Block 4
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| What is a Concussion | Transient alteration in mental status following direct indirect blow to the head
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| Concussion Symptoms *****TEST | Headache, nausea vomiting, fatigue, visual disturbances, balance problems, sensitivity to light/noise, numbness tingling, vomiting, COGNITIVE Mentally foggy, decreased concentration, feeling slowed down slower response to questions.
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| Concussion Symptoms *****Test | EMOTIONAL.. irritability, sadness, feeling more emotional, SLEEP drowsiness, sleeping more or less then usual, trouble falling asleep
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| Concussion RED FLAGS teaching RETURN ER *****TEST | Changes in LOC, worsening headaches, seizures, focal neurologic signs, difficulty awakening, repeated vomiting, slurred speech, increasing confusion, neck pain, weakness numbness arms legs, increasing behavior changes irritability confusion
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| Post concussive syndrome and risk factors | symptoms continue after injury up to 3 months amnesia retrograde/antegrade predictive of PCS
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| What is the treatments | F/u with physician, limit physical and mental activity sleep and nutrition
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| What are signs and symptoms of cerebral contusion | neurologic deficits related bleeding bruising cerebral edema seizures hemiparesis, aphasia personality changes decreased loc or coma
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| Left sided injury has right sided motor function loss |
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| Otorrhea, battle signs, raccoon eyes suspect what | Basilar fracture a linear fracture to the base from frontal or temporal-
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| What is a risk for CSF leakage and what are symptoms | Meningitis - fever headache, nuchal rigidity, altered loc, vomiting, meningeal irritation causes +kernigs sign and brudzinskis photophobia.
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| Big NO NO with Basilar fractures.... | Never suction through nose or attempt to place NG tube.
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| Epidural Hematoma what S/S | Headache nausea vomiting, decreased loc, pupillary changes, motor deficits (hemiparesis, posturing,) seizures
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| Subdural Hematoma | 2-3 days acuteHeadache sudden or progressive nausea, vomiting, decreased loc, hemiparesis. 2-14 subacute headache, ataxia increased confusion, slow cognition, decreasing loc, nausea vomiting. 2 week month chronic and tiredness.
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| Epidural Hematoma special characteristic | "talk and die" loss of consciousness at time of injury the lucid interval followed by loss of counsiousness
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| Epidural TX | Emergent CT then craniotomy
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| supratentorium vs intratentorium | supratentorium frontal, parietal, temporal, occipital lobes. Intratentorium brain stem and cerellbellum
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| Damage to pituatory can cause | watch for vision field cuts "how many fingers do I have up" teach patient to turn head when viewing sides. (optic nerve II)
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| What are post op monitoring cranial surgery | ABC, neuro assessment, I&O, hemodynamics, temperature, ICP, CPP, monitor drains , assess pain , nutrition, periorbital edema cold compresses ( hob 30 ok for supratentorium may be flat for intratentorium may order flat
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| What are post op concerns cranial surgery cont | Monitor for infection, csf leakage, bleeding, DVT, PE, pneumonia, GI bleed, ARDS, Atelectacis
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| Cranial surgery metabolic inbalances | DI decreased ADH from anterior pituatory gland polyuria >200 ml for 2 hours notify doc if it appears another 200 SG nml 1.003 1.030 will be low replace fluids---SIADH blood osmolarity >320 dilutional hyponatremia. Cerebral salt wasting loss of salt
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| Brain Tumors s/s | Headache most common in the morning, focal defficits
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| What is TIA | a warning sign of stroke, micro clot that has desolved, test MRI and Cardiac
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| TIA SS | The signs and sympIf the carotid system is involved, patients may have a temporary loss of vision in one eye (amaurosis fugax)hearing deficits, speaking deficits. considered warning sign of stroke
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| Stroke risk factors TEST.... | HTN #1, Race-African American, Hispanic, hypothyroidism, obesity, sedentary lifestyle, family hx, age over 65, CAD, smoking, Aortic arch or carotid artery disease, preeclamsia, gestational DM, woman higher mortality rate-
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| Treatment of TIA | Plavix neutropenia, thrombotic thrombocytopenia purpura, call for fever chills, sore throat, unusual bleeding , or bruising, Ticlopidin neutropenia cbc every 2 weeks, Dyridamole not preferred but also has vassdialating effect good for pad,cad,Afib warfarn
