Neurological Emergencies

Syncope

Definition:

Syncope (fainting) is sudden and transient loss of consciousness followed

by a fall from a standing or sitting position, which is caused by cerebral
ischemia (lack of blood flow to brain).

Clinical Manifestation:

Before the episode, the patient may complain of:

 Cold, clammy, and sweaty skin

 Fast breathing and pounding heartbeat

 Headache, blurred vision, or double vision

 Lightheadedness or dizziness

 Tingling sensation or numbness

Causes of syncope:

 Vasovagal response (fear, pain, blood phobia, stress, instrumentation)

 Cardiac dysrhythmia (Bradycardia, SVT, pacemaker malfunction).
 Anemia
 Orthostatic hypotension (Rapid drop of BP on standing).
 Hypoglycemia
 Dehydration
Management of syncope:

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– ABCs

– Keep patient supine and elevate legs.

– Oxygen administration

– During assessment, try to get a detailed description of precipitating

factors, signs, and symptoms.

– Intravenous access and fluids if indicated.

– Glucose administration if needed

– Pharmacologic circulatory support as ordered

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 Seizure
Seizure is abnormal episodes of electrical discharges in the cerebral cortex.

Causes of Seizure:

Intracranial Events
 Traumatic birth injury (hypoxia)

 Epilepsy

 Head injury

 Brain tumor
 Cerebrovascular accident (CVA)

Medical Disorders
 Hypertensive crisis
 Heart, liver, lung, or kidney disease

 Systemic lupus erythematosus

Infectious Processes
 Meningitis
 Encephalitis

 Septicemia

Metabolic Imbalances
 Fluid and electrolyte imbalance

 Hypoglycemia

Drug-Related Processes
 Drug Overdose

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  Drug Withdrawal

 Alcohol toxicity

Clinical Manifestation:
 Pleasant or unpleasant sense of smell (aura)
 Convulsions on one side of the body, one area of the body, or entire
body
 Loss of consciousness (Abruptly stopping activity; may fall to the
ground)
 Muscle spasms

 Cyanosis

 Inability to speak or respond

 Excessive salivation
 Staring

 Confusion or altered consciousness

 Loss of bowel or bladder control

 Numbness or tingling in specific body area

 Abnormal movements

 Twitching of eyelids and facial muscles

Types of seizures:
 Generalized seizures
Generalized seizures are produced by electrical impulses from the entire
brain.

 Focal (or partial) seizures

Focal (or partial) seizures occur when seizure activity is limited to a part of
one brain hemisphere. There is a site, or a focus, in the brain where the
seizure begins.

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The different types of generalized seizures are:
 Absence seizures (formerly known as petit mal)

 Tonic-clonic (known as grand mal)

 Clonic seizures: are repetitive, rhythmic jerks that involve both sides
of the body at the same time.
 Tonic seizures: are characterized by stiffening and rigidity of the
muscles. Muscles are maintained in continuous contracted state (rigid
posture).

 Atonic seizures: consist of a sudden and general loss of muscle tone,

which often results in a fall.

 Myoclonic seizures: Sporadic (isolated), jerking movements in parts

or all of the body.

Focal seizures are divided according to their clinical expression into:

 Simple focal seizures (the person remains conscious)

 Complex focal seizures (the person has a change or loss of

consciousness).

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Pre-hospital Emergency care
During a seizure, you should do the following:

 Support victim and ease him to the floor (if seated).

 Clear away any surrounding hard objects to prevent injury to the

victim

 Loosen constrictive clothing

 Do not restrain the patient.

 Do not place any objects in the patient’s mouth.

 place the victim in the recovery position
 stay until the victim is fully recovered (check ABC)

Nursing care for a hospitalized patient with a seizure disorder:

 Ensure patent airway and promote adequate oxygenation. Protect

patient from injury during seizure. During a seizure, the nurse
should do the following:

• Turn the patient to the side and use the chin lift or jaw thrust
maneuver as needed.

• Raise side rails and place pillow or padding around the patient.

• Maintain patient privacy

• Do not restrain the patient.

• Maintain the bed in low position

• Remove or loosen tight clothing

• Never try to force the jaw open or insert an oral airway during the
seizure.
• Suction the oropharynx, as needed.

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• Provide supplemental oxygen via nasal cannula as ordered.

• After the seizure, insert a nasogastric tube (NGT) and connect it to

low suction

 Stay with patient until seizure has passed, observe and record
details of the event:
 Vital signs, O2 saturation, and level of consciousness.

