MANAGEMENT OF PATIENTS WITH ACUTE NEUROLOGIC CONDITIONS

1. Cholinergic Crisis

2. Myasthenia Crisis

Complication from myasthenia crisis

Myasthenia Crisis

exacerbation of the disease process characterized by severe generalized muscle weakness and respiratory and bulbar weakness

Respiratory Failure

Myasthenia crisis may result in this condition.

infection

Most common precipitating factor of myasthenia crisis especially respiratory

undermedication

What medication-related factor can precipitate an exacerbation of the disease myasthenia crisis?

ca channel blockers

What cardiovascular medications can precipitate an exacerbation of myasthenia crisis?

pregnancy

What physiological condition can precipitate an exacerbation of myasthenia crisis?

aspiration pneumonitits

What pulmonary complication can trigger an exacerbation of myasthenia crisis?

Neostigmine methylsulfate

What medication is administered IM or IV during myasthenic crisis until the patient can swallow oral anticholinesterase drugs?

Prostigmin

What is the brand name PMS-Neostigmine also known as

Anticholinesterase

What class of medication is neostigmine?

Corticosteroids

What immunosuppressive medication may be used in conjunction with IVIG and plasmapheresis?

Azathioprine (Imuran)

What immunosuppressive drug may be used as part of the management of myasthenic crisis?

IVIG

What therapy uses intravenous immunoglobulin as part of myasthenic crisis management?

Plasmapheresis

What procedure removes abnormal antibodies from the patient's blood and may be used in myasthenic crisis?

endotracheal intubation

What invasive airway intervention may be required when respiratory weakness becomes severe in myasthenia crisis?

mechanical ventilation

What supportive treatment is used when the patient develops respiratory failure during myasthenic crisis?

overmedication of anticholinesterase drugs

What is the primary medication-related cause of cholinergic crisis?

organophosphate poisoning

What type of poisoning can cause cholinergic crisis?

1. sarin

2. tabun

3. soman

What nerve agents can cause cholinergic crisis through overstimulation of nicotinic and muscarinic receptors?

nicotinic and muscarinic receptors

What receptors are overstimulated in cholinergic crisis?

muscle weakness

What type of muscle problem is seen with nicotinic toxicity?

Muscular Fasciculations

What involuntary muscle movement is a manifestation of nicotinic toxicity?

Miosis and blurry vision

What pupil and vision abnormality is associated with muscarinic toxicity?

bronchospasm

What respiratory condition may occur due to muscarinic toxicity?

lacrimation

What eye-related secretion increases during muscarinic toxicity?

salivation

What oral secretion increases during muscarinic toxicity?

stop

What should be done with all anticholinesterase drugs during cholinergic crisis?

Atropine sulfate

What is an antidote used to manage muscarinic symptoms of cholinergic crisis?

Pralidoxime

What antidote may be used for organophosphate poisoning?

Obidoxime

What other oxime antidote may be used in cholinergic poisoning?

Neurogenic Shock

What type of autonomic nervous system dysfunction is associated with spinal cord injuries above T6?

1. cervical

2. high thoracic

What type of spinal cord injuries are commonly associated with neurogenic shock?

Bradyarrhythmia

What cardiovascular abnormality is commonly seen in neurogenic shock?

peripheral vasodilation

What vascular change contributes to hypotension in neurogenic shock?

1. bradyarrhythmia

2. hypotension

3. temperature dysregulation

What three major manifestations characterize neurogenic shock in a patient with SCI?

4

Very brisk, hyperactive with clonus

3

Exaggerated (brisk)

2

normal response

1

diminished (Hyporeflexia)

0

absent (Areflexia)

Hypotonic Fluids

lower osmolarity than the blood; causes water to move from the extracellular compartment to the intracellular compartment

Hypotonic Fluids

• 0.45% Saline

• 0.225% Saline

• 0.33% Saline

• 5% Dextrose in Water

hypotonic fluids

Cell Swelling and Rupture

Isotonic Fluids

Equal osmolarity as the blood; water will equally transfer in and out of the cells; helps expand plasma (Intravascular) space

• 0.9% Saline

• Lactated Ringer’s Solution

• 5% Dextrose in water

• Fluid overload

• D5W increases glucose

• LR: Not for patients with liver disease (can’t convert lactate to bicarb)

Hypertonic Fluids

• Higher osmolarity than the blood

• Causes water to move from the intracellular to the extracellular compartment

Hypertonic Fluid

• 3% saline

• Dextrose 10% in water

• Dextrose 5% in 0.9% normal saline

• Dextrose 5% in 0.45% normal saline

hypertonic fluid

Cell Dehydration and Shrinkage

Minimize spine movement

initial intervention of patient with spinal cord injury

1. rigid cervical collar

2. supportive blocks on a backboard with straps

What device is recommended to stabilize the cervical spine?

