[N109] Management of the Brain Injured Patient (EBP)

FALSE: Very early mobilization within 24 hours by trained staff is NOT recommended for acute stroke patients.

True/False:

Among acute stroke patients, evidence recommend early mobilization within 24 hours.

30 degrees (too high affects cerebral blood flow)

What is the recommended HOB (head of bed) position for brain-injured patients?

True

(True/False): Raising HOB too high may reduce cerebral blood flow.

≥94% (ayaw natin ng hypoxia)

What is the target SpO₂ for brain-injured patients?

100–180 mmHg

_______ mmHg is the target SBP range in brain-injured patients.

Norepinephrine

Common vasopressor used to support BP in these patients?

32–35 mmHg (ayaw natin ng hypercapnia)

What is the ETCO₂ target in ventilated brain-injured patients?

36–37.8°C

What is the recommended body temperature range for brain-injured patients?

It increases cerebral metabolic rate (CMR) → increases ICP

• Hindi magandang may lagnat ang CCU patient kasi mabilis na nga ang metabolism

• Hindi na nga kaya mag-cope ng brain sa metabolism kaya dapat aggressive tayo sa pag-normalize ng body temp

Why is fever dangerous in neuro-ICU patients?

True

True/False: Among immobilized patients hospitalized with acute ischemic stroke or intracerebral hemorrhage, graduated compression stockings are not recommended for use.

>80 mmHg (at least 60–70 mmHg in most guidelines)

Target CPP (cerebral perfusion pressure) in brain injury?

≥80 mmHg

What MAP is targeted in the first 24 hours?

65 mmHg

After 24 hours, acceptable MAP is at least ___ mmHg.

Isotonic solutions (PNSS, LR, D5W)

Preferred IV fluids in brain injury?

Hyperchloremic metabolic acidosis

In using PNSS, we watch out for _________________________________ due to its high chloride content.

Plain LR, since there is no risk of acidosis and components are more balanced

Which is preferred for volume resuscitation in isotonic solutions?

D5W & colloids (increase cerebral edema / complications)

Which fluids should be avoided?

• PNSS

• LR

• D5W

• Colloids

It is hypotonic and increases cerebral edema.

Why should D5W be avoided in brain injury?

Hydroxyethyl starch (Voluven)

It is a crystalloid IV fluid which is also used for fluid resuscitation

Urasol

Another alternative choice for fluid resuscitation that is used in certain protocols

Vasopressor support

This support is used to maintain SBP and MAP when fluids alone are insufficient

Norepinephrine

First-line vasopressor option for traumatic brain injuries to maintain CPP?

Epinephrine, Vasopressin

Other vasopressors that may be used?

>30%

Target hematocrit (Hct) in TBI patients?

≥10 g/dL (debatable: 7–9 may be acceptable, but ≥10 preferred in neurocritical care)

Hemoglobin (Hb) target in brain-injured patients?

It worsens cerebral ischemia

Low hematocrit can lead to decreased oxygen delivery therefore?

>30%

• Normal: 36-48 (Female), 30-54 (Male)

Target Hct in patients with TBI

blood transfusions (PRBCs)

To maintain the Hct threshold, hcp may require ___________

FALSE: higher

True/False: Lower Hct levels are often needed in TBI to support cerebral perfusion and oxygenation

• We sedate to let the patient rest despite the high metabolic demands, and in doing so, it also helps decrease the ICP.

• Most patients with mechanical ventilator or ET are stressed and agitated, they try to resist, since the mech vent pushes the air. We give sedatives to avoid agitation.

Why do we sedate brain-injured patients?

• coughing

• agitation

• pain

Sedation minimizes spikes in ICP caused by?

• Reduces hyperadrenergic state → ↓ cerebral metabolic rate (CMR) → ↓ cerebral blood volume (CBV) → ↓ intracranial pressure (ICP)

• Decreased CMR causes a decrease in cerebral blood volume because:

  • Low CMR leads to vasoconstriction

  • Vasoconstriction decreases cerebral blood flow, reducing CBV and ultimately lowering ICP

Explain the physiologic cascade of sedation in brain-injured patients.

Propofol

Which sedative has a fast onset/offset, useful for sedation vacations?

Sedation vacations

These are periods where sedation is paused to assess the patient’s neurologic status.

Midazolam

Which sedative has a longer duration of action compared to propofol?

Monro-Kellie Hypothesis

• An increase in the volume of one component must be offset by a decrease in the volume of one or both of the others to maintain stable ICP

• For example:

  • Inflammation (r/t TBI) → ↑ brain tissue volume

  • Bleeding → ↑ cerebral blood volume

  • Sedation helps by reducing blood volume (via vasoconstriction)

Sedation is related to which principle of intracranial dynamics?