 The nurse should carefully observe and record details of the event
because the diagnosis and subsequent treatment often rest solely on
the seizure description. Note all aspects of the seizure:
 What events preceded the seizure?

 When did the seizure occur?

 How long did each phase (aural [if any], ictal, postictal) last?

 What occurred during each phase?

 Note the exact onset of the seizure (which body part was
affected first and how)

 Note the course and nature of the seizure activity (loss of

consciousness, tongue biting, stiffening, jerking, total lack of
muscle tone……)

 Assessment of the postictal period should include a detailed

description of:
 level of consciousness

 vital signs

 pupil size and position of the eyes

 muscle soreness
 speech disorders (aphasia, dysarthria)

 weakness or paralysis

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  sleep period

 After motor activity stops, the nurse should do the following:

 Place the patient in the side lying position.

 Monitor vital signs, O2 saturation, and level of consciousness, pupil

size and reactivity every 15 minutes until condition stabilizes.

 Inspect the oropharynx, tongue, teeth for seizure-related injury.

Reassure and orient the patient after seizure.

 Give IV dextrose for hypoglycemia as ordered.

 Avoid excessive environmental stimulation during the postictal
period.

Status epilepticus:

 Status epilepticus is a state of continuous seizure activity or a

condition in which seizures recur in rapid succession without return to
consciousness between seizures.

 It is the most serious complication of epilepsy and is a neurologic

emergency. Status epilepticus can occur with any type of seizure.
During repeated seizures the brain uses more energy than can be
supplied.

 Neurons become exhausted and cease to function. Permanent brain

damage may result. Tonic-clonic status epilepticus is the most
dangerous because it can cause ventilatory insufficiency, hypoxemia,
cardiac dysrhythmias, hyperthermia, and systemic acidosis, all of
which can be fatal.

Emergency treatment for patients with status epilepticus include:

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 If seizure are persistent or frequent recur, notify the doctor
immediately and anticipate the need for endotracheal intubation and
mechanical ventilation.

 Administer I.V anti-seizure medication as ordered. Commonly

ordered medications for status epilepticus consists of diazepam
(Valium), lorazepam (Ativan), fosphenytoin (Cerebyx), phenytoin, or
phenobarbital. Rationale: Prolonged seizures may result in respiratory
depression or arrest, cardiovascular insufficiency, or cerebral edema.
Anti-seizure medications suppress the ectopic focus.

 I.V. thiamine in patients with chronic alcoholism or those who are

undergoing withdrawal.

 Observe the patient closely for vital signs (P, BP, R, Temp, LOC).

 I.V. dextrose 50% when seizures are secondary to hypoglycemia

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 Increased Intracranial Pressure (↑ICP)

Definition:
Increased intracranial pressure (ICP) is a rise in pressure around the brain. It
may be due to an increase in the volume of cerebrospinal fluid, cerebral
blood, or brain tissue.
Causes:
 Head injury (most common condition)
 Brain tumors
 Hemorrhage
 Stroke
 Toxic and viral encephalopathy
Clinical manifestation:
 Deteriorating level of consciousness
 Fixed, dilated pupils
 Vital sign changes known as Cushing’s triad or reflex. Cushing’s triad
refers to bradycardia, increasing systolic pressure, widening pulse
pressure (the difference between the systolic and the diastolic
pressures) and respiratory irregularities. Respiratory changes include:
 Cheyne-Stokes breathing: periods of apnea, decreased respiratory rate
and depth.
 Ataxic breathing: irregular breathing with a random sequence of deep
and shallow breaths.
Diagnostic investigations:
The diagnostic studies used to determine the underlying cause of increased
ICP are: The patient may undergo
 Computed tomography (CT) scanning
 Magnetic resonance imaging (MRI)
 Cerebral angiography

