Neuro Critically Ill Notes

Tumor that originate from brain cells, meninges (membranes covering the brain), nerves, and glands

Primary brain tumor

• Glioma

• Meningioma

• Oligodendroglioma

• Acoustic neuroma

• Pituitary adenoma

Types of primary brain tumors

Tumor from the glial cells that support and nourish nerve cells

Glioma

Tumor from the meninges (layers of the brain) that can cause increased ICP

Meningioma

Tumor from oligodendrocytes which support and insulate axons in the CNS

Oligodendroglioma

Tumor from CN VIII that can cause compression of other CNs and brain tissue

Acoustic neuroma

Tumor that causes hypersecretion of pituitary hormones

Pituitary adenoma

• Acromegaly from increased GH

• Amenorrhea from increased prolactin

• Decreased urine output from increased ADH

• Adrenal hyperfunction

S/S of pituitary adenoma

• Lung

• Melanoma

• Renal

• Breast

• Colorectal

Cancers that can metastasize to the brain

• Papilledema

• Headache

• N/V

• Seizures

• Decreased alertness

• Cognitive impairment

• Personality changes

• Hemiparesis

• Abnormal reflexes

• Cranial nerve palsies

• Ataxia

S/S of increased ICP

Swelling of the optic disk

Papilledema

One-sided muscle weakness

Hemiparesis

Lack of voluntary coordination causing clumsy movements, balance issues, and walking difficulties

Ataxia

• Change in LOC

• Headache

• Vision changes

• Seizure activity

• Bradycardia

• N/V

• Numbness and tingling

• HTN with widening pulse pressure

• Pupillary changes secondary to compression of CN III

S/S of brain tumors

• Comprehensive neuro exam to determine which part of the brain is affected

• Biopsy to get a sample of brain tissue to stage the tumor

• MRI and CT scans used to obtain a sample for the biopsy

• PET and CT scans if metastasized from somewhere else

Diagnostic tests for brain tumors

Chemotherapy, radiation therapy, craniotomy

Treatment for brain tumors

Must be able to cross the blood-brain barrier to treat brain tumors

Chemotherapy

• Carmustine

• Temozolomide

• Thiotepa

• High doses of methotrexate

Chemotherapy meds

Type of chemotherapeutic agent known as a radiosensitizer given to make cancer cells more susceptible to radiation

Temozolomide

• Fatigue

• Diarrhea

• Weight loss

• N/V

• Mucositis

• Hair loss

• Sterility

• Neutropenia

Side effects of chemotherapy

• Destroys both tumor and normal cells by damaging cellular DNA

• Delivered by focusing on the affected area using technologies like the CyberKnife

Radiation therapy

• Fatigue

• Headache

• Swelling

• Visual changes

• Neurological disturbances

• Hearing loss

• Facial numbness

• Reddening of the skin (sunburn appearance)

Side effects of radiation therapy

A section of the skull is removed (bone flap) to biopsy brain tissue or remove the tumor

Craniotomy

• Increased ICP

• Intracranial hemorrhage

• Vasogenic edema

• Seizures

• Venous thromboembolism (VTE)

• Diabetes insipidus (DI)

Complications of brain tumors

• Blood–brain barrier becomes inflamed and more permeable causing cerebral edema

• Common after brain tumor resection

Vasogenic edema

• Osmotic diuretics

• Hyperventilation

• HOB > 30 degrees

• Dexamethasone to decrease inflammation

Treatment for vasogenic edema

Benzos during and antiepileptics after to prevent recurrence

Treatment for seizures

• Bradycardia

• Increased systolic BP

• Irregular RR

Cushing’s triad

Occurs late in increased ICP signaling herniation syndrome, a medical emergency

Cushing’s triad

⬆ urine output, ⬇ USG, ⬇ urine osmolality, ⬆ serum sodium, ⬆ serum osmolality

S/S of diabetes insipidus

SCDs and SUBQ heparin

VTE prophylaxis

• Dexamethasone to treat and prevent further cerebral edema

• Osmotic diuretics to treat cerebral edema

• Stool softeners to decrease Valsalva and straining which can increase ICP

• Antiepileptics to prevent seizures

• Heparin to prevent VTE

• Opioids for pain

Meds for brain tumors

• Frequent neuro checks

• Vital signs

• Estimated blood loss

• Strict Is & Os

• USG, urine osmolality, serum sodium and osmolality

• Pain level

Nursing assessments for brain tumors

• Administer meds as ordered

• Replace urine loss and electrolytes as ordered

• Elevate HOB 30-45 degrees and maintain head in good alignment

• Apply SCDs

Nursing interventions for brain tumors

• Taper steroid dose down, don’t stop abruptly

• Glucose monitoring due to hyperglycemia from steroids

• Some antiepileptics may require blood draws to ensure that they are maintained at therapeutic levels

