Acute Intracranial Problems Megan McClintock, MS, RN Megan McClintock, MS, RN11/4/11

Head Injury

Skull Fractures Basilar Basilar Frontal Frontal Temporal Temporal Parietal Parietal Posterior fossa Posterior fossa

Head Trauma Diffuse Injuries Diffuse Injuries Concussion Concussion Diffuse axonal injury (DAI) Diffuse axonal injury (DAI) Focal Injuries Focal Injuries Lacerations Lacerations Contusions Contusions Hematomas Hematomas Cranial nerve injuries Cranial nerve injuries

Complications Epidural hematoma Epidural hematoma Bleeding between the dura and the skull Bleeding between the dura and the skull Arterial or venous Arterial or venous Initial LOC, brief lucid interval, decrease in LOC Initial LOC, brief lucid interval, decrease in LOC Headache, nausea, vomiting Headache, nausea, vomiting Subdural hematoma Subdural hematoma Bleeding between the dura mater and the arachnoid layer Bleeding between the dura mater and the arachnoid layer Usually venous Usually venous Acute, subacute, or chronic Acute, subacute, or chronic Symptoms similar to a stroke, TIA, or dementia Symptoms similar to a stroke, TIA, or dementia Intracerebral hematoma Intracerebral hematoma Usually occurs in frontal or temporal lobes Usually occurs in frontal or temporal lobes

Diagnostic Studies CT CT MRI (for smaller lesions) MRI (for smaller lesions) Cervical spine xrays Cervical spine xrays Most important to diagnose timely and get them to surgery (if needed) and keep ICP from increasing Most important to diagnose timely and get them to surgery (if needed) and keep ICP from increasing Craniectomy Craniectomy Craniotomy with surgical evacuation Craniotomy with surgical evacuation Hemicraniectomy Hemicraniectomy

Goals Maintain cerebral blood flow Maintain cerebral blood flow Remain normothermic Remain normothermic Control pain Control pain Prevent infection Prevent infection Attain maximum cognitive, motor, sensory function Attain maximum cognitive, motor, sensory function

Interventions Prevention Prevention Monitor for changes in neuro status Monitor for changes in neuro status Encourage family members to stay Encourage family members to stay Lubricating eye gtts, tape eyes shut Lubricating eye gtts, tape eyes shut Do not allow fever or shivering Do not allow fever or shivering Watch for otorrhea/rhinorhea Watch for otorrhea/rhinorhea HOB up HOB up Collection pad (no packed dressings) Collection pad (no packed dressings) No NG tubes No NG tubes No sneezing or blowing nose No sneezing or blowing nose No nasotracheal suction No nasotracheal suction

Brain Tumors Can occur anywhere Can occur anywhere Can be primary or secondary Can be primary or secondary

Brain Tumors Symptoms depend on location Symptoms depend on location Dx studies – CT, MRI, no LP, biopsy Dx studies – CT, MRI, no LP, biopsy Tx – surgical removal, VP shunt, radiation therapy, chemotherapy Tx – surgical removal, VP shunt, radiation therapy, chemotherapy

Cranial Surgery Burr hole Burr hole Craniotomy Craniotomy Craniectomy Craniectomy Cranioplasty Cranioplasty Stereotactic Stereotactic Shunt Shunt

Interventions Hair is shaved in the OR Hair is shaved in the OR Usually need ICU after surgery Usually need ICU after surgery Prevention of increased ICP Prevention of increased ICP Frequent neuro assessments for first 48 hrs Frequent neuro assessments for first 48 hrs Closely monitor F&E status Closely monitor F&E status Prevention of pain and nausea Prevention of pain and nausea HOB at 30 degrees (except for posterior fossa, burr hole) HOB at 30 degrees (except for posterior fossa, burr hole) Do not position patient on operative side with craniectomy Do not position patient on operative side with craniectomy

Brain Abscess Accumulation of pus within the brain tissue Accumulation of pus within the brain tissue Sx – headache, fever, n/v, focal symptoms, s/s of  ICP Sx – headache, fever, n/v, focal symptoms, s/s of  ICP Tx – antimicrobial therapy, may need surgical drainage or removal (if encapsulated) Tx – antimicrobial therapy, may need surgical drainage or removal (if encapsulated) If untreated, mortality is almost 100% If untreated, mortality is almost 100%

Bacterial Meningitis Usually Streptococcus pneumoniae, Neisseria meningitidis, used to be Haemophilus influenzae Usually Streptococcus pneumoniae, Neisseria meningitidis, used to be Haemophilus influenzae Less common in summer Less common in summer MEDICAL EMERGENCY!!!! MEDICAL EMERGENCY!!!! Sx – fever, headache, n/v, nuchal rigidity, photophobia, decreased LOC,  ICP, skin rash Sx – fever, headache, n/v, nuchal rigidity, photophobia, decreased LOC,  ICP, skin rash Cx – neuro deficits, chronic headache, Waterhouse-Friderichsen syndrome Cx – neuro deficits, chronic headache, Waterhouse-Friderichsen syndrome

Treatment Dx – blood culture, CT, LP (high protein, low glucose, purulent) Dx – blood culture, CT, LP (high protein, low glucose, purulent) Tx – immediate antibiotic therapy (after culture), may give decadron Tx – immediate antibiotic therapy (after culture), may give decadron

Interventions Prevention with immunizations Prevention with immunizations Vigorous treatment of ear and resp infections Vigorous treatment of ear and resp infections Seizure precautions Seizure precautions Codeine for pain Codeine for pain Dark room, cool cloth, quiet, decreased stimuli Dark room, cool cloth, quiet, decreased stimuli Avoid restraints Avoid restraints Family at bedside Family at bedside Control fever Control fever Respiratory isolation!!!! Respiratory isolation!!!!

Viral Meningitis Also called aseptic meningitis Also called aseptic meningitis Caused by a variety of viruses, sometimes through personal contact or by insects, most people have the viruses but don’t develop meningitis Caused by a variety of viruses, sometimes through personal contact or by insects, most people have the viruses but don’t develop meningitis Usually mild and self-limiting Usually mild and self-limiting Give antibiotics until you confirm that it is viral Give antibiotics until you confirm that it is viral Only treat symptoms Only treat symptoms

Encephalitis Acute inflammation of the brain Acute inflammation of the brain Can be fatal Can be fatal Usually caused by a virus Usually caused by a virus See as a complication of AIDS See as a complication of AIDS Sx – fever, headache, n/v, then CNS abnormalities Sx – fever, headache, n/v, then CNS abnormalities Tx – may need ICU, antivirals, Tx – may need ICU, antivirals,

1.Intracranial pressure monitoring is instituted for a patient with a head injury. The patient’s arterial blood pressure is 92/50 mm Hg, and intracranial pressure is 18 mm Hg. Using these values to calculate the patient’s cerebral perfusion pressure (CPP), the nurse determines that 1.the CPP is adequate for normal cerebral blood flow. 2.to prevent cerebral hypoxemia, the patient’s blood pressure should be increased. 3.the CPP is so low that ischemia and neuronal death are imminent. 4.lowering the patient’s blood pressure will reduce the intracranial pressure, increasing cerebral blood flow.

3.Management of the patient with bacterial meningitis includes 1.administering antibiotics immediately following collection of specimens for culture. 2.waiting for results of a CSF culture to identify an organism before initiating treatment. 3.providing symptomatic and supportive treatment because drug therapy is not effective in treatment. 4.obtaining skull x-rays and CT scans to determine the extent of the disease before treatment is started.