Critical care - test 4

What is shock and why is it a medical emergency?

- Shock - mismatch of oxygenation and blood flow, as well as decreased tissue perfusion where cells/tissue may start to die

- Medical emergency - happens quickly, high rate of mortality, organs shut down, blood shunted to most vital organs

What are the 4 types of shock?

- Cardiogenic

- Hypovolemic

- Distributive Shock

* (neurogenic, anaphylactic, septic)

- Obstructive Shock

Comparison of different types of sock

- Hypovolemic: Hypotension, tachycardia, Weak thready pulse, Cool, pale, moist skin, U/O decreased

* Decreased CO, Increased SVR

- Cardiogenic: Hypotension, tachycardia, Weak thready pulse, Cool, pale, moist skin, U/O < 30 ml/hr, Crackles, tachypnea

* Decreased CO, Increased SVR

- Neurogenic: Hypotension, Bradycardia, Warm Dry Skin

* Decreased CO, Venous & arterial vasodilation, loss sympathetic tone

- Anaphylactic: Hypotension, tachycardia, Cough, dyspnea, Pruritus, urticaria, Restlessness, decreased LOC

* Decreased CO, Decreased SVR

- Septic: Hypotension, Tachycardia Full bounding pulse, tachycardia, pink, warm, flushed skin, Decreased U/O, fever

* Decreased CO, Decreased SVR

CARDIOGENIC SHOCK

Systolic or diastolic dysfunction of the heart decreases cardiac output

- Causes - MI, cardiomyopathy, blunt injury, pulmonary hypertension, cardiac tamponade, slow heart rhythms, fast heart rhythms, CHF

What are some common assessment findings of cardiogenic shock.

- sharp decrease in cardiac output, vasodilation, tachycardia, hypotension, crackles, tachypnea, delayed cap refill, narrowing pulse pressure, weak peripheral pulses, cool, clammy skin, decreased urine output, anxiety

- Want to restore heart function, oxygen, nitrates, diuretics (worry about potassium)

- 50% morality rate

Cardiogenic shock lab values

BNP, Troponin, ABG, CMP, KK-MB, BUN, Creatinine

HYPOVOLEMIC SHOCK

Loss of intravascular fluid volume. (Bleeding, 3rd spacing, vomiting, diarrhea)

Causes: bleeding, trauma, surgery, Vomiting, diarrhea, loss of lots of fluids

Assessment findings: tachycardia, hypotension, cool clammy skin, decreased Urinary output, confusion

Interventions: blood and fluid replacement, Normal Saline: 3 ml of isotonic solution for 1 ml of blood loss

- want to know why happened and don't want to give to much fluid

Hypovolemic shock lab values

HGB, HCT, RBC, BUN, Creatinine, CMP, Vitals

DISTRIBUTIVE: NEUROGENIC SHOCK

Hemodynamic phenomenon that occurs within 30 minutes of spinal cord injury and can last up to 6 weeks.

What are some common assessment findings of neurogenic shock?

- severe pain, hypotension, bradycardia, not temp regulation, dry skin, initially flushed -> hypothermia, vasodilation, hypotension

Causes spinal cord injury

Interventions: maintain airway (o2 intubate), cautious fluid administrations, vasopressors, atropine, stabilize spinal cord, monitor temp

Neurogenic shock lab values

Kidney function: BUN, Creatinine, GFR, ABGs

DISTRIBUTIVE:ANAPHYLACTIC SHOCK

Acute life-threatening allergic reaction to a substance

- (contrast, blood, insects, drugs, vaccines, latex)

- antibiotics can be a cause

- peanuts can be a cause

What are some common assessment findings of anaphylactic shock?

- massive vasodilation, increase in capillary permeability

- Sudden onset: dizziness, chest pain, incontinence, tachycardia, wheezing, stridor, swelling of the lips, tongue, and airway

Interventions: epinephrine, maintain airway, intubation, remove cause, bronchodilators, steroids, antihistamines

SEPTIC SHOCK

- The result of an infection

- Vasodilation, maldistribution of blood flow, myocardial depression

What are some common assessment findings of septic shock?