33–38 mmHg (4.5–5.0 kPa)

Normal target pCO₂ range in TBI patients?

Vasodilation → ↑ cerebral blood flow → ↑ ICP

How does hypercapnia affect ICP?

Vasoconstriction → ↓ ICP, but risk of ischemia if prolonged

Effect of hypocapnia (↓ pCO₂)?

Short-term emergency ICP crisis management (first 24 hrs)

• Short-term hyperventilation may be a bridge therapy while initiating other ICP-lowering interventions

When is hyperventilation therapy used?

Hyperventilation → ↓ pCO₂ → cerebral vasoconstriction → ↓ ICP

How does hyperventilation affect ICP?

respiratory alkalosis

In hyperventilation therapy, there is a risk for _____________________

high backup rates (A/C mode)

• kasi palagi silang nagha-hyperventilate A/C, back-up rate ay mataas, to decrease ICP

• To be expected in patients who are newly connected to mechanical ventilators

Respiratory alkalosis is expected in mechanically ventilated patients with _________________________

↑ CVP → ↓ venous return → ↑ ICP

• Kapag mataas ang PEEP, tumataas ang CVP so pwedeng mag decrease ang cardiac output

Why is high PEEP dangerous in TBI?

Low PEEP

High or low PEEP is preferred in the first 24 hours post-TBI?

• Avoid high PEEP early to prevent ↑ intrathoracic pressure and ↓ venous return which increases ICP

  • high PEEP = hyperinflated lungs = maiipit yung ibang organs = decreased venous return = increased ICP

  • high PEEP = arterial din

  • dec cerebral tissue perfusion; affected din ang BP

• Decreased PEEP is used temporarily to help stabilize ICP

Why should we avoid high PEEP early post-TBI?

Sedatives and hyperosmolar therapies (e.g. mannitol, hypertonic saline)

What pharmacologic support are often used alongside ventilator strategies?

Neurogenic fever

This occurs when there is damage or disruption to the hypothalamus or other areas of the brain involved in temperature regulation

• brain injury

• stroke

• CNS infections

• neurological disorders

Causes of neurogenic fever include?

sepsis

Neurogenic fever occurs in the absence of?

True

True/False: Even if core temperature is only slightly elevated without infection, ICP can still rise.

• Patient presents with fever unresponsive to antipyretics (e.g., paracetamol)

• No signs of sepsis or infectious cause

• Standard interventions like sponge baths are often ineffective

What are the usual clinical presentation of patients with neurogenic fever?

32–36°C

Target temperature management (therapeutic hypothermia) aims for what range?

• External cooling methods such as:

  • ice sponge baths

  • cooling blankets

• Sedation with agents like propofol

  • it can suppress metabolic rate and reduce temperature

  • sometimes paracetamol is changed to propofol for better effect

What are the nursing interventions for neurogenic fever?

Permissive hyperthermia

This refers to a controlled allowance of slightly elevated body temperature

• aggressive cooling may cause more harm than benefit

• Metabolic needs require higher temperatures (e.g. supporting enzymatic or immune responses)

Permissive hyperthermia is employed only in specific situations where?

Therapeutic hypothermia

This is usually used for TBI patients to decrease metabolic demands.

32-36 degrees C

Target temperature management for therapeutic hypothermia

80-130 mg/dL

For critically-ill patients without diabetes, the normal blood glucose range is?

≤180 mg/dL

For critically-ill patients with diabetes, the normal blood glucose range is?

> 130 mg/dL

Blood glucose of > _____ mg/dL us associated with worse outcomes in critically-ill patients due to SNS activation.

• < 70 or 80 mg/dL

• > 180 mg/dL

Which CBG levels do we usually refer?

hypoglycemia (may cause metabolic crisis)

What do we watch-out for in the blood sugar control of a brain-injured patient?

• Insulin (2-4 units)

What type of drug is administered and its dose when blood sugar is elevated?

C. 4–6 units

Example insulin PRN approach in notes: for >200 mg/dL give:
A. 1 unit
B. 2–4 units
C. 4–6 units
D. 10 units

Irreversible neurological damage

Less than 30 mmHg CPP causes __________________________

50-70 mmHg

What is the target CPP post-TBI?

at least 80 mmHg

We expect a MAP of ______________ for the first 24 hours post-TBI

at least 65 mmHg

We expect a MAP of ______________ after 24 hours post-TBI

> 20%; < 60 mmHg

A decrease in DBP > ___% from baseline or DBP < ___ mmHg is associated with significant death rates.