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  Transcranial Doppler studies provide information about cerebral
blood flow.
Complications:
 Brain stem herniation
 Diabetes insipidus
 Syndrome of inappropriate antidiuretic hormone (SIADH)
Medical Management:
Increased ICP is a true emergency and must be treated promptly. Immediate
management to relieve increased ICP involves:
• Decreasing cerebral edema: administering osmotic diuretics
(mannitol) and corticosteroids (eg, dexamethasone), restricting fluids,
controlling fever (antipyretic medications and use of a cooling
blanket).
• Maintain cerebral tissue perfusion: Maintaining systemic blood
pressure and oxygenation. The cardiac output may be manipulated to
provide adequate perfusion to the brain. Improvements in cardiac
output are made using fluid volume and inotropic agents such as
dobutamine hydrochloride. Arterial blood gases (ABG) must be
monitored to ensure that systemic oxygenation remains optimal.
• Hemoglobin saturation can also be optimized to provide oxygen more
efficiently at the cellular level.
• Lowering the volume of CSF: ventriculostomy or exraventricular
drain is used to relieve elevated ICP when the normal flow of
cerebrospinal fluid inside the brain is obstructed. Caution should be
used in draining CSF because excessive drainage may result in
collapse of the ventricles.

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Nursing Interventions

Maintaining a patent airway and Achieving an adequate breathing

pattern:
 Assess the patency of the airway.
 Elevating the head of the bed may aid in expansion of chest cavity
and clearing secretions.
 Suction, as necessary for no more than 15 seconds / catheter Insertion
because time should be limit to prevent the build-up of CO2 cerebral
vasodilator, which leads to  ICP.
 The patient is hyper-oxygenated before and after suctioning to
maintain adequate oxygenation.
 Auscultate chest at least every 8 hours to determine the presence of
abnormal breath sounds or any areas of congestion.
 Monitor ABG, PaCO2 is usually maintained at 35 to 45 mm Hg.
 Coughing is discouraged because coughing increase ICP.
Optimizing cerebral perfusion:
 Assess the patient's level of consciousness, pupillary reactions (size,
position, and reactivity), and vital signs every 1 hour and as necessary.
Rationale: Changes in any of these parameters may indicate
deterioration in the patient's neurologic condition.
 Monitor ICP (if an ICP monitoring device is in place) Rationale: ICP
indicates how well the three components of the intracranial cavity are
balanced.
 Instruct the patient to avoid the following activities:
 straining at stool
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  holding breath while moving or turning in bed
 coughing
 nose blowing
 extreme hip flexion (90 degrees or more)
Rational: These activities increase intra-thoracic and intra-abdominal
pressure, which decreases cerebral venous return and increasing ICP.
• Instruct the alert patient to avoid pushing the feet against a footboard
or the arms against the bed. Rational: Theses activities produce
isometric muscle contractions. Which increase muscle tension without
lengthening the muscle. Theses contractions raise the systemic blood
pressure and result in increased ICP.
• Administer prescribed medication, for shivering Rational: Shivering
is a form of isometric contraction and thus can increase ICP.
• Use restraints only when absolutely necessary and as ordered.
Rational: Restraints may cause the patient to struggle. Both the
simulating and the resulting increased activity (producing increased
heart rate and increased blood flow to the brain) elevate ICP.
• Space activities when possible, especially routine care activities, such
as baths, mouth care, and bed changes. Rational: Closely spaced
activities can have a cumulative effect, causing greater and more
prolonged elevation of increased ICP than a single activity.
• Elevate the head of bed 30 to 60 degrees at all times, or as ordered
Rational: to improve venous drainage of the brain.
• keep patiet’s head and neck in a natural position at all times,
Rational: because compression or distortion of the jugular veins
increases ICP.
• Avoid the Valsalva maneuver, which can be produced by straining at
defecation or moving in bed, Rational: Valsalva maneuver increases
intra-abdominal and intra-thoracic pressure which lead to increase
ICP.
• Stool softeners may be prescribed.
• If the patient is alert and able to eat, a diet high in fiber may be
indicated.
• Instructed the patient to exhale when moving or being turned in
bed.
• Note abdominal distention, which increases intra-abdominal
and intra-thoracic pressure and ICP.
• Enemas and cathartics are avoided if possible.
• Structure the environment to reduce unpleasant stimuli. Rational:
Unpleasant or noxious stimuli can increase ICP. They also increase
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 systemic blood pressure, which may increase ICP in the patient with
poor or absent autoregulation.
• Avoid unnecessary emotionally stimulating conversation (for
example, about prognosis or condition)
• Provide a quiet room
• Avoid jarring the patient’s bed.
• Provide soft stimuli, such as a soft voice, soft music, and a
gentle touch when necessary.
• Space painful nursing or medical procedures
• When necessary to awaken the patient, use gentle touch and a
soft voice.
• Avoid unnecessary disturbances.
Maintaining negative fluid balance:
 Monitor fluid intake and output hourly.
 An indwelling urinary catheter is inserted to permit assessment of
renal function and fluid status.
 Assess vital signs, and monitor blood pressure to assess fluid volume
status.
 Monitor skin turgor and mucous membranes.
 Administered intravenous fluid at a slow to moderate rate with an
intravenous infusion pump to prevent too-rapid administration and
avoid over-hydration.
 Frequently rinsing the mouth, lubricating the lips, and removing
encrustations relieve dryness and promote comfort.
Preventing infection:
• Maintain strict sterile or aseptic technique as appropriate for
catheterization, endotracheal tube care, and closed intracranial
drainage system care Rational: Sepsis is the primary concern with
any invasive equipment or procedure. Using the appropriate technique
will help prevent infection.
• The dressing over the ventricular catheter must be kept dry because a
wet dressing is conducive to bacterial growth.
• The patient is monitored for signs and symptoms of meningitis: fever,
chills, nuchal (neck) rigidity, and increasing or persisting headache.
• Assess periodically for signs and symptoms of infection: Rational:
Early detection of infection allows for prompt and appropriate
intervention. signs and symptoms of infection may include:
• Redness, tenderness, or warmth around infection sites or
wounds (check daily)
• Cloudy or foul-smelling drainage (check daily)
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• Fever
• Elevated WBC count (monitor as ordered) positive urine,
sputum, blood, or wound cultures (monitor as ordered)
• Infiltrates chest x-ray (monitor as ordered).