- Assessment findings: fever, Increased WBC, hyperglycemia, decreased systolic BP, altered mental status, decreased Respirations, if chronic could have leukopenia, or hypothermic

- Causes: improper sterility, infection, releases cytokines/body responds, UTI, pneumonia

- Interventions: antibiotics, cultures, increase fluids, prevent ulcers, O2, vasopressors, monitor

- Up to 30% in septic shock never identify cause

Septic shock lab values

Lactic acid, Procalcitonin, glucose, sed. rate, CRP, WBC, Bands, culture

Obstructive shock

- Physical Obstruction to blood flow

- Decreased Cardiac Output

What are some comment assessment findings of obstructive shock?

- Assessment findings: decreased CO, JVD, high afterload, paradoxical pulses, cool/clammy

- Causes: cardiac tamponade, tension pneumothorax, compartment syndrome, pulmonary Embolism, Right ventricular thrombi, anything that causes blood not to move forward (clot)

- Interventions: airway patency/ O2, intubations, treat obstructive cause, increased fluids (temp)

obstructive shock labs

lactic acid, WBCs, BUN, Creatinine, Troponin, ABGs, EKG

Signs of shock

Normal Map 70 - 110

- if below 60 have poor organ perfusion

STAGES OF SHOCK: INITIAL STAGE

Usually not clinically apparent

Metabolism changes at cellular level from aerobic to anaerobic

- Lactic acid builds up and must be removed by liver

- Process requires O2, unavailable due to decreased tissue perfusion

Blood Pressure decreases - causes vasoconstriction

Which organs does the body prioritize to perfuse?

- Brain, Heart, Lungs

- So worry about kidneys and GI tract

- Changes in kidney output

- When in initial phase if fix patient should return to normal

Metabolism needs oxygen and glucose. If lose oxygen go from aerobic to anaerobic. This results in lactic acid build up which burns

STAGES OF SHOCK: COMPENSATORY STAGE

- Body can compensate for changes in tissue perfusion

- If cause of shock is corrected, patient recovers with little or no residual effects

- If cause of shock is not corrected, patient enters progressive stage

- Patient is transferred to ICU

- Major decrease in cellular perfusion

Symptoms

- Decreased BP so compensate by

* Increased HR, Vasoconstriction, Decreased U/O

- Then after:

* Stimulate SNS: so HR stays increased, Blood pressure goes up, cool, clammy skin to shunt blood flow to core.

- Then after:

* The heart will then Need more oxygen due to increased O2 heart consumption

* Eventually may shunt blood from lungs: dead air space in lungs -> issues with breathing

* If all this happens will need to enter ICU due to low BP maintenance and issues breathing.

STAGES OF SHOCK PROGRESSIVE STAGE

Clinical Assessment Findings:

- Anasarca

- Myocardial Dysfunction

- Third spacing of fluid

- Fluid moves into the alveoli

- GI System becomes ischemic

- Kidneys

- Liver Failure

1.Pulmonary system:

- Crackles, wheezing

- Fluid - alveoli (improper gas exchange)

GI: due to shunting

- constipation

- Paralytic ileus

- Absent/decreased bowel sounds

- Abdominal pain: Acid build up -> GERD, ulcers, aspiration; so will likely be on PPI

Liver failure

- Can't excrete lactic acid due no liver not getting oxygen

- Decreased Kidney perfusion

- Anasarca, third spacing

Cardiac

- Not getting enough oxygen

- Chest pain: myocardial ischemia

- Dysrhythmias: ST changes

- Edema

STAGES OF SHOCK: REFRACTORY STAGE

What are some assessment findings during the refractory stage of sepsis?