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| Carotid stenosis major surgery | stenosis can be heard with bell
Carotod endarectomy bleeding bp must be stabilized watch cn dr will provide parameters. Carotid angioplasty cath lab procedure bleeding thrombus, stroke cms
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| Two major sources of blood flow to brain | carotid and vetebral
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| Ischemica stroke most common causes | thrombosis, atherosclerosis, embolis (A fib number one cause)
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| Homonculus Motor | portion of the frontal lobe that controls motor function from 9 toes 10 hips 12 shoulder wrist hand being most supra medial 3 throat, face, nose eyes, lips to 5 being most jaw tongue pharnyx
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| Middle cerebral artery most common stroke |
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| left side stroke | harder to assess, rt sided paralysis,impaired speech language aphasias, slow performance, aware of deficits,depressed impaired comprehension to language and math
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| right side stroke | lt sided paralysis, left sided neglect, tends to deny or minimize problems is a safety risk, impaired judgement impaired time concepts
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| Stroke collaborative care | ABC's, stroke rating scale (fast,NIH stroke scale) Time of symptoms onset, Vital signs 02 sat, Labs, plattlet, cant delay blood glucose, PT, INR, PTT, electrolyte, renal function, cbc, troponin, ekg, noncontrast or mri of head interpret in 45 min
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| 2 standard stroke assessments | Fast face, arms, speech, timing or NIH loc, visual, skills, sensation, and inattention, language, cerebral integrity. 0-42 points higher score more neuro impairment
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| Basic stroke assessment | change in loc, extremities hemiplegia, stiff, flaccid, hemiparalysis, Eyes (II, III, IV, VI)
swallow assessment first nurse pt fails then cant be rn, skin color temp, speaking ability aphasia receptive-expressive, blood pressure, sensation, headache
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| What important point about bp and stroke | Bp is a symptom of stroke a compensatory measure >220/120 to high. If pt is candidate for thrombolytic bp must be no more then 185/110 then maintain bp below 185/105 for 24 hours after tpa/ 2-3 days after stroke bp will be addressesed
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| Stroke and BG | don't unless <60 >140-180
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| Stroke edema | 24-48 hours after
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| TPA treatment requirements | withing 3 hours of stroke onset must be witnessed. excluded
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| TPA exclusions | Hemorhagic stroke, BP >185/110, previous trauma,active bleeding, pregnancy, seizures, blood glucose <50 or >400
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| TPA | weight based dosing 10% over 10 min the rest over one hour,
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| TPA monitoring | SUDDEN decrease in LOC, headache, N/V, new neurologic deficit, signs of bleeding or tongue swelling (S/E altaplace)
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| TPA administration do's and dont's | avoid using automatic bp cuff, avoid unnecessary arterial and venous puncture, IM injections, monitor all puncture sites and gingivae bleeding, for evidence of bleeding, use a draw sheet to move and position patient, observe urine/stool for blood,HH
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| TPA post | No anticoagulants or ASA unitl 24hours after stroke-Begin ASA 24-48 hours after stroke
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| MAP = | normal 50-150
systolic+2(diastolic)/3
120/80 120+160=280/3=93
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| CPP= | MAP-ICP
normal CPP 70-100
head injury ideal 50-70
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| ICP | manitol,head of bed, neutrol neck, control vomiting (control ICP), calm quiet environment, no vegals, hypertonic normal saline, no lumber pressure, prophalaytic seizure, fever control shivering, csf, monitoring and drainage. hyperventilation vent
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| Phenytoin | no more then 50mg/min purple glove, extravasate. central line preffered, push slowing hypotension-proarrythmic effect
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| Phosphenytoin | 150mg/min
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| Management of Extraventricular catheter | high risk infection aseptic technique, don't flush, wash hands clear dressing, review site redness color of drainage CSF should be clear
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| Two types of hemorrhagic strokes | intracebral : htn not much you can do
subarachnoid : risk avm are congenital but not gentic risk for meningitis
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| Cerebral aneurysms s/s | change in vision, eom, ptosis (CN II, III, IV, VI) photophobia, nuchal rigidity, pain above and behind eye.
