopdie
• Aspapresultpofpbrainpinjury,pthepincreasepinpthepvolumepofponepcomponentpmustpbe
compensatedpforpbypapdecreasepinpthepvolumepofponepofpthepotherpcomponents
o Cerebralpedema
• ThepbrainpcanpcompensatepforpincreasedpICPpbypsendingpbloodpvolumepintopthepsinusesporp
jugularpveins.
• IncreasedpICPpispthepleadingpcausepofpdeathpfrompheadptraumapinppt.pwhopreachpthep
hospitalpalive
o HappenspwhenpthepbrainpcanpnoplongerpcompensatepforpthepincreasedpICP
o AspICPpincreases,pcerebralpperfusionpdecreases,pleadingptopbrainptissuepischemiap
andpedema
o Brainpherniationpsyndrome:pwhenpthepbrainpispforcedpdownwardpthrupthepFormanp
ofpMonro
> HEMORRHAGE
• Causespapbrainphematomap(collectionpofpblood)porpclot,pmaypoccurpatpthepprimarypinjuryp
orpariseplaterpfrompvesselpdamage
4
45: NEUROLOGIC PROBLEMS
p p
MONITORING FOR INCREASED INTRACRANIAL PRESSURE
p p p p
• MostpatpriskpforpincreasedpICPpresultingpfrompedemapduringpthepfirstp72phr.pafterponsetpofpap
stroke
• Mayphavepworseningpneuropchangespstartingpwithinp24-
48pafterptheirpendovascularpprocedurepfrompincreasedpICP
• Assessptheseppt.pQp1-4phr.
CHART 45-6 KEY FEATURES
p p p
• DecreasedpLOCp(lethargyptopcoma)
• Behaviorpchanges:prestlessness,p irritability,pandpconfusion
• HA
• N/Vp(maypbepprojectile)
• Changepinpspeechppattern/slurredpspeech:
o Aphasia
• Changepinpsensorimotorpstatus:
o Pupillarypchanges:pdilatedpandpnonreactivep(“brownppupils”)porpconstrictedpand
pnonreactive
o Cranialpnervepdysfunction
o Ataxia
• Seizuresp(usuallypwithinpfirstp24phr.pafterpstroke)
• Cushing’sptriad:
o SeverepHTN
o Widenedppulseppressure
o Bradycardia
• Abnormalpposturing:
o Decerebrate
o Decorticate
>> INTERVENTIONS
p
• ForpincreasedpICPpexperiencingpapstroke:
o ElevatepHOBp–psittingpthempuppispverypimportant
o O2ptherapyp(forpO2p<p94%)
o Maintainpheadpinpmidline,pneutralppositionp–
ppromotespvenouspdrainagepfrompthepbrain
1
, 2
o Avoidpsuddenpandpacutephipporpneckpflexionpduringppositioning
o AvoidpthepclusteringpofpRNpproceduresp–pcanpelevatepICPpevenpmore
▪ Notpforpneuroppt.
o Hyperoxygenatepbeforepandpafterpsuctioning
o Providepairwaypmanagementptoppreventpunnecessarypsuctioningpandpcoughingp
thatpcanpincreasepICP
o Maintainpquietpenvironmentpifppt.phaspapHA
o Keepptheproomplightsplowptopaccommodatepandpphotophobia
o MTpBP,pheartprhythm,pO2psat,pbloodpglucose,pandpbodyptempptoppreventpsecondaryp
brainpinjurypandppromoteppositivepoutcomespafterpstroke
▪ MDpusuallyplikepBPptopbepslightlypelevatedpafterpapstrokep(SBPp=p140-150)
• CRITICALpRESCUE!!p–pBepalertpforpS/SpofpincreasedpICPpinpthepheadpinjurypandpreportpany
neuropdeteriorationptopthepMDporpRapidpResponsepTeampimmediately!