- Very very low Cardiac output: extremely low MAP (way below 60)

- Cells not being perfused

- Systemic hypoxia

- Multisystem organ failure

DIAGNOSTIC STUDIES with shock

Thorough history and physical examination

No single study to determine shock

- Blood studies

* Elevation of lactate

- 12-lead ECG, continuous ECG monitoring

- Chest x-ray

- Hemodynamic monitoring

- lactate with {sepsis}

- ECG - {cardiogenic}

- Chest X-ray: really any, anaphylactic, obstructive, septic, cardiogenic

- Hemodynamic: really all of them

LACTIC ACID: SEPTIC SHOCK

Aerobic - Anaerobic (absolute lack of oxygen)

- Lactic Acid builds-up

- Normal blood levels 0.5 - 1 mmol/L

- Sepsis criteria at above 2 mmol/L with a low blood pressure.

- Severe sepsis defined at Lactic Acid levels above 4 mmol/L

PROCALCITONIN: SEPTIC SHOCK

- Used in critically ill patients

- Levels determine if the condition is caused by a virus or bacteria

Test Result: Interpretation

- <0.05: Healthy

- 0.05 - <0.5: Systemic infection is unlikely

- 0.5 - <2.0: Systemic infection is possible but other causes (trauma, surgery, cardiogenic shock) may cause an increase

- >2.0: High likelihood to progress to sepsis

Generally in ICU

INTERVENTIONS with shock

- General management strategies

- Ensure patent is responsive

- Ensure a patent airway

- Maximize oxygen delivery

Hemoglobin levels can be dangerously low due to hypoperfusion. How can levels be increased?

- Fluids, blood, {volume expansion}

- If have issues with LOC think about oxygen

- If lose 1 ml of blood need 3 ml of isotonic solution (normal saline), if normal electrolytes and normal kidneys may use lactated ringer

VOLUME EXPANSION

Cornerstone of therapy for septic, hypovolemic, and anaphylactic shock = volume expansion

- One or two large-bore IV catheters or central venous catheter

- Isotonic Fluids

What are the priorities of the nurse while infusing isotonic fluids at a fast rate?

- With these types of shock Lose fluid so blood pressure bottoms out.

- Priority when infusing fast

* Fluid overload, Crackles, Shortness of breath, Weeping - legs, arms, Edema, Decreased LOC (lethargic) -> cerebral edema -> increased Intracranial pressure, Increased weight, Increased BP, Bounding pulses, Increased HR

The client's blood pressure remains low after fluid resuscitation. What is the next step in treatment?

Meds: Dobutamine, Dopamine, epinephrine, hydrocortisone, Norepinephrine (Levophed), Phenylephrine, Nitroglycerin, Sodium Nitroprusside, Vasopressin

- Dopamine cause renal vasodilation to increase blood pressure and increased renal perfussion

NUTRITION in shock

Nutrition is vital to decreasing morbidity from shock

- Start enteral nutrition within first 24 hours

- Parenteral nutrition used only if enteral feedings contraindicated

Need to ensure patients well hydrated and that cells have sugar and oxygen

SIRS (SYSTEMIC INFLAMMATORY RESPONSE SYNDROME)

SIRS is widespread inflammation that can occur in infection, trauma, shock, ect. May result from or lead to MODS. Most frequently associated with sepsis.

SIRS

- Pulmonary symptoms

-> pulm edema

-> wheezes, crackles

-> Diminished lung sounds

(SpO2 -> 92%) (generally less than 92% NOT GOOD)

-> Oxygen

-> Diuretics

-> steroids

-> albuterol

MODS

2 or more organs

Respiratory system is often first organ impacts by SIRS and MODS

- ARDS - Acute Respiratory Dysfunction Syndrome

- AKI - Acute Kidney Injury

- (cardiac, liver, endocrine, gastrointestinal system, etc.)

Very poor outcomes with three or more organs involved

Spinal Cord Injury

- Trauma or damage to the spinal cord

- Can be temporary or permanent

- 17,000 Americans suffer an injury each year

- Can be large disruption of life, loss of function, economic impact

- Some remain at home some need nursing home care

- Gateway between brain and rest of body

- In injury gateway is broken

Preventing head injuries

- No texting while driving

- Seat belts

- Car seats

- Helmets bikes and motorcycles

- Drunk driving, impaired driving

- Using safety equipment while playing sports

common causes of head injury

Most common men 16 - 30

1.Motor vehicle accidents

2.Falls

3.Violence

4.Sports

5.Miscellaneous

Type of Injuries of spine

Primary Injury

- Initial impact (trauma, compression, gunshot wound)

