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Neurological Emergencies

Sabreena Stratton MSN, RN, CCRN, CEN

Learning Objectives

•  Understand basic anatomy of the brain

•  Complete a focused assessment of a brain injured patient

•  Treatment modalities for various head injuries

CEN Exam 10% is Neuro 15 questions

http://www.studytechnology.org/special/img/barr3.gif

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Central Nervous System

Neuro Anatomy •  Cranium •  Meninges: surround and

protect •  Dura (separates Cerebrum

from Cerebellum) aka: Supratentorial

•  Arachnoid •  Pia

•  Brain •  3 lbs •  20% CO & 02 consumption •  Ventricles-interconnected

cavities

http://chestofbooks.com/reference/American-Cyclopaedia-8/images/The-Brain-enclosed-in-its-Membranes-and-the-Skull.jpg

Central Nervous System…

•  Cerebrum • Left and right

hemispheres lobes • Corpus

callosum •  Cerebellum •  Brainstem

https://headway.revolutiondata-cms.com/uploads/public/images/System%20Images/Sitepages/About%20brain%20injury/Brain%20lobes.jpg

Central Nervous System

•  Cranial Nerves •  Not consciously controlled

•  Cerebral Blood Flow •  Circle of Willis •  Internal Carotid Arteries •  Vertebral Arteries •  Venous drains through sinuses in

dura into jugular veins

•  CSF •  7-10ml/hr •  Protector •  Transport system

•  Spinal Cord •  Spinal Canal from Brain Stem to

L-1 and L-2

http://drroynissim.com/files/2012/08/Central-Nervous-System.jpg

Cranial Nerves

I.  Olfactory II.  Optic III.  Oculomotor IV.  Trochlear V.  Trigeminal VI.  Abducens VII.  Facial VIII.  Acoustic IX.  Glossopharyngeal X.  Vagus XI.  Spinal Accessory XII.  Hypoglossal

Unconscious? III, IV, VI: pupils; eye movement V, VII: corneal, grimace IX, X: cough, gag

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Peripheral Nervous System

•  31 Spinal Nerves •  dermatomes

•  Autonomic Nervous System •  Sympathetic •  Fight or flight

•  Parasympathetic •  Conserve energy

Neuro Assessment

http://www.istudentnurse.com/wp-content/uploads/2013/11/Brains-Neurology-Nursing-School-870x320.jpg

What is the most reliable indicator of neurologic

function??

Level Of Consciousness

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AVPU

u Oriented x4, awake, following commands

u Responds to voice; not fully oriented

u Responds to painful stimulus u Unresponsive

Alert Verbal Painful Stimulus Unresponsive

Level of Consciousness

Central vs. Peripheral Stimulation??

http://www.braininjuryhawaii.com/wp-content/uploads/2011/03/Glasgow_Coma_Scale_Chart.gif

Pupils

Herniation

Uncal: lateral shift of brainàipsilateral dilated pupil

Supratentorial: brain pushing

downwardà

Pinpoint: parasympathetic Dilated: sympathetic

What percentage of the population have a normal

finding of unequal pupils??

http://upload.wikimedia.org/wikipedia/commons/f/f2/Trauma_subdural_arrows.jpg

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Monro-Kellie Doctrine http://classconnection.s3.amazonaws.com/285/flashcards/674285/jpg/picture51342119659286.jpg

Intracranial Pressure

EARLY

Headache Nausea/Vomiting

Amnesia LOC

Drowsiness

LATE

Fixed, dilated pupil Unresponsive

Posturing Hypertension

Altered Respirations

Intracranial Pressure

EARLY

Headache Nausea/Vomiting

Amnesia LOC

Drowsiness

LATE

Fixed, dilated pupil Unresponsive

Posturing Hypertension

Altered Respirations

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Vitals

Heart rate Increased: ↑ ICP Decreased: ↑ ICP (terminal), neurogenic shock, autonomic dysreflexia

Blood pressure Increased: ↑ ICP, autonomic dysreflexia Decreased: ↑ ICP (terminal), neurogenic shock

Respirations (abnormal): brain stem compression Temperature

Increased: hypothalamic injury, neurogenic shock Decreased: neurogenic shock

Cushing’s Reflex: Hypertension, widening pulse pressure, decreased heart rate Treatment??

Neuro Assessment

SENSORY

Meningitis

Headache N/V

Lethargy Chills

Photophobia Nuchal Rigidity

Brudzinski’s Reflex Kernig’s Reflex

Inflammation of the meningeal layers surrounding the brain and spinal cord ²  Viralàgradual onset, less acute.

²  Enterovir, herpesvirus ²  Increased Protein, normal lglucose, clear CSF, 10-1000

leukocytes

²  Bacterialàacute onset, fatal in 50% ²  Streptococcus, neisseria, haemophilus, group B and Listeria ²  Higher protein>200, decreased glucose, pruluent, leukocytes

1,000-20,000

²  Fungalàimmune-compromised individuals ²  Aspergillus , Candida ²  Low Leukocytes <500, low glucose, >200 protein

Treatment CT head before Lumbar Puncture

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Stroke

Decreased CBFàdeprived 02 and glucoseàcellular

ischemiaàcerebral infarction

v 500,000 Americans suffer stroke annually with 20% mortality rate the first year

v 50% caused by thrombosis vs. emobolic v 80-85% are ischemic v Symptoms vary on affected brain and can occur slowly as

blood flow gradually decreases

TIA vs. RIND vs. CI

Stroke

Treatment

ABC’s Intubation Manage SBP>220 Identification of Stroke Type ThromboemobolicàtPA HemorrhagicàSurgical intervention and ICP manageent

http://floydmemorial.com/wp-content/uploads/2011/05/different_types_of_strokes.jpg

