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Methylprednisolone (solumedrol)

Methylprednisolone (solumedrol)

• prevents extension of the spinal cord injury

• stabilizes damage

• decreases swelling

• increases nerve conduction

Anterior cord syndrome

• damage only to the anterior 2/3rds of the cord

• due to hyperflexion

central cord syndrome

• central cord damage

• caused by hyperextension

  • think whiplash injuries

positioning to prevent ICP

• Midline

• 15 to 30 degree of bed 

• No tight trach ties

• Do not sit up straight 

  • Bc it’ll decrease venous return

How a patient will present in spinal shock

• complete loss of all motor, sensory, & proprioceptive function below level of lesion

• flaccid paralysis

• bowel & bladder retention

• no reflex arc

normal ICP

below 15

ICP with head injury

keep below 20

Normal CPP

70-100

CPP calculation

MAP - ICP = CPP

management of ICP

• positioning

• maintain PaCO2 of 35

  • + / - 2 mmhg

• Maintain PaO2 > 70 mmhg

• minimize suctioning

  • administer lidocaine prior to necessary suction

• Minimize peep

  • enhances venous blood flow

• sedate as needed

Cushing’s triad

• bradycardia

• systolic hypertension

• bradypnea

Medications to decrease ICP

• mannitol

  • osmotic diuretic

• Furosemide

  • loop diuretic

why do we give diuretics with increased ICP?

to decrease cerebral edema

Subdural (SDH)

• Blood between dura and arachnoid, commonly from rupture of veins that connect brain and dura

• Injury:  acceleration/deceleration, rotational injuries

Epidural (EDH)

• Blood between skull and dura

• Injury pattern:  skull fracture with middle meningeal artery laceration, from direct blow (MVA, fall)

Diffuse Axonal Injury (DAI)

Widespread stretching and tearing of axons secondary to acceleration/deceleration or rotational injury resulting in diffuse microscopic changes

Subarachnoid Hemorrahge (SAH):

A type of hemorrhagic CVA that results in subarachnoid bleeding

• Cerebral aneurysm

• Arteriovenous malformation (AVM)

2 major complications from subarachnoid hemorrhage

• rebleeding

• vasospasm

what medication is given for vasospasm

Nimodipine

Nimodipine

• used for vasospasm

• calcium channel antagonist

• used for 21 days

what scale determines deterioration of a subarachnoid hemorrhage

hunt hess scale

Triple-H therapy

1. arterial hypertension

2. Hypervolemia

3. hemodilution

maintain Arterial hypertension for subarachnoid hemorrhage if clipped

160-200 mmhg

maintain Arterial hypertension for subarachnoid hemorrhage if unclipped

120-150 mmHg

Vault fracture

commonly parietal and temporal

Basilar s&s

• battle sign

  • bruising over mastoid process

• raccoon eyes

• CSF leak from nares/ears

• CN damage

concussion

transient injury - no necrosis

Contusion

Brain bruise (superficial parenchyma) usually secondary to acceleration/deceleration injury

Coup

impact of the skill

contrecoup

• rebound

• CAT scan

  • look for swelling and bruising

  • involves over 2-3 days

• Can create significant increase in ICP

Hematomas

Space that is occupied by the lesion of blood

purpose of Ventriculostomy

• monitor ICP

• Drains CSF

what can ventriculostomy be used for

epidural hematomas

ventriculostomy procedures

• drill burrow hole

• put sensor into ventricle of the brain

• place catheter into non-dominate ventricle

• done at bedside to OR

diabetes insipidus (DI)

• too little antidiuretic hormone

• excessive urine output

Medication for DI

Vasopressin

treatment for DI

• fluid and electrolytes

• vasopressin

• gie antidiuretic hormone

complications of having little antidiuretic hormone

• urine concentrated

• hypernatermic

• hyper osmotic

SIADH

• too much antidiuretic hormone

• decreased fluid output

treatment for SIADH

• fluid restriction

what happens when there is too much antidiuretic hormone

• hold onto fluid

• urine becomes diluted

• hyponatremic

• hypo-osmotic

Injury to what brain structures can cause SIAHD and DI

posterior pituitary and hypothalamus

Mild GCS

• GCS = 13-15

• LOC < 15 min

moderate GCS

• GCS = 9-12

• LOC < 6 hours

severe GCS

• GCS = 3-8

• LOC > 6 hours

Parkland formula (first 24 hours) formula

4 mls Ringers Lactate X Kg body weight X % TBSA burned

• Give half of this volume over the first 8 hours

• Give half of this volume over the next 16 hours

What are we worried about with inhalation injuries if they’re on a vent?

• cardio-compliance

  • can their chest expand?

  • able to take a deep breath?

When would you preform an escharotomy

• if your have a circumferential burn of chest or extremities

what is a escharotomy

• “Cut until you bleed”

• performed to get a pulse / breathe

Superficial (First degree) site

only epidermal

S&s of Superficial (First degree)

• appears red/pink

• dry

• painful

  • think sun burn

how long does it take for a superficial (first degree) burn to heal

about 5-7 days

Partial Thickness (Second degree) site

epidermis and dermis

s&s of partial thickness (second degree)

• red

• blistered

• painful

• mottled

how long does it take for partial thickness (second degree) to heal

• 10 days - 3 weeks

  • scarring and potential for grafting

How do partial thickness (second degree) burns happen

• contact with flames, hot liquids, intense radiant head or contact with hot surfaces for prolonged time

Full Thickness (Third degree) site

down to the fascia and maybe deeper

Full Thickness (Third degree) s&s

• appears white or charred

• non painful within wound

healing time for Full Thickness (Third degree)

• Most likely need grafting especially if it's more than 4 cm or 3rd degree  

• Epithelial cells aren’t able to grow, the bed is destroyed

What type of burn can cause myoglobinuria

electrical

complications of electrical burns

• Rhabdomyolysis 

• Dysrhythmias

electrical burn characteristics

• charring at entry and exit

  • Small 

  • Iceberg effect - path of least resistance 

    • Can follow nerves, bones, muscles, vessels 

•  tend to have less surface burns but more internal tissue burns

what should we do if there is an electrical burn?

• flush kidneys

  • increased likelihood of ATN

where does fluid move in burn shock within the first 24-48 hours

• interstitial space

What can cause noxious stimuli

• laying on something uncomfortable

• constipation

• full bladder

• needle stick

how is Autonomic Dysreflexia manifested

• pounding headache

• bradycardia

• vasodilation

  • facial flushing

  • profuse sweating

  • piloerection

• systemic vasoconstriction

• hypertensive crisis

A patient with an injury to C5 is moved out of the ICU and complains of a severe headache. What would the nurse do? 

find the noxious stimuli and remove it

Autonomic Dysreflexia

• occurs with lesions at or above T6

• 6 months and longer post- injury

• results from autonomic nervous system disruption

palmar method

• 1 % of TBSA

• used for burns that are spread out

  • oil splatter \s