* Why suffer injury originally

- Secondary Injury

* Ongoing progressive damage

* Cell death

* This can go on weeks or months after initial injury

* Hemorrhagic areas can happen within an hour - ischemia within a few hours

* Edema can cause permanent damage

Spinal Shock

Characterized by

- ↓ Reflexes

- Loss of sensation

- Absent thermoregulation

- Flaccid paralysis below level of injury

- Lasts days to weeks

- Issue with Injury

- Transient condition that presents after acute spinal cord injury

- Not a circulatory disorder

- Masks post-injury neurologic function

Assessment findings:

- loss of deep tendon reflexes

- Loss of sphincter reflexes

- Loss of sensation

- Flaccid paralysis

neurogenic shock due to spinal injury

Characterized by

- Hypotension

- Bradycardia

- Loss of SNS innervation

- Peripheral vasodilation

- Venous pooling

- ↓Cardiac output

- T5 or higher injury

- ISSUE with Circulation

- Hemodynamic result of spinal cord injury at or above T5

- Can occur within 30 minutes of spinal cord injury

- Lasts up to 5-6 weeks

- Massive vasodilation (loss of SNS vasoconstrictor tone)

- Pooling of blood in blood vessels, tissue hypoperfusion, and impaired cellular metabolism

Assessment findings:

- hypotension

- Bradycardia

- unable to regulate body temperature

- Warm at first, but then skin cools taking on temperature of the environment (poikilothermia)

Medication

- Atropine to increase Bradycardia

- Vasopressors (levophed, noroepinephrine, phenelephrine) to increase BP

- Fluids (NS) - to sustain patients

Classifications of Spinal Cord Injury

3 types

- Mechanism of Injury

* Flexion, hyperextension, compression, flexion-rotation injury

- Level of Injury

* Skeletal level

-- Neurologic level is the lowest segment of the spinal cord with normal sensory and motor function on both sides of the body

----* Tetraplegia (quadriplegia) - all four extremities

----* Paraplegia - loss of sensation of the legs

- Degree of Injury

* Complete and incomplete - motor and sensory

loss based on injury location

- Cervical - tetraplegia

- C4 level or higher - need mechanical ventilation

- Thoracic - paraplegia

- Lumbar - paraplegia (just legs effects)

- Sacral - mostly elimination concern

Mechanisms of spinal Injury

Complications from Spinal Cord Injuries

Respiratory system

- Respiratory depression, Decreased lung expansion, Decreased cough, C4 or higher will need mechanical ventilation

- Management: Augmented cough, Chest PT, Vibrating chest

- Risks: Pneumonia, Aspiration risk

- Cardiac: Decreased circulation, Decreased peripheral circulation: SNS T9

* Interventions: Pulse check, SCDs, VTE, Medications

- Urinary system: Incontinence, Neurogenic bladder, UTI

* Interventions: Catheter, Suprapubic Cath, Bladder scan, Antibiotics and cultures if needed

Spinal Cord Injuries

How would the GI system and Integumentary systems be affected by a spinal cord injury?

GI

- Decreased motility

- Blockages/constipation

- Ileus

- Stress ulcers

- Aspiration

- Intervention: PPI (Pantoprazole - IV), Laxative, NG tube, Ostomy, Speech therapy, Occupational therapy, Mobility as possible

Skin

- Breakdown

- Pressure injury

- Infections

- Dry skin

- Intervention: Skin assessment, Repositioning/turning, Hygiene, Increase protein, moisturizer

Metabolic Concerns with spinal injury

Electrolytes imbalance from NG tube and suctioning

- Weight loss is common

- High protein diet

Which type of acid-base issue would the nurse expect?