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 Head Injury
Definition:

Head injury includes any injury or trauma to the scalp, skull, or brain.
Males are twice as likely to sustain a TBI as females. Children ages 6
months to 2 years, young adults ages 15 to 24, and older adults are most at
risk for head trauma.

Causes of head injury:

Head injury commonly results from:

 Motor vehicle (the most common cause of serious injuries)

 Falls
 Interpersonal violence: assault, gunshot or knife wounds
 Sports-related accidents (e.g., Diving, boxing, football)
 Industrial accidents
 War-related injuries

Scalp injuries/Lacerations:

 Scalp injury is a cut wound of scalp and easily recognized type of

head trauma.
 The major complications associated with scalp laceration are blood
loss and infection.

Emergency care for scalp injury:

 Control bleeding using direct pressure (use sterile gauze)

 Clean and irrigated the wound to remove foreign matter
 Suturing the wound
 Cover the wound using sterile gauze and bandage

Skull injuries and fractures of the skull may occur with or without brain
injury.

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Types of skull fractures are:

 Linear fracture (non-displaced cracks in the bone)

 Comminuted fracture (the bone is broken into fragments)
 Depressed fracture (bone fragments pressing into the intracranial
cavity)
 Compound (scalp injry and depressed skull fracture with
communicating pathway to intracranial cavity)
 Basilar fracture (fracture of the bones in the base of the skull). The
dura mater can easily tear, and CSF can leak from the ears or nose.

Manifestations of Basilar skull fracture may include:

 Cranial nerve deficits

 Battle’s sign (post-auricular ecchymosis),
 Periorbital ecchymosis (raccoon eyes)
 Rhinorrhea (CSF leakage from the nose) or otorrhea (CSF leakage
from the ear)

The risk of meningitis is high with a CSF leak, and antibiotics should be
administered as a preventive measure. Two methods of testing can be used
to determine whether the fluid leaking from the nose or ear is CSF:

 Dextrostix or Tes-Tape strip to determine whether glucose is present.

 Halo or ring sign

Brain injuries:

A serious form of head injury is traumatic brain injury (TBI).

Brain injury can be classified as:

 minor (GCS 13 to 15)

 Moderate (GCS 9 to 12)

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  Severe (GCS 3 to 8).

Types of brain injury include:

 Concussion: Concussions are transient neurological deficits caused

by shaking the brain. It is the most minor and most common form of
head injury.
 Contusion: Contusions are surface bruises of the brain.
 Cerebral laceration: Cerebral laceration is the tearing of cortical
tissue.
 Intracranial hemorrhage: Intracranial hemorrhage, may be due to an
arterial or venous bleed. Bleeding occurs in the epidural space,
subdural space, subarachnoid space, ventricles, or intracerebrally.
Neurological change is caused by pressure on the brain resulting from
the hemorrhage.

