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Neurological Emergencies

Neurological Emergencies. Increased Intracranial Pressure Concussion Skull Fractures Contusion Epidural Hematoma Subdural hematoma. Subarachnoid Hemorrhage Aneurysm Rupture Spinal Cord Injuries Autonomic Dysreflexia. Surgical Neurological Emergencies.

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Neurological Emergencies

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  1. Neurological Emergencies

  2. Increased Intracranial Pressure Concussion Skull Fractures Contusion Epidural Hematoma Subdural hematoma Subarachnoid Hemorrhage Aneurysm Rupture Spinal Cord Injuries Autonomic Dysreflexia Surgical Neurological Emergencies

  3. Medical Neurological Emergencies • Headache • Stroke • Shunt Problem

  4. Assessment

  5. Assessment A - airway B - breathing C - circulation D - DISABILITY

  6. Assessment • ATLS- Primary Survey • A –Alert • V – Responds to Vocal stimulus • P – Responds to Painful stimulus • U –Unresponsive to ALL stimulus • Glasgow Coma Scale • Motor Response • Pupillary Status • Vital Signs

  7. Assessment • Awareness(ability to interact with and interpret environment) • Orientation(person, place, time) • Memory(short and long) • Judgment and reasoning • Communications(verbalization and comprehension) • Follow Commands • Attention span • Knowledge of current events

  8. Assessment • Motor Strength

  9. Assessment • GLASGOW COMA SCALE • Best Eye Opening • Best Verbal Response • Best Motor Response

  10. Assessment Best Eye Opening • Spontaneously……………..….4 • To Verbal Command………….3 • To Pain………………………….2 • No Response…………………..1

  11. Assessment Best Verbal Response • Oriented, Converses…………….5 • Disoriented, Converses…………4 • Inappropriate words………….….3 • Incomprehensible sounds……….2 • No Response…………………..…1

  12. Assessment Best Motor Response • Obeys Commands……..….…………..6 • To Pain • Localizes Pain……………….…….5 • Flexion Withdrawal…………….….4 • Abnormal Flexion……………...….3 • Abnormal Extension………………2 • No Response……………………...1

  13. Assessment Glasgow Coma Scale Pediatrics • Verbal (2 to 5 years) • Appropriate words or phrases………..5 • Inappropriate words…………………...4 • Persistent cries and/or screams…..…3

  14. Assessment Glasgow Coma Scale Pediatrics • Verbal (0 to 23 months) • Smiles or coos appropriately…………5 • Cries and consolable…………………4 • Persistent inappropriate crying and / or screaming…………………..3

  15. Assessment • Mild • GCS Score 14-15 • Moderate • GSC Score 9-13 • Severe • GCS Score 3-8 Severity of Injury

  16. A desk scores a “3”

  17. Assessment Pupillary Response • Size • Shape • Spherical • Symmetrical • Beware of the oval pupil • CN III compression • Reaction • Hippus – fails to hold constriction with light on

  18. Hyperarousability Trauma Shock Hypoxia Metabolic abnormalities Alcohol Medications or illicit drugs Endocrine disturbances Hyperthermia Psychiatric illness Hypoarousability Trauma Shock Hypoxia Metabolic abnormalities Alcohol Medications or illicit drugs Endocrine disturbances Hyperthermia Psychiatric illness Etiologies of Altered LOC

  19. A Alcohol E Epilepsy I Insulin (too much, too little) O Oxygen (too much, too little) U Uremia or other metabolic issues T Trauma, toxicity, tumors, thermoregulation I Infections, ischemia P Psychiatric, poisonings S Stroke, syncope or other neurologic / cardiovascular causes Loss of Consciousness“A,E,I,O,U TIPS”

  20. Assessment Babinski’s Reflex • Present when stroking of Planter surface of foot causes • Flexing of great toe • Fanning of other toes • Normally present in children <2yo • Presence in >2yo indicates problem in corticospinal tract (nerve path spine to brain)

  21. Posturing • Abnormal posturing is a late sign of increasing ICP • Decorticate • Abnormal flexion • Decerebrate • Abnormal extension

  22. Meningeal Signs • Nuchal rigidity • Stiff neck, pain on flexion • Photophobia • Positive Brudzinski’s • Involuntary flexion of knees/hips when neck flexed • Positive Kernig’s • Unable to straighten leg when hip fully flexed in supine patient

  23. Surgical Neurological Emergencies

  24. Reviewing the brain… • Our brains are just like Emergency Room Nurses………….

  25. Our heads are hard! The skull is hard!! It does not stretch or expand!

  26. We are ALWAYS hungry! • The brain needs a constant supply of oxygen and glucose. It cannot store glucose OR oxygen Don’t worry…..I just have time for a quick bite on the run!!!

