Management of Client with Neurologic Trauma Anatomy of the cranium There are various brain contents that are

e localized within a rigid structure. Cranium The cranial vault contents include:

The brain The cerebral spinal fluid The cerebral blood

Cerebral Spinal Fluid (CSF) 150 cc in adults at all times Children slightly less

Produced by choroid plexus 20 cc/hr or 500 cc/day CSF is eliminated by being absorbed into venous system at the subarachnoid villi and jugular system

Cerebral blood and brain Cerebral blood Sum of blood in capillaries, veins, and arteries Brain 80% of the total intracranial volume All of these contents are maintained @ a balanced pressure referred to as intracranial pressure (ICP)

Increase Intracranial Pressure Is the pressure exerted by the cranium on the brain tissue, cerebrospinal fluid (CSF), and the brains circulating blood volume

Constantly fluctuating in response to activities such as exercise, coughing, straining, arterial pulsation, and respiratory cycle

Measured in millimeters of mercury (mmHg) At rest normally 7-15 mmHg for a supine adult

Monro-Kellie Doctrine

The ICP within the skull is directly related to the volume of the contents.

Defined as the Monro-Kellie Doctrine

This doctrine states that any increase in volume of the contents within the brain must be met with a decrease in the other cranial contents. Monro-Kellie Doctrine

Vintracranial

vault

=Vbrain+Vblood +Vcsf

CAUSES OF INCREASE INTRACRANIAL PRESSURE Causes of ICP include a rise in cerebrospinal fluid pressure, increased pressure within the brain matter, bleeding into the brain or fluid around the brain, or swelling within the brain matter itself. - Mass effect: such as brain tumor, infarction with edema, contusions, subdural or epidural hematoma, or abscess all tend to deform the adjacent brain.
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Generalized brain swelling: acute liver failure, hypertensive encephalopathy (tend to decrease the cerebral perfusion pressure but with minimal shifts)

- Increase in venous pressure: heart failure, obstruction of jugular veins, thrombosis - Obstruction to CSF flow and/or absorption: hydrocephalus, meningeal disease (infections) An increase in intracranial pressure is a serious medical problem. The pressure itself can damage the brain or spinal cord by pressing on important brain structures and by restricting blood flow into the brain.

Subdural hematoma develops when blood vessels that are located between the membranes covering the brain (the meninges) leak blood after an injury to the head. This is a serious condition since the increase in intracranial pressure can cause damage to brain tissue and loss of brain function. Elevation of ICP may be graded as follows:

Normal ICP Mild Elevation

0 15mmHg 16 20 mmHg 21 30 mmHg

Moderate Elevation

Severe Elevation 31 40 mmHg Very Severe Elevation 41 mmHg and above PATHOPHYSIOLOGY: Increased ICP is a syndrome that affects many patients with acute neurologic conditions. An elevated ICP is most commonly associated with head injury, secondary effect in other conditions, such as brain tumors, subarachnoid hemorrhage, and toxic and viral encephalopathies. Increased ICP from any cause decreases cerebral perfusion, stimulates further swelling (edema), and shifts brain tissue through openings in the rigid dura, resulting in brain herniation (next slide), a frequently fatal event.
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Early Manifestation: - Decreased level of consciousness - Confusion - Restlessness - Lethargy - Difficulty with memory and thinking - Changes in vision - Headache Later Manifestation: - Continued decrease in LOC (stuporous, comatose) - Dilated pupils, no reaction to light - Hemiplegia that progresses - Vomiting
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- Hypethermia - Bradycardia Late Changes: - Exhibits abnormal motor responses in decorticate or decerebrate posture (coma) - Decreased LOC with difficulty to arouse - Pupils will unilaterally enlarged progressing to fixed and dilated - Speech absent with only moaning - Respiration will be irregular advancing to hyperventilation and respiratory arrest - Loss of corneal and gag reflexes - Positive Babinski reflex (abnormal reflex) - Vital Signs will present the CUSHING TRIAD Hypertension, bradycardia and widening pulse pressure the form of

Decorticate posture is an abnormal posturing in which a person is stiff with bent arms, clenched fists, and legs held out straight. The arms are bent in toward the body and the wrists and fingers are bent and held on the chest. Decerebrate posture is an abnormal body posture that involves the arms and legs being held straight out, the toes being pointed downward, and the head and neck being arched backwards. The muscles are tightened and held rigidly.

Assessment and Diagnostic Findings: The patient may undergo cerebral angiography, computed tomography (CT) scanning, or magnetic resonance imaging (MRI).

Transcranial Doppler studies provide information about cerebral blood flow. The patient with increased ICP may also undergo electrophysiologic monitoring to monitor the pressure (next slide).

Lumbar puncture is avoided in patients with increased ICP because the sudden release of pressure can cause the brain to herniate.