• Fall precautions due to new motor or visual deficits

• Wear hats and head coverings to decrease heat loss from head due to alopecia from chemotherapy

• Mouth care with soft toothbrush and non-alcoholic mouthwash to decrease mouth discomfort from sores caused by chemotherapy

Client education for brain tumors

Rapidly progressing, fatal disease of the spinal cord that causes muscle weakness and atrophy but does not impair the senses or ability to think

ALS

Other name for ALS

Lou Gehrig’s disease

Type of ALS that prominently affects the muscles involved in speech, swallowing, and tongue movements

Bulbar ALS

Other name for Bulbar ALS

Progressive bulbar palsy

1. Motor neurons in the brain and spinal cord progressively degenerate from oxidative stress

2. Motors neurons eventually die from degeneration, causing the brain to lose the ability to initiate and control muscle movement

3. Without direction from the CNS, muscles gradually weaken, atrophy, and twitch

4. Eventually all voluntary muscles are affected causing paralysis, but sensation is intact

5. Affects the diaphragm and chest wall, resulting in respiratory failure and the need for an artificial airway and ventilator support

Pathophysiology of ALS

Term for muscle twitching

Fasciculation

Gradual onset of progressive weakness

Hallmark sign of ALS

• Muscle cramps or stiffness

• Dropping objects

• Uncontrolled laughter or crying

• Slurred or slow speech

• Difficulty swallowing (dysphagia)

• Hyperreflexia (increased reflexes)

• Difficulty breathing

• Voice hoarseness

• Head drop due to weak neck muscles

• Muscle twitching

• Choking or drooling due to dysphagia

• Paralysis

• Tongue atrophy

Other S/S of ALS

Spasticity

Sign of upper motor neuron damage

Flaccidity

Sign of lower motor neuron damage

• Vitamin B12 level for deficiency

• Rapid plasma reagin (RPR) for neurosyphilis

• TSH level for hypothyroidism

• Rheumatoid factor for rheumatoid arthritis

• Creatine phosphokinase (CPK) for muscle injury

• Electrolyte panel for imbalances

• CBC and peripheral smear for leukemias/plasma cell dyscrasias

• Anti-MAG and anti-GM1 antibodies for other neuromuscular diseases

• Parathormone for deficiency

• Urinalysis and 24-hour urine for heavy metals

• Serum lead, acid maltase, and hexosaminidase levels for other metabolic-neuromuscular diseases

• Free erythrocyte protoporphyrin for porphyrias

Diagnostic labs used to rule out conditions similar to ALS

• Antinuclear antibody (ANA) as a general autoimmune screen

• ESR as a general inflammatory screen

Other labs for ALS

• Serum protein electrophoresis/immunofluorescent electrophoresis for protein disorders

• Muscle and/or nerve biopsy

• X-rays, CT scan, and MRI

• Lumbar puncture to evaluate CSF protein and cytology

• Electromyography (EMG) or nerve conduction velocity (NCV)

Diagnostic tests used to rule out conditions similar to ALS

• Clinical manifestations of both upper and lower motor neuron damage

• Genetic testing if there is a known family history

• Swallow studies to see if swallowing ability has been effected

Diagnostic tests for ALS

• PT, OT, and speech therapy to maximize function

• Gastric feeding tube to help meet nutritional requirements

• Artificial airway and mechanical ventilation when the chest and diaphragm muscles weaken

• Diaphragm pacing system as an adjunct to noninvasive ventilatory support

Treatment for ALS

• Muscle relaxant like baclofen for muscle cramps

• Laxatives like miralax for constipation

• Analeptics like modafinil for fatigue and weakness

• TCAs like amitriptyline for excessive salivation, pain, and depression

• Riluzole to slow disease progression and prolong the need for ventilation

• Antioxidants like edaravone to reduce decline in daily functioning

• Glycopyrrolate for excessive salivation

Meds for ALS

• Aspiration of food or fluid

• Respiratory failure

• Pneumonia

• Pressure injuries

• DVT or PE

• Constipation

• Contractures

• Depression

• Weight loss

• Loss of the ability to care for self

Complications of ALS

• Airway

• O₂ saturation

• Motor strength

• Skin

• Coping skills

Nursing assessments for ALS

• Perform passive ROMs

• Administer meds as a supportive measures

• Turn, cough, and deep breath to promote gas exchange

• Turn/reposition q2h to maintain skin integrity

• Provide emotional support

Nursing interventions for ALS

• Report increased difficulty swallowing or breathing

• Inform when repositioning is needed due to discomfort

• Alternative communication strategies

Client education for ALS

Acquired autoimmune disorder that affects the neuromuscular junction causing fluctuating muscle weakness and fatigue