C. < 180 mmHg

For acute ischemic stroke, the systolic BP goal within the first 6 hours is:
A. < 140 mmHg
B. < 160 mmHg
C. < 180 mmHg
D. < 200 mmHg

C. 140–160 mmHg

For intracerebral hemorrhage (ICH), the BP goal within 6 hours is:
A. 100–120 mmHg
B. 120–140 mmHg
C. 140–160 mmHg
D. 160–180 mmHg

FALSE: Ayaw natin both extremes (not too low → ischemia, not too high → bleeding).

True or False
In brain-injured patients, we want BP to be either very low or very high.

Nicardipine drip

What is the preferred antihypertensive in hospitals for brain-injured patients?

True

True or False
Titration of nicardipine drip is typically done in increments of 5 cc/hr, monitoring every 5–10 minutes (sometimes more aggressive at 30 mins).

B. Titrate up

If MAP is elevated and the target is not yet reached, what should be done?
A. Titrate down
B. Titrate up
C. Stop infusion
D. Give fluids

Down

If MAP is too low, the nicardipine drip should be titrated _______.

C. 1 hour (sometimes 30 mins for more aggressive control)

How long is the usual titration interval for nicardipine in brain-injured patients?
A. 10 minutes
B. 30 minutes
C. 1 hour
D. 2 hours

Mannitol, Hypertonic Saline

The two common osmotherapy agents in neurocritical care are __________ and __________.

B. Osmotic diuretic

Mannitol is primarily classified as:
A. Loop diuretic
B. Osmotic diuretic
C. Vasodilator
D. Calcium channel blocker

Acute Kidney Injury

• Mannitol can crystallize in renal tubules

What is the common adverse effect of mannitol?

True

True or False
The early effect of Mannitol is reduction in cerebral blood volume by plasma expansion, increased cardiac output, and reduced viscosity.

C. BBB stabilization (that’s HTS, not Mannitol)

Which of the following is NOT an early mechanism of Mannitol?
A. Plasma volume expansion
B. Improved cardiac output
C. BBB stabilization
D. Vasoconstriction

Autoregulation

Mannitol requires intact __________ for its effects.

C. Shift to hypertonic saline

If a patient develops Mannitol-induced AKI, the intervention is:
A. Increase Mannitol dose
B. Shift to loop diuretics
C. Shift to hypertonic saline
D. Restrict fluids

renal tubules

Mannitol can crystallize in the __________, worsening renal failure.

C. 5%

The most common concentration of Hypertonic Saline used is:
A. 1.5%
B. 3%
C. 5%
D. 7.5%

1.0

Unlike Mannitol, HTS has a reflection coefficient of __________, meaning full osmotic effect.

True

True or False
HTS stabilizes the BBB, while Mannitol requires an intact BBB.

D. Hypotension (that’s more with Mannitol)

Which is NOT a complication of HTS?
A. Hypernatremia
B. Hyperchloremic metabolic acidosis
C. Central pontine myelinolysis
D. Hypotension

intracranial hypertension

One risk of HTS is rebound __________ __________.

B. Hypertonic saline

Which agent is safer in a patient with renal failure?
A. Mannitol
B. Hypertonic saline

blood pressure

Mannitol decreases ICP but may lower __________, while HTS decreases ICP and usually maintains or slightly increases it.

C. Hypernatremia (that’s HTS)

Which is NOT an adverse effect of Mannitol?

A. Hypotension

B. Renal failure

C. Hypernatremia

D. Rebound ICP increase

True

True or False
Mannitol + HTS together can be synergistic by maintaining isotonicity and promoting fluid removal.

C. Either

For acute ischemic stroke, which osmotic agent may be used?
A. Mannitol
B. HTS
C. Either

B. HTS

For intracerebral hemorrhage (ICH), which is more recommended?
A. Mannitol
B. HTS

True

True or False
Mannitol is sometimes preferred in practice because it does not require pharmacy preparation.

Remove 150 cc; add 7.5 vials (20 cc/vial) (850 cc + 150 cc)

To prepare 3% HTS: Start with 1L PNSS, remove ______ cc, then add ______ mini poly ampules of D5050 (20cc each).

C. Stabilizes BBB directly (that’s specific to HTS, not a universal “ideal” trait)

Which of the following is NOT a characteristic of the ideal osmotic agent?

A. High reflection coefficient

B. Inert and nontoxic

C. Stabilizes BBB directly

D. Minimal systemic side effects