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Intracranial pressure monitoring is performed by inserting a catheter into the head with a sensing device to monitor the pressure around the brain. MEDICAL MANAGEMENT: Increased ICP is a true emergency and must be treated immediately through: Invasive monitoring of ICP to identify increased pressure early in its course (before cerebral damage occurs), to quantify the degree of elevation, to initiate appropriate treatment, access to CSF for sampling and

to provide drainage,

and to evaluate the effectiveness of treatment. Decreasing cerebral edema:

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 Osmotic diuretics (mannitol) may be given to dehydrate the brain tissue and reduce cerebral edema. They reduce the volume of brain and extracellular fluid. Corticosteroids (eg, dexamethasone) help reduce cerebral edema when a brain tumor is the cause of increased ICP. Maintaining cerebral perfusion: The cardiac output may be manipulated to provide adequate perfusion to the brain. Inotropic agents such as dobutamine hydrochloride are used. The effectiveness of the cardiac output is reflected in the cerebral perfusion pressure, which is maintained at greater than 70 mm Hg. A lower cerebral perfusion pressure indicates that the cardiac output is insufficient to maintain adequate cerebral perfusion. Lowering the volume of CSF and cerebral blood: CSF drainage is frequently performed because the removal of CSF with a ventriculostomy drain may dramatically reduce ICP and restore cerebral perfusion pressure. Controlling fever: Preventing a temperature elevation is critical because fever increases cerebral metabolism and the rate at which cerebral edema forms. Maintaining oxygenation: Arterial blood gases must be monitored to ensure that systemic oxygenation remains optimal.

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 Hemoglobin saturation can also be optimized to provide oxygen more efficiently at the cellular level. Reducing metabolic demands: Cellular metabolic demands may be reduced through the administration of high doses of barbiturates when the patient is unresponsive to conventional treatment.

Nursing Process: The Patient with Increased ICP Assessment: Obtain a history of events leading to the present illness; it may be necessary to obtain this information from significant others. The neurologic examination should include an evaluation of mental status, level of consciousness (LOC), cranial nerve function, cerebellar function (balance and coordination), reflexes, and motor and sensory function. Assessment of LOC includes eye opening; verbal and motor responses; pupils (size, equality, reaction to light).

Because the patient is critically ill, ongoing assessment will be more focused, including pupil checks, assessment of selected cranial nerves, frequent measurements of vital signs and intracranial pressure, and use of the Glasgow Coma Scale.

GLASGOW COMA SCALE:

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The Glasgow Coma Scale is a tool for assessing a patients LOC. Scores range from 3 (deep coma) to 15 (normal).

Glasgow Coma Scale Eye opening response 4 Spontaneous To voice To pain None Best verbal response Oriented Confused Inappropriate words Incomprehensible sounds 2 None Best motor response Obeys command Localizes pain Withdraws Flexion (decorticate) Extension (decerebrate) None 1 4 3 2 1 6 5 2 1 5 4 3 3

Total Nursing Diagnoses:

3 to 15

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 Ineffective airway clearance related to diminished protective reflexes (cough, gag) Ineffective breathing patterns related to neurologic dysfunction (brain stem compression, structural displacement) Ineffective cerebral tissue perfusion related to the effects of increased ICP Planning and goals Maintenance of a patent airway, Normalization of respiration, Adequate cerebral tissue perfusion through reduction in ICP, Nursing Interventions:

Maintaining patent airway. Assess the patency of the airway. Suction with care the secretions obstructing the airway, because transient elevations of ICP occur with suctioning. The patient is hyperoxygenated before and after suctioning to maintain adequate oxygenation. Discourage coughing because it increases ICP. Auscultate the lung fields at least every 8 hours to determine the presence of abnormal breath sounds.
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 Elevate the head of the bed may aid in clearing secretions as well as improving venous drainage of the brain.

Achieving an adequate breathing pattern Monitor the patient constantly for respiratory irregularities. This includes Cheyne-Stokes respirations (alternating periods of hyperpnea and apnea) and hyperventilation (increased rate and depth of breathing) (Next slide). A neurologic observation record is maintained. Repeated assessments of the patient are made frequently to immediately note improvement or deterioration. In case of deterioration, preparations are made for surgical intervention.

Optimizing cerebral tissue perfusion Maintain head alignment and elevate head of bed 30 degrees. The rationale is that hyperextension, rotation, or hyperflexion of the neck causes decreased venous return. Avoid extreme hip flexion as this increases intraabdominal and intrathoracic pressures, leading to rise in ICP. Avoid the Valsalva maneuver (straining at stool) as it raises ICP. Administer stool softeners as prescribed. If appropriate, provide high fiber diet.

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 Note abdominal distention. Avoid enemas and cathartics (sorbitol, magnesium citrate, sodium sulfate).

When moving or being turned in bed, instruct the patient to exhale to avoid the Valsalva maneuver

If the patient is on mechanical ventilation, preoxygenate and hyperventilate him, before suction, using 100% oxygen on the ventilator. Suctioning should not last longer than 15 seconds. Avoid activities that raise ICP if possible. Space nursing interventions; this may prevent transient increases in ICP. During nursing interventions, the ICP should not rise above 25 mm Hg and should return to baseline levels within 5 minutes. Patients with Patients with the potential for a significant increase in ICP should receive sedation or paralyzation before initiation of many nursing activities. Avoid emotional stress, frequent arousal from sleep, and environmental stimuli (noise, conversation). Isometric muscle contractions (Pushing against an immovable wall) are also contraindicated because they raise the systemic blood pressure and hence the ICP.

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