o Thep1stp signpofpincreasedpICPpispapdecliningpLOC
2
, 3
TRAUMATIC BRAIN INJURY (TBI)
p p p
>>>pPATHO
• Canpleadptoptemporarypandppermanentpim
pairmentpinpcognition,pmobility,psensorypp
erception,pandppsychosocialpfunction
• Directpinjury:pblowpdirectlyptopthephead
• Indirectpinjury:pforcepappliedptopanotherpbo
dyppartpwithpapreboundpeffectptopthepbrain
• Sheared:preboundporprotatedponpthepbrain
pstem
• Bruised:pcontusionpofpthepbrain
• Torn:placerationpofpthepbrainpaspitpmovesp
acrosspthepinnerpsurfacepofpthepcranial
• Accelerationpinjury:pcausedpbypnpexternalpforcepcontactingpthephead,psuddenlypplacingp
thepheadpinpmotion
• Decelerationpinjury:poccurspwhenpthepmovingpheadpispsuddenlypstoppedporphitspap
stationarypobject
•
PRIMARY BRAIN INJURY
p p
• Occurspatptheptimepofpinjuryp--pDivespandphitsphead
• Canpbepfocalporpdiffuse
o Focal:pconfinedptopapspecificpareapofpthepbrainpandpcausesplocalizedpdamagepthat
canpoftenpbepdetectedpwithpapCTpscanporpMRI
o Diffuse:pdamagepthroughoutpmanypareaspofpthepbrain
▪ UsuallyptoopsmallptopdetectpwithpCTpscanpatpfirstpbutpcnpworsenptopap
detectablepsize
▪ MRIpcanpseepmicroscopicpinjuries
• Classifiedpaspopenporpclosed
o Open:pwhenpthepskullpispfracturedporppiercedpbypappenetratingpobject
o Closed:pthepintegritypofpthepskullpstayspintact
• Furtherpdefinedpaspmild,pmoderate,porpseverep–
pusuallypdeterminedpbypthepGlasgowpcomapscalepimmediatelypafterpresuscitation,ppresen
cepofpbrainpdamagepshownpinpCTpscanporpMRI,pestimationpofpforcepofptheptrauma,pandpS/S
3
, 4
SECONDARY BRAIN INJURY
p p
• Anypprocessespthatpoccurpafterpthepinitialpinjurypandpworsenporpnegativelypinfluenceppt.
poutcomes.
o Increasedpswellingpdueptopprimarypbrainpinjury
• Resultpformpphysiologic,pvascular,pandpbiochemicalpeventspthatparepanpextensionpofpthep
primarypinjury.
o Mostpcommonpsecondarypinjuriespresultpfromphypotensionpandphypoxia,p
intracranialpHTN,pandpcerebralpedema.
o DamageptopthepbrainptissuepoccurspprimarilypbecausepthepdeliverypofpO2pandpgluc
oseptopthepbrainpispinterruptedpfrompcerebralpedemapandpincreasingppressure.
> HYPOTENSIONpANDpHYPOXIA
• Hypotensionp=pMAPp<p70
o r/tpshockporpclotpformation
• Hypoxemiap=pPaO2p<p80
o r/tpresp.pfailure,pasphyxiation,porplosspofpairwaypandpimpairedpventilation
o leadsptopdecreasedpcognition
• Theseprestrictpthepflowpofpbloodptopvulnerablepbrainptissue
> INCREASEDpINTRACRANIALp PRESSURE
• NormalplevelpofpICPp=p10p–p15pmmpHg
• ApsustainedpICPpofp20pispdetrimentalptopthepbrainpbecausepneuronspbeginptopdie
• Aspapresultpofpbrainpinjury,pthepincreasepinpthepvolumepofponepcomponentpmustpbe
compensatedpforpbypapdecreasepinpthepvolumepofponepofpthepotherpcomponents
o Cerebralpedema
• ThepbrainpcanpcompensatepforpincreasedpICPpbypsendingpbloodpvolumepintopthepsinusesporp
jugularpveins.
• IncreasedpICPpispthepleadingpcausepofpdeathpfrompheadptraumapinppt.pwhopreachpthep
hospitalpalive
o HappenspwhenpthepbrainpcanpnoplongerpcompensatepforpthepincreasedpICP
o AspICPpincreases,pcerebralpperfusionpdecreases,pleadingptopbrainptissuepischemiap
andpedema
o Brainpherniationpsyndrome:pwhenpthepbrainpispforcedpdownwardpthrupthepFormanp
ofpMonro
> HEMORRHAGE
• Causespapbrainphematomap(collectionpofpblood)porpclot,pmaypoccurpatpthepprimarypinjuryp
orpariseplaterpfrompvesselpdamage
4