  27. We may be tough on the outside…..

  28. …But we’re softies on the inside.

  29. Increased Intracranial Pressure • The skull is a rigid box and within that box are these components • Brain 80% • Blood 10% • CSF 10% • The volume of the intracranial components must remain constant

  30. Cerebral Compensation • CSF • Shunting intracerebral fluid to ventricles • Too slow in trauma • Brain • Herniation • Not user friendly to pt • Blood • Vasoconstriction / vasodilation I’m really in trouble now!!!

  31. Intracranial Pressure • Intracranial pressure reflects • Brain • Cerebrospinal fluid • Blood • As intracranial pressure increases, cerebral perfusion pressure decreases • Leads to cerebral ischemia and hypoxia • In a hypotensive patient, even a marginally elevated ICP can be harmful • Adequacy of cerebral perfusion pressure is most important

  32. Increased Intracranial Pressure • Initially -intracranial volume increases-ICP remains stable. • System becomes less compliant, or less able to tolerate increases in volume • Later, intracranial volume cont’s to increase, less compliance will be unable to buffer the increases and ICP will rise

  33. Increased Intracranial Pressure

  34. Increased Intracranial Pressure Assessment • Early picture of increased intracranial pressure (IICP) • LOC • Loss of insight • Loss of recent memory • Restless, irritable, uncooperative behavior • Requires more stimulation to get same response • Speech less distinct • Sudden quietness in a very restless patient

  35. Increased Intracranial Pressure Early Increasing ICP Motor function • Usually contralateral to lesion • Pronator drift • Loss of one or more grades on the strength scale • Increased tone

  36. Increased Intracranial Pressure • Early Increasing ICP • Pupils • Sluggish to light response • Usually unilateral • Ipsilateral to lesion • Papilledema or bulging of optic discs • Blurred vision

  37. Increased Intracranial Pressure • Early Increasing ICP • Vital signs • Occasionally tachycardic • Occasional hypertensive swings

  38. Increased Intracranial Pressure • Late Increasing ICP • LOC • Arousable only with deep pain • Unarousable • Motor function • Dense hemiparesis • Abnormal flexion • Abnormal extension • No response (flaccidity preliminary to death)

  39. Posturing • Abnormal posturing is a late sign of increasing ICP • Decorticate • Abnormal flexion • Decerebrate • Abnormal extension

  40. Increased Intracranial Pressure Sign & Symptoms- Impending Herniation • Decreased LOC • Motor Dysfunctions • Pupillary abnormalities • Impaired Reflexes • Changes in Vital Signs • Irregular respirations

  41. Increased Intracranial Pressure Late Signs Increasing ICP Vital signs • Cushing’s triad • Very late sign of increasing ICP, last ditch effort to perfusebrain • Elevated SBP • Bradycardia • Widening pulse pressure

  42. Increased Intracranial PressureHerniation

  43. Increased Intracranial Pressure Interventions • ABC’s • Mechanically decrease ICP • Hyperventilation • Osmotic Agents

  44. Increased Intracranial Pressure Hyperventilation Goal is to keep CO2 low range of normal • Lowering CO2 controversial • less than 30 mmHg, may cause hypoperfusion, and can be correlated to decreasing survival rates(decreases CBF) • May be needed for Brief periods- acute neurological deterioration or longer in some specific cases. • Vasoconstricts vessels and reduces CBF • Aggressive hyperventilation may cause cerebral ischemia

  45. Increased Intracranial Pressure Osmotic Agents • Mannitol: • IV push • reduces ICP within 15 minutes with continued effectiveness for 2-3 hours • max dose 1gm/kg q 3 hours • Monitor serum osmolarity

  46. Increased Intracranial Pressure Treatment of ICP • Easiest to manipulate is BP and CSF • proper head alignment • sedation • Surgery

  47. Goal • Keep SBP>90

  48. Concussion • Transient impairment of neurological function caused by a mechanical force • Rapid acceleration-deceleration • if repeated can produce a permanent deterioration in intellect • recent studies suggest long term impairment even with “moderate”concussion • “moderate” if loss of consciousness

  49. Concussion • Traumatic reversible neurological deficit • Reversible in minutes to hours • Retrograde or antegrade amnesia

  50. Concussion • Diagnosis • CT scan • Rule out other injury • Clinical picture • History of injury

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