Clinical manifestation of head injury:

Neurological deficits depend on the extent and location of injury. It may

include:

• Loss of consciousness for a few seconds to a few minutes

• No loss of consciousness, but a state of being daze, confused or

disoriented

• Headache

• Nausea or vomiting

• Nervousness

• Dizziness, vertigo

• Fatigue or drowsiness
• Insomnia (difficulty sleeping)

• Sleep more than usual

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 • loss of mentation (ability to concentrate, remember)

• Problem with speech

• Pupillary abnormalities (changes in shape, size, and response to light)

• Altered or absent gag reflex

• Absent corneal reflex

• Changes in vital signs (altered respiratory pattern, hypertension,
bradycardia, tachycardia, hypothermia or hyperthermia)

• Sensory dysfunction (Vision and hearing impairment)

• Spasticity
• Motor dysfunction (e.g., hemiparesis, hemiplegia, paraplegia)

• Abnormal posturing (decorticate or decerebrate)

• Seizures

Possible complications of head injury include:

• Intracranial hemorrhage

• Increased ICP due to edema or hematoma formation

• Infection (in open and penetrating wounds)

• Respiratory failure

• Brain herniation

• Epidural hematoma results from bleeding between the dura and the
inner surface of the skull. An epidural hematoma is a neurologic
emergency.

• Subdural hematoma occurs from bleeding between the dura mater

and the arachnoid layer. Subdural hematomas are acute (within 48

19
 hours of injury), subacute (from 2 to 14 days after injury), or chronic
(from 2 weeks to months after injury).

• Subarachnoid (below the arachnoid) and intraventricular (within

the ventricles of the brain) hemorrhages are common in severe head
injury. Blood in the subarachnoid space interferes with the
reabsorption of CSF, further increasing intracranial pressure.

• Intracerebral hematoma occurs from bleeding within the brain

tissue. It usually occurs within the frontal and temporal lobes.

Diagnostic Studies
• CT (MRI), positron emission tomography (PET), transcranial Doppler
studies

• A cervical spine x-ray series, CT scan, or MRI of the spine may also
be indicated, since cervical spine trauma often occurs at the same time
as a head injury.

Emergency nursing management

N.B: Observation and management of increased ICP are the primary

management strategies.

Pre-hospital:
 Ensure patent airway and consider stabilize cervical spine (assume
neck injury with head injury).

 Assess for rhinorrhea, otorrhea, and scalp wounds.

 Control external bleeding with sterile pressure dressing.

 Administer O2 via non-rebreather mask.

 Establish IV access with two large-bore catheters to infuse normal

saline or lactated Ringer’s solution according physician order.

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  Administer fluids cautiously to prevent fluid overload and increasing
ICP.

 Assess vital signs, level of consciousness, pupil size and reactivity.

 Maintain patient warmth using blankets.

In-hospital:

 Elevating the head of the bed 30 to 60 degrees at all times, or as

ordered. Rational: may aid in expansion of chest cavity and
improving venous drainage of the brain.

 Keep the head and neck in a natural position Rational: because

compression or distortion of the jugular veins increases ICP.

 Assess the patency of the airway.

 Administer O2 via non-rebreather mask.

 Monitor vital signs (pulse, blood pressure, respiratory pattern,

temperature, level of consciousness and pupillary reactions) every 1
hour and as necessary. Rationale: Changes in any of these parameters
may indicate deterioration in the patient's neurologic condition.

 Monitor ABG levels as ordered (PaCO2, is usually maintained at 35

to 45 mm Hg).

 Anticipate need for intubation if gag reflex is impaired or absent.

 Suction, as necessary. The patient is hyper-oxygenated before and

after suctioning to maintain adequate oxygenation.

 Monitor fluid intake and output hourly.

 Insert urinary catheter to permit assessment of renal function and fluid

status.

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 Administered intravenous fluids at a slow to moderate rate with an
intravenous infusion pump to prevent too-rapid administration and
avoid over-hydration.

 Maintain strict aseptic technique as appropriate for catheterization,

endotracheal tube care, and closed intracranial drainage system care
Rational: Sepsis is the primary concern with any invasive equipment
or procedure. Using the appropriate technique will help prevent
infection.

 Avoid Valsalva maneuver, Rational: Valsalva maneuver increases

intra-abdominal and intra-thoracic pressure which lead to increase
ICP.

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 Cerebrovascular Accident (CVA)

Definition:

Cerebrovascular accident (CVA), or stroke, is a “brain attack.” It is a

sudden loss of function resulting from disruption of the blood supply to a
part of the brain.

