9/14/14

Neurological
Emergencies

Sabreena Stratton
MSN, RN, CCRN, CEN

•  Understand basic anatomy of the brain

•  Complete a focused assessment of a brain injured patient

•  Treatment modalities for various head injuries

Learning Objectives

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

CEN Exam 10% is Neuro

15 questions

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

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

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
•  Cranial Nerves
•  Not consciously controlled I.  Olfactory
II.  Optic
•  Cerebral Blood Flow III.  Oculomotor
•  Circle of Willis IV.  Trochlear
V.  Trigeminal
•  Internal Carotid Arteries VI.  Abducens
•  Vertebral Arteries VII.  Facial
•  Venous drains through sinuses in VIII.  Acoustic
dura into jugular veins IX.  Glossopharyngeal
X.  Vagus
•  CSF XI.  Spinal Accessory
•  7-10ml/hr XII.  Hypoglossal
•  Protector
•  Transport system Unconscious?
III, IV, VI: pupils; eye
•  Spinal Cord movement
•  Spinal Canal from Brain Stem to V, VII: corneal, grimace
L-1 and L-2 IX, X: cough, gag

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

Central Nervous System

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•  31 Spinal Nerves
•  dermatomes
•  Autonomic Nervous
System
•  Sympathetic
•  Fight or flight
•  Parasympathetic
•  Conserve energy

Peripheral Nervous
System

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

Neuro Assessment

What is the most reliable

indicator of neurologic
function??

Level Of Consciousness

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Alert
u Oriented x4, awake, following
commands

Verbal
u Responds to voice; not fully
oriented

Painful Stimulus u Responds to painful stimulus

u Unresponsive
Unresponsive

AVPU

Level of Consciousness

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

Central vs. Peripheral Stimulation??

Herniation
Uncal: lateral shift of
brainàipsilateral dilated pupil

Supratentorial: brain pushing

downwardà

Pinpoint: parasympathetic
Dilated: sympathetic
http://upload.wikimedia.org/wikipedia/commons/f/f2/Trauma_subdural_arrows.jpg

What percentage of the

Pupils population have a normal
finding of unequal pupils??

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

EARLY LATE

Headache Fixed, dilated pupil

Nausea/Vomiting Unresponsive
Amnesia Posturing
LOC Hypertension
Drowsiness Altered Respirations

Intracranial Pressure

EARLY LATE

Headache Fixed, dilated pupil

Nausea/Vomiting Unresponsive
Amnesia Posturing
LOC Hypertension
Drowsiness Altered Respirations

Intracranial Pressure

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Heart rate
Increased: ↑ ICP
Cushing’s Reflex: Decreased: ↑ ICP (terminal), neurogenic
Hypertension, shock, autonomic dysreflexia
widening pulse Blood pressure
pressure, decreased Increased: ↑ ICP, autonomic dysreflexia
heart rate Decreased: ↑ ICP (terminal), neurogenic
shock
Respirations (abnormal): brain stem
Treatment?? compression
Temperature
Increased: hypothalamic injury,
neurogenic shock
Decreased: neurogenic shock

Vitals

SENSORY

Neuro Assessment

Inflammation of the meningeal layers

Headache surrounding the brain and spinal cord
N/V ²  Viralàgradual onset, less acute.
²  Enterovir, herpesvirus

Lethargy ²  Increased Protein, normal lglucose, clear CSF, 10-1000

leukocytes

Chills ²  Bacterialàacute onset, fatal in 50%

²  Streptococcus, neisseria, haemophilus, group B and Listeria
Photophobia ²  Higher protein>200, decreased glucose, pruluent, leukocytes
1,000-20,000
Nuchal Rigidity ²  Fungalàimmune-compromised
Brudzinski’s Reflex individuals
²  Aspergillus , Candida
Kernig’s Reflex ²  Low Leukocytes <500, low glucose, >200 protein

Treatment
CT head before Lumbar Puncture

Meningitis

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Decreased CBFàdeprived 02 and glucoseàcellular

ischemiaàcerebral 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

ThromboemobolicàtPA

HemorrhagicàSurgical
intervention and ICP manageent

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

Stroke

Neuro Trauma

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Protects brain from

injury acting as a
cushion

Extensive vascular
supply with poor
vasoconstrictive
properties

Direct pressure,
wound care, staples,
tDAP

Scalp Lacerations

Clinical presentation
affected by:
•  type of fracture
•  area involved
•  damage to underlying
structures
S/S
•  Combative
•  Racoon Eyes
•  Battle’s Sign
•  Heotympanum
•  CSF leak

Skull Fractures

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:
http://www.braininjury.com/images/injured01.gif
Ø Prservation of neuro
function
Ø Pain control
Ø Adequate hydration

Cerebral Contusions

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u Bleeding b/w skull and dura

mater
u Middle Meningeal Artery
involvement >50% mortality
rate
u 50% don’t have skull fracture
u Unconsciousàlucidityàuncon
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

Epidural Hematoma

Subdural Hematoma
Bleeding into subdural space between the dura mater and arachnoid

Occur more frequently than other intracranial injuries

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

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

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

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

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

Diffuse Axonal Injury

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

What is the patients GCS?

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A patient has survived a A.  Deep vein thrombosis, a frequently

TBI and was discharged neglected complication of
with a basilar skull immobility
fracture.
B.  Meningitis, a potential
complication of basilar skull
He presents back to the fractures
ED from a rehab center
C.  Hypothalamic dysfunction or
with an elevated
‘storming’ a potentially lethal
temperature. Although
febrile syndrome after head trauma
the POC is multifactorial,
the most important aspect D.  Foreign bodies still embedded in
will center on the skull base, a common source of
identifying… infection

Questions…

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

Discharge teaching would be considered

effective if the caregiver of a concussed
patient…

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

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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

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.

References

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