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| Subarachnoid Hemorrhage | "the worst headache of my life" ruptured aneurysm, lumbar puncture will show RBC, LOC, vomiting, CN deficits III, IV, VI, stiff neck photophobia, hemiparesis, hemiplegia, aphasia, congnitive deficits, seizures, widened pulse pressure, bradycardia, sys htn
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| Subarachnoid treatment | monitor and control bp prevent rebleed, labetlol, nitroprusside, hob30, reduced external stimulation, quiet, low lights, restrict visitors sedation and analgesia nimodipine, stool softner no straining
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| Subarachnoid BP | <160/80 mean >65
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| Sub arachnoid S/S rebleed | sudden dever headache, n/v, change in loc, new neuro deficits.
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| Subarachnoid vasspasms | CCb day 2 nimodepine only for vasospasm 60mg q3hrs for 21 days-risk of vasospasms 2-14 days
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| Sub arachnoid hydrocephalus | blood in csf plugs arachnoid villi, ventriculostomy acute.
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| Never try to reduce ICP by doing what ? | drying someone out
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| Status epilecticus | Main reason withdraw from meds, ETOH, drugs, stroke head trauma, brain tumor, cerebral edema, metabolic disturbances, infections meningitis, encephalitis
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| Tonic clonic seizures | only generalized tonic clonic seizures are life threatening emergencies.
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| Status epilepticus is defined as | A seizure that lasts >5 min or repeated seizures over 30 minutes, all seizure can become SE, but tonic clonic are life threatening
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| Treatment | no face mask, give med asap benzo 4-8 mg @ 2 mg a min-also consider hypoglycemia,
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| Status epilepticus meds | Ativan 4-8mg @ 2 mg min/Phenytoin 50mg/min watch for hypotension fosphenytoin 150mg/min for over 37min consider phenabarbutal can administer as analgesic on as sedation for longer midazlopam, or propofol
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| Types of Spinal cord injury | Complete total loss of motor and sensory quadriplegia, parapalegia (lower extremities)
Incomplete preserved motor or sensory
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| Three types of incomplete CSI | central cord syndrome "can walk to the door but cant open it"
Anterior cord syndrome "loss of motor, pain temp, below injury with intact touch, vibration touch,
Brown sequard syndrome loss of motor function position and vibratory sense ipsilateral
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| Spinal cord injury | Emergency management ABCDE approach-Airway maintain neutral airway-Breathing ensure patient is breathing o2, Circulation pulse,BP, disability neuro check, Exposure remove clothing to assess whole body ---maintain c spine until cleared
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| Spinal cord injury breathing emergency cont | C3,C4, c5- keep diaphragm alive Still monitor 6 and below monitor because edema can spread and require vent
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| Spinal cord Emergency | Foley, Ng, IV, consider steroid protocol, methypredisone, evaluate for decompression laminectomy, realignment of vertebral column, stabilize with skeletal traction
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| Cervical Traction | Tongs require special bed, weights applied to increase disc space, pin care teach family, Halo brace makes patient top heavy, no weights, halo vest, head is fixed, pin care once a shift
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| Medications indicated in SCI <8hrs old | Solu-medrol (methylprednisolone) loading dose 30/mg/kg 15 min 5-4/mg/kg/ every hour for next 23 hours every patient gets PPI or H2
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| Neurogenic shock SCI .........TEST | T6 or higher loss of sympathetic response below to heart and peripheral vascular resistance. vasodilation below, main sign bradycardia,hypotension unopposed vegal tone, hypothermia patient must be kept warm fluid trapped in lower extremities hy
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| Neurogenic shock treatment meds .....Test | Norepinephrine, neosynephrine, atropine to increase heart rate wrap lower extremities to increase bp abdominal binders,
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| Spinal shock ..........Test | Loss of all neuro activity below level of injury flaccid paralysis, loss of pain, touch pressure, no somatic or visceral sensation, Atonic cant void, recovery 1-2days -4-6weeks, recovery hyperreflexia spinal reflex +bilateral babinskis anal wink
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| Autonomic Dysflexia (hyperflexia) BP is indicator | injury to T6 and above is risk factor, only seen in post spinal shock resolved, noxious stimuli causes overreaction sns-causing massive constriction below injury leading to increased HTN, and bradycardia
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| Autonomic Dysflexia (hyperflexia) cont | elevate hob 30: severe htn, headache, flushed face, nasal congestion, anxiety, remove all clothes binders, pressure divices and sit them up first, use anesthetic for tx of bladder distention and fecal impaction, find and remove noxious stimuli