Risk Factors for Stroke:

Non-modifiable risk factors include:

 Age
 Gender

 Ethnicity or race
 Family history or heredity

Modifiable risk factors include:

 Past history of a transient ischemic attack (TIA)

 Hypertension
 Heart disease

 Diabetes mellitus
 Sleep apnea

 Metabolic syndrome

 Lifestyle

 Smoking

 Excessive alcohol consumption

 Obesity

 Lack of physical exercise

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  Poor diet

 Drug abuse

Transient ischemic attack (TSA)

 Causes: severe cerebral vasospasm

Transient ischemic attacks (TIAs) are mini-strokes and frequently precede

a stroke. A TIA is a temporary or transient episode of neurological
dysfunction caused by temporary impairment of blood flow to the brain. The
loss of motor or sensory function may last from a few seconds to minutes to
1 hour.

The classic symptoms of transient ischemic attacks are:

 Sudden blurring of vision or blindness,
 Loss of balance or coordination,

 Difficulty speaking or understanding simple statements,

 Weakness/numbness/paralysis in the face, arm, or leg.

Types and causes of stroke:

Strokes are classified as:

 Ischemic stroke
 thrombus

 embolus

 Hemorrhagic stroke

 uncontrolled hypertension, is the most common cause of

intracerebral hemorrhage

 ruptured aneurysm
 ruptured arteriovenous malformation

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  coagulation disorders, anticoagulant and thrombolytic drugs

 head injury

Ischemic Stroke

An ischemic stroke results from inadequate blood flow to the brain from
partial or complete occlusion of an artery. Nearly 85% of strokes are
ischemic. TIA attack is usually a precursor to ischemic stroke. Ischemic
strokes are further divided into thrombotic and embolic strokes.

Hemorrhagic Stroke

Hemorrhagic strokes account for 15% of cerebrovascular disorders and are

primarily caused by an intracranial or subarachnoid hemorrhage. Patients
generally have more severe deficits and a longer recovery time compared to
those with ischemic stroke

Clinical manifestations:

Clinical manifestations of stroke vary according to the location of

interrupted blood supply in the brain. Common neurological deficits are:

 Motor deficits

 Hemiplegia (paralysis of one side of the body on the side

opposite of the brain lesion),

 hemiparesis (weakness of one side of the body)

 Dysarthria (impairment of speech caused by muscle

dysfunction)

 Dysphagia (impairment of swallowing muscles).

 Sensory deficits include

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  Visual deficits of double vision, decreased visual acuity,
hemianopia, the loss of vision in half of the visual field on the
same side of both eyes.

 Decreased sensation to touch, pressure, pain, heat, and cold.

 Confusion and disorientation.

 Intellectual deficits include memory impairment, poor judgment,

short attention span

 Emotional deficits include depression and decreased tolerance to

stressors.

 Bowel and bladder dysfunction: Most clients experience initial

bowel and bladder dysfunction. Use of bowel and bladder retraining
programs, most clients regain continence of bowel and bladder.

 Unilateral neglect: These clients usually show unilateral neglect, or

the failure to recognize or care for the affected side of the body.

Diagnostic Studies for Stroke:

Once the individual suspected of TIA or stroke arrives in the emergency

department, it is important to rapidly assess and diagnose the patient usually
through:

 Non-contrast head CT or MRI

These tests can rapidly distinguish between ischemic and hemorrhagic stroke
and help determine the size and location of the stroke. Rapid access to these
diagnostic tools is important, since the results will determine treatment
options for the patient.

 Cardiac imaging
 Cerebral angiography

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  Transcranial Doppler (TCD), ultrasonography
 Carotid duplex scanning
 A lumbar puncture
 Blood tests

Medical Management:

• Medical management of the client with CVA is directed toward

airway maintenance and supportive therapy during the first 24 to 48
hours.

• Early diagnosis of the cause and type of stroke is necessary to

determine the appropriate treatment.

• Maintaining adequate cerebral perfusion and preventing cerebral

edema to reduce neurological deficit.

• Respiratory failure is treated with mechanical ventilation; temperature

is regulated, with the help of a hypothermia blanket if necessary.

Pharmacological

• Antihypertensive drugs are used to control blood pressure.

• To dissolve the clot, thrombolytic drugs such as alteplase (Activase),

anistreplase (Eminase), streptokinase (Streptase), or urokinase
(Abbokinase) are given within 3 hours of the stroke. A stroke caused
by bleeding would not be treated with thrombolytic agents.