- Metabolic alkalosis - getting rid of body acid in stomach

Diagnostic Studies with spinal injury

- CT scan is the preferred

- MRI soft tissue

- Doppler studies for DVT

Immediate Goals after an Injury to the spine

Patient airway

Adequate circulating blood volume

- Check pulse, cap refill, BP, Heart rate, urinary output

Preventing secondary injury

- Recommended immobilization includes a backboard and straps

* Not always recommended with penetrating trauma

* Don't want vertebra to move and cause more damage

Treatments after spinal injury

Non-operative

- Stabilization - eliminate movement to cause more damage while healing

Surgical therapy - many options to stabilize spine, reduce compression, anterior approach and posterior approach

Medication Therapy with spinal injury

Low-molecular-weight heparin

- Prevent VTE

Vasopressor agents

- Maintain mean arterial pressure >85-90 mm Hg

- Significant risk of complications

Want to perfuse spinal cord to help heal and maybe reverse if spinal shock

Phenylephrine and levophed

- Can have cardiac complications when trying to keep MAP > 85

* Dysrhythmias

-- V. Tach

-- A. Fib

* Elevated troponin levels

Respiratory Dysfunction with spinal injury

First 48 hours are most critical.

Assessment

- lung auscultation

- SpO2

- shallow breathing (issue with effort)

Risk for aspiration

- leave head of bed up

Want to help get mucus up to prevent pneumonia

Cardiovascular Instability with spinal injury

Low BP

Low HR

Dysrhythmias

Bladder and Bowel Management with spinal injury

Neurogenic bladder - Foley, no sensation of full bladder bladder can rupture

- CAUTI

- Intermittent catheterization

Bowel Program

-Neurogenic bowel - no voluntary or involuntary reflex

Spasticity with spinal injury

- Can be both beneficial and undesirable

- Ashworth and modified Ashworth scales

- Treatment

* ROM exercises

* Antispasmodic drugs

* baclifen

* Botulinum toxin injections

Involuntary movement

- can cause contractions

- keeps muscles moving

Autonomic Dysreflexia with spinal injury

Massive uncompensated cardiovascular reaction mediated by sympathetic nervous system

- SNS responds to stimulation of sensory receptors - parasympathetic nervous system unable to counteract these responses.

- Hypertension and bradycardia

Causes: Kinked catheter, Tight clothes, Fecal impaction, Kidney stones

- Results In: Flushing above injury, Decrease in HR, Increase in BP

Autonomic Dysreflexia manifestations

Most common precipitating factor is distended bladder or rectum

Manifestations

- Hypertension (up to 300 mm Hg systolic)

- Throbbing headache

- Marked diaphoresis above level of injury

- Bradycardia (30 to 40 beats/minute)

- Sit patient upright

- Loosen anything that is tight

- Socks

- belt

Manifestations

- Flushing of skin above level of injury

- Blurred vision or spots in visual field

- Nasal congestion

- Anxiety

- Nausea

Autonomic dysreflexia nursing interventions

Nursing interventions

- Elevate head, sit upright

- Notify HCP

- Assess for and remove cause

- Immediate catheterization

- Remove stool impaction if cause

- Remove constrictive clothing/tight shoes

- Monitor and treat BP

- Patient and caregiver teaching

Rehabilitation with Spinal Injury

- Respiratory

- Bladder - Long term catheter placement and care

- Bowel - bowel programs

- Spasticity - involuntary movements

- Skin care

- Pain Management

- Sexuality

- Grief and Depression

components of intra cranial area

Components

- brain, blood, cerebral spinal fluid

What causes increased ICP?

Causes:

- trauma to head

- strokes

- meningitis

- leaning over

- sneezing, coughing

- eating too much

Transient increases are normal. (pressure fluctuates a little bit)

Brain hematoma

Bleeding in the brain

Pressure pressing brain into skull

Widened pulse pressure

- normal should be 40 - 60 mm Hg

- widened pulse pressure causes Decreased Cardiac Output

- so worry about Decreased Perfusion to the Brain

Can easily be hypothermic

Can have decreased Respirations

both due to pressure/damage to brain stem

Brain could go into Cushing's triad

- Systolic HTN, Widened pulse pressure

- Decreased HR (bradycardia)

- Irregular breathing pattern (Decreased respirations)