Log roll technique

What technique should be used when moving a patient with spinal cord injury?

rapid sequence intubation with in line spinal immobilization

What type of intubation may be used when mechanical ventilation is required?

intubation over a flexible fiberoptic laryngoscope

What intubation method is preferred if the clinical situation allows?

Crystalloid fluid bolus

What is the immediate treatment for profound hypotension in a patient with spinal cord injury?

Repetitive fluid boluses

If hypotension is caused by spinal shock rather than hemorrhage, what should be avoided?

inotropes

What medications should be started when hypotension is due to spinal shock and does not respond appropriately to limited fluid resuscitation?

urinary retention

What condition should be assessed in the urinary system of a patient with spinal cord injury?

hemodynamic stabilization

What is the primary goal of the initial management of neurogenic shock?

cardiac output

What hemodynamic parameter should be maintained to prevent secondary injury?

hypotension

What condition should be treated first to prevent secondary spinal cord injury?

1. IV Infusion Crystalloids

2. resuscitation

What is the first step in managing hypotension in neurogenic shock?

1. vasopressor

2. inotropes

What is the second step when managing hypotension after initial fluid resuscitation?

Phenylephrine

What is the first-line vasopressor for neurogenic shock?

bradycardia

What adverse effect should be watched for when administering phenylephrine?

1. norepinephrine

2. epinephrine

What are the second-line vasopressors used in neurogenic shock

1. atropine (AtroPen)

2. Glycopyrrolate (Glycate)

What is the first-line medication for treating bradycardia in neurogenic shock?

1. isoproterenol (isuprel)

2. theophylline (Uniphyl)

3. aminophylline (Truphylline)

What are the second-line medication for treating bradycardia in neurogenic shock?

C spine immobilization

What should be performed initially to prevent further spinal cord damage?

1. Miami J

2. Philadelphia Collar

What type of cervical collar may be used for initial C-spine immobilization?

Decompression Surgery

What type of surgery may be performed to manage neurogenic shock when spinal cord compression is present?

Laminectomy with spinal fusion

What is an example of decompression surgery?

1. Neural shock

2. Areflexia

What are the other terms for spinal shock?

30 to 60 mins after SCI

When can spinal shock begin after a spinal cord injury?

release of catecholamines

What causes the transient increase in blood pressure at the beginning of spinal shock?

hypotension

What condition immediately follows the initial transient increase in blood pressure?

flaccid paralysis

What type of paralysis occurs during spinal shock?

Anhidrosis

What sweating abnormality may occur above the level of injury?

Areflexia

What happens to reflexes below the level of injury?

1. Contraction of quadriceps

2. extension or flexion of toes

What is the first sign of resolution of spinal shock?

hyperreflexia

What reflex change indicates resolution of spinal shock?

reflex empyting of the blaldder

What bladder function returns as spinal shock resolves?

bulbosongiosus reflex

What reflex involving penile erection returns as spinal shock resolves?

1. dopamine (intropin)

2. Dobutamine (Dobutrex)

What inotropic medications may be used in the management of spinal shock?

1. Phenylephrine (Neo Synephrine)

2. norepinephrine (Levophed)

What medications are listed as chronotropes in the management of spinal shock?

Atropin (Atropen)

What medication is indicated for bradycardia in spinal shock?

Paralytic Ileus

What gastrointestinal complication commonly develops in patients with spinal shock?

GI Decompression

What intervention may be required for paralytic ileus?

Thermoregulation

What body function is altered because of spinal shock?

Venous thromboembolism

What complication should VTE prophylaxis help prevent in untreated SCI patients?

72 Hrs

Within what period can thromboembolism develop in untreated SCI patients?

regular turning using log roll

What nursing intervention helps prevent pressure ulcers?

intermittent catheterization

What is the preferred method for managing urinary retention in spinal shock?

Proton pump inhibitors

What type of medication is used for gastric ulcer prophylaxis for 4 weeks?

1. Omeprazole (Prilosec)

2. Esomeprazole (Nexium)

3. Pantoprazole (Protonix)

4. Lansoprazole (Prevacid)

Example of PPI

Methylprednisolone (Solu Medrol)

What corticosteroid may be administered parenterally in Spinal shock?

1. impaired breathing pattern r/d to impairement of diaphragm

2. impaired physical mobility r/d neuromuscular impairement

Nursing Diagnosis of spinal shock

maintain patent airway

nursing management of spinal shock