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| Autonomic Dysflexia (hyperflexia) cont | If you cant find source may need antihypertensive medication alpha adrenergic blocker, dozasosin, terazosin, ccb,education to patients good skin care no tight clothing, belts, pants, fiber, and monitor bp
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| Guillian Barre autoimmue | Caused by gastric virus 1-3 weeks post, demylination, mostly men, sever pain, paralysis from floor up, recover from head down, could impact breathing may need vent
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| Guillian Barre | Assess for progressive paralysis, paresthesis, pain muscle weakness, difficulty eom, dysphagia, diplopia, bladder bowel dysfunction, autonomic dysfunction hypo hyper tension
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| Diagnostics and TX | Lumbar puncture for CSF, plasmaphoresis to remove antibodies risk for bledding, IV IGg, 9,10, 12 may be impaired cause aspiration may need NPO ROM, monitor DVT, skin breakdown and eye care
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| Lumbar puncture procedure | have patient empty bladder, latereal recombunt, or seated on side of bed,lye flat 6-8 hours after procedure
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| Myelogram | Lumbar puncture then contrast is injected into spinal column, hold prior phenothiazine lowers seizure threshold must have hob30 for 12 hours force fluids 2000-3000ml per 24hours
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| Cerebral Angiography | NPO 4-6 hours prior to exam Obtain baseline neuro assessment; mark peripheral pulses Maintain bedrest for 6-8 hours Observe puncture site for bleeding, hematoma formation. Monitor peripheral pulses if femoral access Force fluids to clear contrast dye
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| Electroencephalography | inform pt of electrodes on head and electricity will not enter, may have to wash hair/scalp Withhold stimulants, ant depressants, tranquilizers, and anticonvulsants for 24-48 hours Withhold dietary stumulants (i.e. coffee, tea, cola, chocolate)before
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| . •CN I (olfactory) sense of smell •CN II (optic) vision - can have patient ID how many fingers you are holding up, use an eye chart, monitor for visual field cuts by holding up fingers in upper and lower quadrants while the patient looks at your nose | •CN III (oculomotor) pupil constriction, elevation of upper eyelid and extraocular movement - assess size, shape, and direct light action of pupils; observe for ptosis (drooping of eyelid); check extraocular movements
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| •CN IV (trochlear) check extraocular movements •CN V (trigeminal) facial sensation and mastication (chewing) •CN VI (abducens) check extraocular movements •CN VII (facial) check facial expressions (puff cheeks, smile, show teeth, wrinkle brow) | •CN IX (glossopharyngeal) palate, pharynx ("Open your mouth, stick out your tongue and say ahhhh.")
•CN X (vagus) gag reflex
•CN XI (spinal accessory) shoulder shrug
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| •CN XII (hypoglossal) movement of tongue ("Open your mouth, stick out your tongue and say ahhhh.") | Pay special attention to assessment of CNs II, III, IV, & VI. These are the most frequently checked during a brief neuro assessment.
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| 2 component of conciousness | •Arousal and wakefulness - wakefulness reflects activity of the reticular activating system •Content of consciousness - cognitive mental functions; reflects cerebral cortex activity
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| Phenobarbital (Luminal), Phenytoin (Dilantin), Fosphenytoin (Cerebyx), Carbamazepine (Tegretol), Valproate (Depacon), Valproic acid (Depakene), Clonazepam (Klonopin), Gabapentin (Neurontin), | Topiramate (Topamax), Lamotrigine (Lamictal), Pregabalin (Lyrica)
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| Take with food to decrease GI irritation, but avoid milk and antacids (impairs absorption) Do not discontinue medication without consulting physician Avoid alcohol or other CNS depressants Avoid over-the-counter medications - | Avoid over-the-counter medications - check with health care provider before taking OTC or herbals Wear a Medic-Alert bracelet
Maintain good oral hygiene and use a soft toothbrush; preventative dental checkups
Follow up with periodic blood studies
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| Follow up with periodic blood studies Urine may be a turn a pink-red or red-brown color (harmless) |
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| Manitol | Monitor patients with pre-existing HF very carefully - shift in fluid may cause pulmonary edema.Monitor serum osmolality - keep osmo at approximately 310 - 315 mOsm
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| Manitol cont | Administer through a filter
Max effects within 15-30 minutes; can last for 1-3 hours Urinary catheter may be necessary to accurately monitor diuresis Monitor electrolytes, serum osmo, BUN, creatinine, I & O
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| Late stages of increased ICP | Later stage of increased ICP
Cushing's response occurs first - the systolic BP rises causing a widened pulse pressure and the patient's heart rate slows
If ICP is not managed the patient may go on to exhibit the
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| Late stages of ICP cont- | s/s of Cushing's Triad:
