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Cc 11 neuro
Critical Care (408)
Loma Linda University
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Assessing Neurological Function
Motor Function* spontaneous occurs without external stimuli & may NOT occur by request localization extremity opposite the extremity receiving pain crosses midline of body in attempt to remove the noxious stimuli when you’re trying to illicit a cough response and the patient grabs the tube to relieve them from pain withdrawal extremity flexes normally in response to painful stimuli to avoid stimulus decortication abnormal flexion response (pull in) look at shoulder and legs (core) may occur spontaneously or in response to noxious stimuli decerebration abnormal extension response (come out) may occur spontaneously or in response to noxious stimuli flaccid no response to painful stimuli
Cerebral Hemodynamics
history clinical manifestations, associated complaints, precipitation factors, progression & family hx neuro dz physical exam LOC motor function pupil function respiratory function vital signs complete neuro exam has NOT been done until all 5 above are performed analysis of laboratory & diagnostic data Na+& BG are notorious for mimicking neuro problems
intracranial pressure (ICP) normal: 0- >20/10+ min requires intervention cerebral perfusion pressure (CPP) 80- kept close to 80 to provide adequate blood flow to brain if CPP drops below 80 brain ischemia may develop CPP = MAP - ICP ICP Monitoring Devices Ventriculostomy only one w/ CSF access for drainage/sampling Subarachnoid bolt or screw no penetration of brain tissue less infection rate Subdural catheter least invasive, not always accurate on ICP read Intraparenchymal catheter fiberoptic catheter in parenchymal tissue hole is punched in dura & catheter is inserted about 1 cm into brain’s white matter Fiber optic transducer-tipped catheter can be placed ANYWHERE in subdural, subarachnoid space, in ventricle or directly in brain tissue it is easily damaged and cannot be recalibrated after placement
Level of Consciousness goal: alert/oriented x4: person, place, time, event alert responds to external stimuli confused disoriented to one of the following: person, place, time, event impaired judgment, safety awareness, & decision making decreased attention span delirious disoriented to time, place, & person loss of contact w/ reality often auditory & visual hallucinations lethargic drowsiness needs stronger stimulus to awaken BUT still able to respond obtunded less than full alertness (ALOC) questions answered w/ minimal response stupor responds ONLY vigorous & continuous stimuli (often withdrawal) comatose no evidence of responsiveness absent eye opening or eye movement to noxious stimuli
Respiratory Patterns* Cheyne-stokes rhythmic crescendo & decrescendo of rate & depth brief periods of apnea central neurogenic very deep, rapid w/ NO apneic periods cluster clusters of irregular gasping long periods of apnea ataxic irregular, random, deep & shallow irregular apneic periods
Contributors to Increased ICP* IV colloids, crystalloids, blood products
↑ blood flow
vasopressors
↑ pressure ↑ blood flow
Trendelenburg position
↑ blood flow
warming measures
promotes ↑ blood flow
shivering/fever
↑ blood flow
coughing, suctioning, sneezing agitation, external stimuli pain hypoventilation
hypercapnia → ↑ CO
↑ cerebral blood flow
↑ ICP
↓ seizure threshold
Superficial Reflexes corneal – cotton ball or eye drop blink cough – suction in ETT if intubated gag plantar
noxious stimuli should not produce a motor response other than spinally mediated reflexes vegetative state partial arousal not truly aware non purposeful eye movement
bottom of foot – check Babinski reflex positive Babinski in adults = BAD Pupils Function (PERRLA) want them to be equal round reactive to light accommodation change or inequal pupil size significant neurologic sign dilated/nonreactive herniation (compression of oculomotor nerve) pinpoint/nonreactive pathway disturbances with brainstem involvement
Interventions to Decrease ICP* osmotic and other diuretics hyperventilation
hypocapnia ↓ cerebral blood
flow
↑ HOB
got to be quick with turns cooling measures (arctic sun) rest/sedation/paralytics (shivers
→↑BP)
hypertonic saline 2% - in peripheral line 3% or higher - CVC blood pressure control CSF drainage
Glasgow Coma Scale* | Max Score = 15 Eye Opening 4 spontaneous 3 to speech 2 to pain 1 none Verbal Response 5 oriented 4 confusion 3 inappropriate 2 incomprehensible 1 none Motor Response 6 obeys commands (without external stimulus) 5 localizes to pain (opposite arm crosses midline to remove stimulus) 4 withdraws from pain (flexes to avoid stim) 3 flexion to pain (décor – can be spontaneous) 2 extension pain (decerebration – ^^) 1 none (flaccid)
Vital Signs
blood pressure (BP) **→↑ ICP
heart rate (HR) rhythm respirations
Cushing’s triad* →↑ ICP &
HERNIATION
bradycardia (↓HR) systolic HTN (↑BP) abnormal respirations
Paralytics nimbex/vecuronium titrate using train of four ALWAYS given w/ sedation & pain meds protect airway when giving sedation
Stroke – CT scan to d/t which stroke
Clinical Presentation of Stroke
Herniation
Ischemic - BLOCK thrombotic atherosclerosis embolic atrial fib carotid dissection hypoxic Hemorrhagic - BLEED subarachnoid (SAH) caused by rupture of cerebral aneurysm AVM traumatic idiopathic (unknown cause)
intracerebral (ICH) caused by HTN trauma
numbness or weakness face, arm, or leg especially on one side of the body sudden confusion trouble speaking or understanding sudden trouble seeing one or both eyes sudden trouble walking dizziness, loss of balance, or coordination sudden, severe headache with no known cause
BEFAST – G (glucose check) balance eyes face arms
Cingulate no clinical manifestations but if not corrected will develop to central or uncal herniation Central small reactive pupils slowly progress to fixed, dilated pupils respiratory changes. late stages = affects brainstem same as uncal. Uncal (the worst) affects the brainstem - BADD pupil dilation on one side ALOC respiratory changes to respiratory arrest decorticate or decerebrate posturing without interventions both pupils dilated and
Aneurysm Arteriovenous Malformation (AVM)
one area may lose some function blood pressure control beta blockers etc.
↓ blood pressure – just
enough for adequate perfusion possible ventriculostomy craniotomy/craniectomy Intracerebral Hemorrhage (death/disability HIGH) bleeding directly into cerebral tissue destroys cerebral tissue
cerebral edema & ↑ ICP
can have improvement hypertension most common cause
Cc 11 neuro
Course: Critical Care (408)
University: Loma Linda University
