Neurologic Support

NEU 1
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 Objectives

• Review principles of primary and secondary

brain injury
• Describe neurologic examinations needed to
assess and follow patients
• Discuss general therapeutic principles
• Review specific management principles for
selected pathophysiological conditions

NEU 2
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 Patient Care - Mr. G.
Mr. G., a hypertensive patient with mitral
stenosis and atrial fibrillation, takes
medications sporadically and at various doses.
He has fallen down 10 stairs but the primary
event is unknown, i.e. a fall, emboli, a hyper-
tensive bleed, or subarachnoid hemorrhage.
His CT scan shows subarachnoid blood, a
contusion, and a basal ganglion hemorrhage.

NEU 3
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 Concepts of Brain Injury
• Primary injury: area of
maximum neuronal damage
• Penumbra: area of less
injured and potentially
recoverable neuronal tissue
• Secondary injury: follows
primary injury and causes
further neuronal damage

NEU 4
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 Primary Brain Injury

• Trauma: concussion,
contusion, shear injury
• Ischemia: global,
regional
• Inflammation
• Compression: tumor,
edema, hematoma
• Metabolic insults

NEU 5
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 Secondary Brain Injury
• Hypoperfusion: high
intracranial pressure,
edema, vasospasm
• Hypoxia: hypoxemia,
hypoperfusion, high O2
consumption
• Harmful mediators:
reperfusion, inflammation
• Electrolyte or acid-base
changes
NEU 6
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 Goals in Neurologic Injury
• Assure oxygen and nutrient delivery to brain
to meet needs
• Supply = arterial O2 content x cerebral blood
flow
• Demand = cerebral metabolic rate for O2
• Autoregulation couples supply and demand
• Global vs. regional supply and demand

NEU 7
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 Global vs. Regional Dynamics

• Heterogenous zones of injury

• Large regional variations in supply vs. demand
• Regional intracranial pressure, cerebral blood
flow and perfusion pressure cannot be
measured
• Global parameters used to evaluate
abnormalities and guide therapy

NEU 8
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 General Principles

• Prevent abnormal oxygen demands

– Avoid fever
– Avoid seizures
– Avoid anxiety, agitation, pain

NEU 9
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 General Principles
• Promote oxygen delivery
– Adequate systemic O2 transport
– Optimal mean arterial pressure
– Avoid prophylactic or routine
hyperventilation
– Euvolemia
– Consider iv lidocaine for intubation
– Nimodipine for subarachnoid bleed
NEU 10
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 Assessment

• Early identification of ischemic stroke

• Rule out surgical lesion
• Tests of anatomy: CT, MRI, blood flow
• Tests of function: neurologic exam,
Glasgow Coma Scale (GCS) score
• Serial evaluations required

NEU 11
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 Glasgow Coma Scale
Score Eye Opening Best Verbal Best Motor

1 No response No response No response

2 To pain Incomprehensible Extensor
3 To speech Inappropriate Flexor
4 Spontaneous Disoriented Withdraws to pain
5 — Oriented Localizes pain
6 — — Obeys command

NEU 12
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 Urgent Neurosurgical Consultation

• Intracranial mass lesions

• Open/depressed skull
fracture
• Hydrocephalus
• Intracranial blood,
especially cerebellar and
subarachnoid
• Cerebrospinal fluid leakage

NEU 13
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 Head Trauma –
ICP Monitoring Unavailable
• Rule out mass lesions
• Consider neurosurgical consult early
• Assure ABCs
– Maintain systolic pressure >90 mm Hg
– Target mean arterial pressure 90 mm Hg
– Avoid hypoxemia
• Align head with trunk
• Keep head of bed flat or < 30o elevation
NEU 14
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 Head Trauma –
ICP Monitoring Unavailable
• Maintain PaCO2 at 35–40 torr (4.7- 5.3 kPa)
• Infuse dextrose-free normal saline
• Treat fever and agitation
• Maintain metabolic homeostasis
• Assess and treat coagulation defects
• Consider prophylactic anticonvulsants
• Consider mannitol if neurological status
deteriorates
NEU 15
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 Considerations for Intracranial
Pressure Monitoring
• Glasgow Coma Scale score < 8
• Abnormal CT scan
• Normal CT scan with two of following:
– Age > 40 yrs
– Hypotension
– Decerebrate or decorticate posturing

NEU 16
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 Intracerebral Hemorrhage
(Nontrauma, Nonstroke)
• Blood pressure control
controversial
• Modest reduction of
blood pressure if signi-
ficant systemic effects
• Use - and -blocker or
calcium channel blocker
• Consultation for possible
clot removal
NEU 17
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 Stroke (Nonhemorrhagic)
• Intravenous thrombolysis in
first 3 hours
• Early referral/consultation
• Consider aspirin, heparin
therapy
• Treat hypertension cautiously
• Edema or hemorrhagic
conversion may require ICP
monitoring or surgery
NEU 18
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 Metabolic / Infectious Disorders
• Provide thiamine, glucose,
naloxone as indicated
• Evaluate electrolytes, renal and
hepatic function
• Assess for focal neurologic signs
• CT scan to rule out mass lesions
• Consider lumbar puncture and
empiric antibiotics

NEU 19
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 Seizures
• Treat during evaluation
• Lorazepam: 0.05–0.1 mg/kg iv, repeat if
ineffective
• Phenytoin/fosphenytoin: 18–20 mg/kg iv,
infusion at <50 mg/min for phenytoin
• Consider propofol, midazolam, phenobarbital
• Avoid neuromuscular blockade
• EEG monitoring is desirable

NEU 20
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 Subarachnoid Hemorrhage
• CT scan diagnosis
• Systolic BP <150 mm Hg to
prevent rebleeding
• Nimodipine 60 mg po every
4 hrs
• Maintain euvolemia
• Prevent/treat hyponatremia
• Urgent neurosurgical
evaluation

NEU 21
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 Anoxic Injury

• Maintain physiologic
cardiorespiratory and
metabolic variables
• No specific therapy to
reverse injury
• Intracranial pressure
monitoring rarely done

NEU 22
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 Pediatric Considerations

• GCS more difficult to use in

children
• Evaluation of fontanelle in
infants may indicate need for
further evaluation
• Specific dosage changes in
pediatrics

NEU 23
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 Key Points

NEU 24
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