• Anticoagulants, aspirin, heparin, or Coumadin are used to prevent

further clot formation in cases of stroke caused by thrombi.

• Dexamethasone (Decadron) is be used to reduce intracranial pressure.

• Anticonvulsants such as phenytoin (Dilantin) is used if convulsions

are present.

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THROMBOLYTIC THERAPY (t-PA therapy):

Thrombolytic agents are used to treat ischemic stroke by dissolving the

blood clot that is blocking blood flow to the brain.

 Rapid definitive diagnosis of an ischemic stroke by CT .

 initiation of thrombolytic therapy within 3 hours of onset of stroke

 Once it is determined that the patient is a candidate for t-PA therapy,

no anticoagulants are to be administered in the next 24 hours.

Some of the contraindications for thrombolytic therapy include:

 Symptom onset greater than 3 hours prior to admission,

 Patient who is receiving heparin during the past 48 hours with

elevated partial thromboplastin time

 Patient who has had a recent myocardial infarction,

 Patient who has had stroke or serious head injury within 3 months

Nursing management during administration of Thrombolytic agents:

 Continuous vital signs monitoring: vital signs are obtained as follows:

 Every 15 minutes for the first 2 hours,

 Every 30 minutes for the next 6 hours,

 Then every hour for 16 hours.

 Blood pressure should be maintained with the systolic pressure

less than 180 mm Hg and the diastolic pressure less than 100
mm Hg.

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  Airway management is instituted based on the patient’s clinical
condition and arterial blood gas values.

 Bleeding is the most common side effect of t-PA administration, and

the patient should be closely monitored for any bleeding (intracranial,
intravenous [IV] insertion sites, urinary catheter site, endotracheal
tube, nasogastric tube, urine, stool, emesis, other secretions)
(Scroggins, 2000). Intracranial bleeding is a major complication that
occurs in approximately 6.5% of patients.

Emergency nursing management

N.B: Observation and management of increased ICP are the primary

management strategies.

Pre-hospital:

 Ensure patent airway

 Administer O2 via non-rebreather mask.

 Establish IV access with two large-bore catheters to infuse normal

saline or lactated Ringer’s solution according physician order.

 Administer fluids cautiously to prevent fluid overload and increasing

ICP.

 Assess vital signs, level of consciousness, pupil size and reactivity.

 Maintain patient warmth using blankets.

In-hospital:

 Elevating the head of the bed 30 to 60 degrees at all times, or as

ordered. Rational: may aid in expansion of chest cavity and
improving venous drainage of the brain.

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 Keep the head and neck in a natural position Rational: because
compression or distortion of the jugular veins increases ICP.

 Assess the patency of the airway.

 Administer O2 via non-rebreather mask.

 Monitor vital signs (pulse, blood pressure, respiratory pattern,

temperature, level of consciousness and pupillary reactions) every 1
hour and as necessary. Rationale: Changes in any of these parameters
may indicate deterioration in the patient's neurologic condition.

 Monitor ABG levels as ordered (PaCO2, is usually maintained at 35

to 45 mm Hg).

 Anticipate need for intubation if gag reflex is impaired or absent.

 Suction, as necessary. The patient is hyper-oxygenated before and

after suctioning to maintain adequate oxygenation.

 Monitor fluid intake and output hourly.

 Insert urinary catheter to permit assessment of renal function and fluid

status.

 Administered intravenous fluids at a slow to moderate rate with an

intravenous infusion pump to prevent too-rapid administration and
avoid over-hydration.

 Maintain strict aseptic technique as appropriate for catheterization,

endotracheal tube care, and closed intracranial drainage system care
Rational: Sepsis is the primary concern with any invasive equipment
or procedure. Using the appropriate technique will help prevent
infection.

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 Avoid Valsalva maneuver, Rational: Valsalva maneuver increases
intra-abdominal and intra-thoracic pressure which lead to increase
ICP.