Neuro Trauma

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Scalp Lacerations

Protects brain from injury acting as a cushion Extensive vascular supply with poor vasoconstrictive properties Direct pressure, wound care, staples, tDAP

Skull Fractures

Clinical presentation affected by: •  type of fracture •  area involved •  damage to underlying

structures S/S •  Combative •  Racoon Eyes •  Battle’s Sign •  Heotympanum •  CSF leak

Cerebral Contusions

Ø Bruising on the surface of the brain

Ø Acceleration-deceleration injuries

Ø S/S include: Ø N/V, LOC, Vision Changes,

weakness, speech difficulty

Ø Management: Ø Prservation of neuro

function Ø Pain control Ø Adequate hydration

http://www.braininjury.com/images/injured01.gif

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Epidural Hematoma

u Bleeding b/w skull and dura mater

u Middle Meningeal Artery involvement >50% mortality rate

u 50% don’t have skull fracture u Unconsciousàlucidityàuncon

sciousness u Surgical intervention u Outcome is directly related to

the neuro status prior to surgery (should try to maintain a low ICP)

http://upload.wikimedia.org/wikipedia/en/9/9c/Epidural_Hematoma.jpg

Subdural Hematoma

ACUTE •  disipation of energy rupturing bridging veins •  S/S: LOC, hemiparresis, fixed, dilated pupils •  Surgical intervention w/i 4 hours SUBACUTE •  48hrs-2 weeks post injury •  S/S: progressive decline in LOC •  Brain compensates •  Surgical intervention with little or no lasting

deficit CHRONIC •  2weeks-months •  Difficult to ascertain cause •  Tolerate initally by elderly d/t atrophy •  Surgical intervention

•  Burr holes •  Subdural drains

Bleeding into subdural space between the dura mater and arachnoid

Occur more frequently than other intracranial injuries

http://img.medscape.com/pi/emed/ckb/radiology/336139-344482-6137tn.jpg

IPH vs. IVH http://images.radiopaedia.org/images/24884/48b474226d0e18abb5746233123047.jpg

http://www.diagnosticimaging.com/sites/default/files/di/cases/Cocaine%20Induced%20Hypertensive%20Intraparenchymal%20Hemorrhage/03.jpg

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Concussion

Results from a direct blow to the head or from an acceleration or deceleration injury in which the brain collides with the inside of the skull

http://cdn.lifeinthefastlane.com/wp-content/uploads/2010/04/Cubs_concussion.jpg

Diffuse Axonal Injury

Result of blunt trauma causing shearing and disruption of neuronal structures Severity depends on degree of injury and severity of damage from secondary injury Symptoms can resolve over several days or could be permanent—posturing Early CT scans may be unremarkable Serial exams will show areas of edema and microvascular hemorrhage

http://images.radiopaedia.org/images/2274466/45aad11d7ca2b2e23293dd6b50afe7.jpg

What is the patients GCS?

A patient who sustained traumatic brain injury in an MVC 1 hour prior to coming to ED by ambulance. He is combative, not opening his eyes, and groaning when his open ankle fracture is moved GCSà 8

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Questions…

A.  Deep vein thrombosis, a frequently neglected complication of immobility

B.  Meningitis, a potential complication of basilar skull fractures

C.  Hypothalamic dysfunction or ‘storming’ a potentially lethal febrile syndrome after head trauma

D.  Foreign bodies still embedded in the skull base, a common source of infection

A patient has survived a TBI and was discharged with a basilar skull fracture. He presents back to the ED from a rehab center with an elevated temperature. Although the POC is multifactorial, the most important aspect will center on identifying…

WHICH OF THE FOLLOWING BLOOD PRESSURE CHANGES IS ASSOCIATED WITH INCREASED INTRACRANIAL PRESSURE?

A.  Widening pulse pressure B.  Decrease in systolic pressure C.  Increase in diastolic pressure D.  Declining mean arterial pressure

A. Keeps the patient awake all night B. Withholds fluids for 12 hours when the patient is

nauseated C. Seeks assistance when the patient develops lethargy D. Calls the emergency department when the patient is

unable to remember

Discharge teaching would be considered effective if the caregiver of a concussed patient…

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WHICH OF THE FOLLOWING STATEMENTS ABOUT SUBDURAL HEMORRHAGE IS TRUE?

A.  It results from a thrombosed artery B.  It results from a tear in the middle meningeal

artery C.  It may initiate a rapid or slow onset of

symptoms D.  It occurs between the skull and the dura

A patient who sustains a head injury has increased pressure on the left oculomotor nerve. Assessment of the left eye is most likely to reveal… A.  Conjunctival edema B.  Ptosis of the eyelid C.  Dilation of the pupil D.  Ciliary spasm of the eyelid

Bacterial Meningitis is most strongly suggested by a fever and…?

A.  Confusion B.  Slurred speech C.  Nuchal Rigidity D.  Lateral Nystagmus

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Which of the following assessment findings are associated with a skull fracture and would indicate the need for further intervention?

A.  Rhinorrhea and headache or dizziness B.  Decreasing level of consciousness and

restlessness C.  Early evidence of periorbital ecchymosis and

photophobia D.  Otorrhea, nausea and vomiting

References

Chicarelli, M. (n.d.). This is your brain with a side of bacon: Concepts and treatment of brain trauma [Unpublished powerpoint slides].

Howard, P. K., & Steinmann, R. A. (Eds). (2010). Sheehy’s emergency nursing principles and practice (6th ed.). St Louis: Mosby/Elsevier.

McReynolds, S. M. (n.d.). Neurological emergencies [Unpublished Powerpoint slides].

Urden. L. D., Stacy, K. M., & Lough, M. E. 2006. Thelan’s critical care nursing diagnosis and management (5th ed.). St. Louis: Mosby/Elsevier.