- {IF THIS HAPPENS IN NEUROLOLOGIC EMERGENCY AND CAN'T COMPENSATE}

STAGES OF INCREASED ICP

- Stage 1: Total compensation

* hit head but feel fine

- Stage 2: ↓ Compensation; risk for ↑ICP

* starting to have changes

- Stage 3: Failing compensation; clinical manifestations of ↑ ICP (Cushing's triad)

* have Cushing's triad symptoms

- Stage 4: Herniation imminent → death

HERNIATION AND CEREBRAL EDEMA

Brain is enlarging and coming out of where shouldn't

Edema - swelling due to pressure and fluid on the brain

LOC Changes with increase in ICP

LOC Changes

- confusion - agitation

- lethargy

- difficulty arousing

- loss of consciousness

- disoriented

- comatose

- changes in pupils (sluggish, blown pupil)

- Vomiting

- hyperthermia

NURSING ASSESSMENT FINDINGS with ICP

Change in level of consciousness

- Flattening of affect → coma

Change in vital signs

- Cushing's triad (widened pulse pressure, bradycardia, irregular respirations)

- Change in body temperature (will get hyperthermic)

Cushings Triad

Signs of increased intracranial pressure:

1. hypertension

2. bradycardia

3. irregular respirations

NURSING ASSESSMENT FINDINGS with increased ICP

- Compression of oculomotor nerve (Oculomotor nerve (cranial nerve 3))

* Unilateral pupil dilation

* Sluggish or no response to light

* Inability to move eye upward

* Eyelid ptosis

- ↓ In motor function

- Hemiparesis/hemiplegia

- Decerebrate posturing (extensor)

- Indicates more serious damage

- Decorticate posturing (flexor)

DIAGNOSTIC STUDIES

- CT scan / MRI / PET

- EEG (electrical activity in the brain)

- Cerebral angiography (perfusion)

- ICP and brain tissue oxygenation measurement

- Transcranial doppler studies

- Evoked potential studies

- NO lumbar puncture

MEASUREMENT OF ICP

Guides clinical care

Indications

- Glasgow Coma Scale of ≤8

- Abnormal CT scans or MRI

Pupillary changed with increased ICP

- Puipils equal and react normally

- Pupil reacts to light (slowly or briskly)

- Dilated pupil (compressed cranial nerve III)

- Bilateral dilated, fixed pupils (ominous sign)

- Pinpoint pupils (pons damage or drugs)

MEASUREMENT OF ICP devices

- Ventriculostomy

* Catheter inserted into lateral ventricle

- Coupled with an external transducer

Ventriculostomy is gold standard for measuring ICP (normal is 5 - 15)

- can monitor ICP and drain fluid (CSF)

- in the ICU

Apparatus would need to be zeroed

- if not could have incorrect reading

Huge infection risk

- infection precautions

- chlorohexidine to site

- prophylactic antibiotics

- monitor WBC count (neutrophils)

DRUG THERAPY for increased ICP

Drug Therapy

- Mannitol (Osmitrol)

* Plasma expansion

* Osmotic effect

* Monitor fluid and electrolyte status

- Hypertonic saline (use with caution)

* Moves water out of cells and into blood

* Monitor BP and serum sodium levels

-- Risk for fluid overload

Mannitol is diuretic that is used for intracranial pressure by pulling fluid off of brain

Monitor potassium, sodium, and may calcium

- Corticosteroids

* Monitor fluid intake, serum sodium and glucose levels

* Concurrent antacids, H2 receptor blockers, proton pump inhibitors

Decrease inflammation everywhere including the brain

- worry because increase glucose

- if dev. Cushing could have increased sodium which increase fluid and could have decrease potassium

At risk for ulcers so will be on antacids, H2, PPI

Additional:

- Antiseizure medications: risk for seizure

- Antipyretics: risk for hyperthermia

- Sedatives: if combative

- Analgesics: if have pain

- Barbiturates: If at risk of seizures but want to use carefully

NUTRITION with increased ICP

Nutritional Therapy

- Hypermetabolic and hypercatabolic state ↑ need for glucose

- Enteral (if possible) or parenteral nutrition

- Early feeding (within 5 days of injury)

- So can get glucose and heal faster

NURSING PRIORITIES with increased ICP

Respiratory function

- Maintain patent airway

- Elevate head of bed 30 degrees

- Suctioning needs

- Minimize abdominal distention

- Monitor ABGs (CO2 levels)

- Maintain ventilatory support

- Worry about #1 airway, so elevate bed to {30 degrees}. But no more than 30 degrees.