Systolic hypertension with widened pulse pressureBradycardiaChanges in respiratory pattern
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| S/S of uncal herniation | Pupil responses become sluggish on the ipsilateral side
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| Remember that suctioning can increase ICP. Suction only when needed; keep suction to <10 seconds; be sure to pre and post oxygenate |
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| Neuromuscular blocking agents (vecuronium, atracurium | Neuromuscular blocking (NMB) agents cause skeletal muscle paralysis - they do not have analgesic effects!! Patient must be mechanically ventilated
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| EMTLA | Emergency medical treatment labor act : pt must be screen and stabilized regardsless of ability to pay: if transferred must be appropriate shared resp: CONSENT Implied id life or limb when parents aren't unavailabe
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| Reportable conditions | Crimes, commumincable diseases, call forensic try to hold evidence bloody shirt document evidence and lable came from who chain of custody
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| Surveys : what are components.............TEST | Primary (A)irway {B)reathing (C)circulation (D)disability (E)xposure /envirmoent
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| Cont Airway open airway cervical spine suction if needed nasal/oral airway if needed endotracheal tube thrust head tilt Breathing : | Breathing Assess ventilation auscultate lungs absent BS consider tension pneumothorax no x ray needed supplemental 02 abu bahg
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| Circulation | check central pulses bp bleeding skin color temp cpr if needed control bleeding iv fluid blood products type and cross match crystolloids/blood ratio 3:1
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| Disability | brief neuro check eyes verbal motor
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| Enviroment | remove clothing keep warm
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| Secorday Survey | Fulle set of vitals focused adjunts are ekg, sats, cxr, foley, cath, ng tube, lab diagnostics, tetanus prophalatics, Give comfort measured, pqrst pain assessment pain scale (O-10) FACES, FLACC, HISTORY full head to toe amble, inspect posterior surfaces,
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| Secondary survey | after complete intervention and evaluation
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| Obstetrics primary consideration | decreased bp after 20 weeks lay on lt side any changes in loc abnormal, assess fetal heart tones, increased risk of aspiration decreased pulmonary reserve from fetal 02 consumption
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| Tetanus Prohphylaxis | Unkown or <3 shots clean wounds tdap or td
tetanus prone +tig
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| Three or more doses and ≤5 yr since last dose No prophylaxis needed | Three or more doses and 6-10 yr since last dose
No prophylaxis needed
Td or Tdap* (Tdap preferred for ages 11-18)
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| Three or more doses and >10 yr since last dose Td or Tdap* (Tdap preferred for ages 11-18) Td or Tdap* (Tdap preferred for ages 11-18) (Lewis 1772) | Obstructive shock caused by PE or Cardiac Tamponade
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| SHOCK S/S | EARLY a little upstick in in HR Compesatory more obvious increased narrow pulse pressure change in loc increased resp PROGRSSIVE pale blue typchepnic, refractory organs are failing
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| collaborative care urine | mx vs every 15 minutes, mx urine outpule every 30 in .5-1ml/kg/
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| Hypovalemic shock | restore fluid crystolloids, control bleeding treat cause elevate extremites
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| distributive shock | Distributive shock results from excessive vasodilation and the impaired distribution of blood flow can be septic anaphylactic, neurogenic
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| Anaphylatic shock treat | ABCDE oxygen, bronchodialtors, epinephrine, fluids antihistamine, costicosteroids some will peak again after 8-10 hours
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| Neurogenic shock | cervical spine stabilization, fluid atropine, vasoprsssors, temperature, dvt propholaxis ,
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| Vasopressor drugs | dopamine >20mg acts as alpha constricts
dopamine 5-10 acts as beta inotrope neosyneprhine constrction without effects on heart
norepinephrine alpha and beta
epinephrine, vassopressin
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| Vasopressors | correct volume issue run on pump central line use pentolomine (vasodilator)
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| Inoptrope | dobutamine improves contractility, dopamine 5-10 mcg min admiroane can cause neutropnea-nitroprisde reduces preload and after load more then 48 hours measure cyanide levels.
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| monitor loc urinary outout skin cap refill hemodynamics
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| Types of spinal cord injuries | Flexion forward force head anterior -hyperextension head pushed back posterior injury-compression diving straight down- rotation twisting displacement of vertebrae
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