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 Traumatic Spinal Cord Injury
Definition:
Spinal cord injury (SCI) occurs from trauma to the spinal cord or from
compression of the spinal cord caused by injury to the supporting structures.
Causes:
• Motor vehicle collisions (the most common cause of serious injuries)
• Falls
• Interpersonal violence: assault, gunshot or knife wounds
• Sports-related /Recreational accidents (e.g., Diving, boxing, football)
• Industrial accidents
• war-related injuries
Classification of Spinal Cord Injury:
Spinal cord injuries are classified according to the mechanism of injury,
level of injury, or degree of injury.
 According to mechanism of injury:
 Flexion
 Hyperextension
 Flexion-rotation
 Extension-rotation
 Compression
 According to level of injury:
 Cervical
 Thoracic
 Lumbar
 Sacral
 According to degree of injury:

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  Complete cord involvement (total transection) results in flaccid
paralysis and total loss of sensory and motor function and
reflexes at and below the level of the injury.
 Incomplete cord involvement (partial transection) results in a
mixed loss of voluntary motor activity and sensation and leaves
some tracts intact.
Clinical Manifestations:
Impaired movement and sensory function:
 C4 injury, results in quadriplegia (paralysis of all four extremities).
 C6 injury, results in partial paralysis of the hands and arms as well
as paralysis of lower body.
 If the thoracic, lumbar, or sacral spinal cord is damaged, the result is
paraplegia (paralysis and loss of sensation in the legs).
Respiratory manifestation:
 Cervical injury above the level of C4 (called high cervical injuries)
may be fatal because loss of innervation to the abdominal muscles,
diaphragm and intercostal muscles [i.e., total loss of respiratory
muscle function (hanging mechanism)]. Mechanical ventilation is
required to keep the patient alive.
 Cervical injury below the level of C4 Injury below the level of C4
results in diaphragmatic breathing if the phrenic nerve is functioning.
Hypoventilation almost always occurs with diaphragmatic
respirations.
 Cervical and thoracic injuries cause a paralysis of abdominal
musculature and frequently intercostal musculature; therefore the
patient cannot cough effectively enough to remove secretions, leading
to atelectasis and pneumonia.
Cardiovascular manifestations:
 Spinal cord injury above the level of T6 results in bradycardia.
Cardiac monitoring is necessary. In marked bradycardia (heart rate
less than 40 beats/minute), appropriate drugs (e.g., atropine) to
increase the heart rate and prevent hypoxemia are necessary.

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  Peripheral vasodilation results in hypotension: The peripheral
vasodilation reduces the venous return of blood to the heart and
subsequently decreases cardiac output, resulting in hypotension. IV
fluids or vasopressor drugs may be required to support the BP.
Impaired bladder function
 Urine retention: In the early period after injury while the patient is in
spinal shock the bladder is atonic and becomes over-distended. An
indwelling catheter is inserted to drain the bladder.
 Reflex emptying of bladder: In the post-acute phase the bladder can
be hyperirritable, resulting in reflex emptying. the patient urinates
small amounts frequently. However, the bladder may become
distended because of inadequate emptying. Urinary retention increases
the risk of infection and urinary calculi. Catheterization is usually
indicated. The indwelling catheter should be removed and intermittent
catheterization should begin as early as possible.
Impaired gastrointestinal function:
 If the SCI has occurred above the level of T5, the primary GI
problems are related to hypo-motility:
 Delayed gastric emptying.
 Gastric distention
 Stress ulcers
 Paralytic ileus and
 Loss of bowel control: it can be managed successfully with a regular
bowel program coordinated to minimize fecal incontinence.
 Additional GI problems include gallstone formation, constipation, and
fecal impaction.
Impaired skin integrity:
 Pressure ulcers can occur quickly and can lead to major
infection and sepsis.
Impaired Thermoregulation:

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  Decreased ability to sweat or shiver below the level of injury,
which also affects the ability to regulate body temperature.
 Loss of ability to regulate temperature
Peripheral Vascular Problems:
 Deep venous thrombosis (DVT)
 Pulmonary embolism is one of the leading causes of death in
patients with SCI.
Emergency Management:
 Ensure patent airway
 Stabilize cervical spine
 Administer oxygen via nasal cannula or non-rebreather mask
 Control external bleeding
 Establish IV with two large-bore catheters and infuse normal saline or
lactated Ringer’s solution as appropriate
 Assess for other injuries
 Obtain cervical spine radiographs or CT scan
 Prepare for stabilization with cranial tongs and traction
 Administer a high dose methylprednisolone
Ongoing Monitoring
 Monitor vital signs, level of consciousness, oxygen saturation,
cardiac rhythm, urine output
 Keep warmth
 Monitor for urinary retention, hypertension
 Anticipate need for intubation if gag reflex absent

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