- Need to make sure if they actually need to be suctioned because coughing can increase ICP

Fluid and electrolyte balance

- Monitor IV fluids

- Daily electrolytes

Monitor and minimize increases in ICP

PATIENT POSITIONING with increased ICP

HOB elevated appropriately

- Prevent extreme neck flexion

- Turn slowly

- Avoid coughing, straining, Valsalva

- Avoid hip flexion

- 30 degrees

what is a seizure and what are some causes?

- Fever

- Glucose

- Damage

- Anything that can alter pathway in brain

Clinical Manifestations of Seizures

May progress through several phases

- Prodromal phase

- Aural phase

- Ictal phase

-Postictal phase

Complications of Seizures

Status epilepticus (SE)

- State of continuous seizure activity or condition when seizures recur in rapid succession without return to consciousness between seizures

* Any seizure lasting > 5 minutes

* Neurologic emergency

* Can occur with any type of seizure

Have one seizure after another

Medication of choice diazepam or lorazepam

what is the priority during the seizure

- During a seizure, what is the priority of the nurse?

During a seizure

- Maintain patent airway

- Protect patient's head

- Turn patient to the side

- Loosen constrictive clothing

- Ease patient to floor

- Do not restrain patient

- Do not place objects in patient's mouth

Nursing Assessment with seizure

- Bitten tongue, soft tissue damage, cyanosis

- Abnormal respiratory rate

- Apnea (ictal)

- Absent or abnormal breath sounds

- Airway occlusion

- Hypertension, tachy/bradycardia

- Bowel/urinary incontinence, excessive salivation

- Weakness

- Excessive Somnolence

Diagnostic Studies of Seizures

EEG

- May help determine type of seizure and pinpoint seizure focus

- Many patients do not have abnormal findings

- Not definitive because many patients may not have abnormal findings

CBC, Chemistry Panel

CT or MRI in new-onset seizure to rule out structural lesion

Cerebral angiography

- Diagnosing seizure type is necessary to determine appropriate treatment

Chemistry - worry about electrolytes (sodium)

CBC - RBC (anemia can cause issues with oxygenation)

CT/MRI look for tumors

Drugs for Seizures

Seizure disorders are primarily treated with antiseizure drugs

- Goal of therapy is preventing seizures with minimum toxic side effects from drugs

- Cure is not possible

- Antiseizure drugs should not be discontinued abruptly as this can precipitate seizures

- Common side effects involve the CNS and include diplopia, drowsiness, ataxia, and mental slowing

- Can get really drowsy

- Compliance can be an issue

Primary drugs for treatment of generalized tonic-clonic and focal seizures

- Phenytoin (Dilantin)

- Carbamazepine (Tegretol)

- Phenobarbital (Luminal)

- Divalproex (Depakote)

- Primidone (Mysoline)

Primary drugs used to treat absence and myoclonic seizures

- Ethosuzimide (Zarontin)

- Divalproex (Depakote)

- Clonazapam (Klonopin)

•Broad spectrum drugs can be effective for multiple seizure types

- Gabapentin (Neurontin)

- Topiramate (Topamax)

- Lamotrigine (Lamictal)

- Tiagabine (Gabitril)

- Levetiracetam (Keppra)

- Zonisamide (Zonegran)

Pregabalin (Lyrica)

Additional treatment for focal seizures that are not successfully controlled with a single medication

Status epilepticus

- Initially, rapid-acting IV lorazepam (Ativan) or diazapam (Valium)

- Followed by long-acting drugs

Surgical Interventions for seizures

Vagal nerve stimulation

- Adjunct to medications when surgery is not feasible

- Exact mechanism not known

- Thought to interrupt synchronization of epileptic brain-wave activity and stop excessive discharge of neurons

Surgery is an option for many with uncontrolled epilepsy

- Anterior temporal lobe resection

- About 70%-80% are seizure free after this procedure

- 10%-20% have marked reduction in seizure activity

In the emergency department setting, which are the priority focused assessments that should be performed first?

Airway, breathing, circulation order depending on patient

Emergency nursing order of priorities

ABCDEFG...

- Alertness and airway

- Breathing

- Circulation

- Disability

- Exposure and environmental control

- Full set of vitals and family presence

- Get monitoring devices, give comfort

Emergency Nursing - primary nursing

Focuses on

- Airway, breathing, circulation (ABC)

- Disability, exposure, facilitation of adjuncts and family, get resuscitation adjuncts

Uncontrolled external hemorrhage

- Reprioritized to ABC

- Direct pressure

- Pressure dressing

If life-threatening conditions related to ABCs are identified during primary survey, interventions are started immediately and before proceeding to the next step of survey

Alertness and airway

- Determine LOC

- Assess patient response to verbal and/or painful stimuli

- AVPU

* A=alert

* V=responsive to voice

* P=responsive to pain

* U=unresponsive

- LOC, pupillary response (PERRLA), chest rise, lung sounds, vitals (O2) (resp), airway obstruction, patent airway

- sniffing position, O2 if indicated, spine stabilization, Intubate/establish airway

Breathing

- assess ventilation, lung sounds, chest expansion, O2

- O2, intubate, chest tube

Circulation

- pulse, heart rate, cap refill, assess for signs of bleeding

- control bleeding, ensure circulation

Disability

- neuro check, mobility, pain, cranial nerve, speech

- x-ray or imaging, pain control, reorientation, headache, cast, splint

Exposure and environmental control

- safety, rapid triage/vitals, safety scan, neuro exam, ortho consults, hypo/hyperthermia

- labs, xray, spine immobilization, wound irrigation, hypo/hyper thermia manament

Full set of vitals and family presence

- what to do if code and family presence as a result

Get monitoring devices, give comfort

- labs -> CBC (bleeding), type and cross blood, blood sugar, glucose, pregnancy test, urinalysis, CMP, EKG, troponin

- monitor cardiac status -> telemetry

- Pain assessment: opioids, NSAIDS, ketorolac

- NG tube -> if head injury or facial trauma

- O2 + Ventilation -> cont. pulse ox

Airway obstruction

Cause of nearly all immediate trauma deaths

- Irritability, restlessness, gurgling, decreased sats, increased HR, Increased RR, Inspiratory stridor, grabbing at neck, drooling, tripod, accessory muscles, cyanosis

Treatment with airway issues in primary survey

- Open airway

- Suction and/or remove foreign body

- Insert nasopharyngeal or oropharyngeal airway

- In unconscious patients only

- Endotracheal intubation

What are the priority assessments in assessing breathing/ventilation?

Primary assessment for assessing breathing/ventilation

- Chest rise and fall, SPo2, accessory muscles, resp rate, auscultate, symmetry, Capnography, tripod, gasping, sit up, coughing

Concerning lung sounds primary survey

Concerning lung sounds

- Anything adventitious

What are the priority assessments in assessing circulation?

Pulses, color, temp, edema, BP, cap refill, SPo2, HR, LOC changes, fluid (NS), vasopressors, blood

Neurological Assessment with primary survey

Neurological Assessment

- Measured by patient's level of consciousness

- Glasgow Coma Scale

* Standardized for consistent communication among care team members

- Pupils

Secondary Survey

Brief, systematic process to identify all injuries

- History

- Head, neck, and face

- Chest

- Abdomen and flanks

- Pelvis and perineum

- Extremities

- Inspect posterior surfaces

- Just keep reevaluating

secondary surgery - History and head-to-toe assessment

- Obtain history and mechanism of injury, or illness from patient, caregivers, friends, bystanders, and emergency personnel

- Provides suggestions for specific assessment and intervention