Myasthenia gravis

Crosses the synaptic cleft and binds to ACh receptors on the postsynaptic membrane, causing skeletal muscle contraction

Normal ACh function

1. Anti-ACh receptor antibodies bind with ACh receptors and destroy them

2. Postsynaptic ACh binding is blocked and sensitivity to ACh is diminished

3. Skeletal muscle weakness and fatigability

Pathophysiology of myasthenia gravis

May cause the development of Anti-ACh receptor antibodies due to hyperplasia or a tumor

Thymus gland

• Ocular S/S: Ptosis, diplopia

• Bulbar S/S: Difficulty with speaking, chewing, and swallowing

• General S/S:

  • Muscle weakness that increases over the course of the day

  • Difficulty with ADLs like bathing and dressing

S/S of myasthenia gravis

Eyelid drooping

Ptosis

Assay for anti-ACh receptor antibodies

Diagnostic lab for myasthenia gravis

• Repetitive nerve stimulation

• Single-fiber electromyography

• Tensilon test

• Chest CT scan to evaluate for thymoma

Diagnostic tests for myasthenia gravis

• Measures muscle action potential after repeated nerve stimulation to evaluate neuromuscular transmission

• MG result: Decreased muscle response with repetitive stimulation

Repetitive nerve stimulation

• Used to detect an abnormality in neuromuscular transmission using needles placed in the muscle to measure electrical activity

• MG result: Increased jitter

Single-fiber electromyography

Fluctuation of the interval between two muscle fibers firing

Jitter

• Patient visually focuses on an object to test ocular muscles while up to 10 mg of edrophonium is given IV push

• Positive result: Improvement of muscle weakness at 2 to 5 minutes followed by a return to baseline over the next 5 minutes

Tensilon test

• Thickened liquids or enteral tube feedings

• Thymectomy

• Plasmapheresis

Treatment for myasthenia gravis

• Surgery to treat thymoma

• IV neostigmine is given to maintain muscle strength and respiratory function

• Management in an intensive care unit following surgery

Thymectomy

Tumor of the thymus gland

Thymoma

Procedure that removes antibodies that block ACh receptor function from blood plasma to improve muscle strength

Plasmapheresis

Anticoagulant used to prevent clotting in the extracorporeal blood by binding with calcium to prevent calcium-dependent clotting factor reactions

Citrate

• Meds like antihypertensives must be held before treatment

• Instilled the catheter with heparin on nonpheresis days to prevent clotting and maintain patency

• Monitor potassium and calcium levels

Medical management for plasmapheresis

1. A large-bore double lumen catheter is inserted

2. Blood is removed from the arterial lumen and circulated through the machine

3. Plasma is separated from the rest of the blood to remove the antibodies that block ACh receptor function

4. The rest of whole blood is returned through the venous lumen along with normal saline and albumin

5. Heparin is instilled in each lumen following treatment 

Process for plasmaphersis

• Citrate-induced hypocalcemia

• Hypovolemia

• Vasovagal reaction

• Septicemia

• Pneumonia

• Cardiac arrhythmias

• Bleeding/clotting abnormalities

Complications of plasmapheresis

• Early signs: Paresthesias, vibration sensation, nausea/vomiting, and diarrhea

• Late signs: Hypotension, chest tightness, tetany, and cardiac arrhythmias

S/S of hypocalcemia

• Adding calcium or 5% albumin to replacement fluid

• Slowing down citrate infusion

Prevention of citrate induced hypocalcemia

• Pausing the procedure

• Trendelenburg position if not contraindicated

• Administering a bolus of normal saline

Treatment of hypovolemia and vasovagal reaction

• Pallor

• Diaphoresis

• N/V

• Hypotension

• Bradycardia

S/S of vasovagal reaction

• Pyridostigmine

• Neostigmine

• Immunosuppressants

• Eculizumab

• IV immunoglobulin (IVIG)

Meds for myasthenia gravis

• AChE inhibitor taken PO for daily use

• Initial treatment of choice for MG

• Taken 30-60 mins before meals to minimize difficulty with chewing and swallowing

• Missed doses can cause muscle weakness and potential respiratory difficulties

Pyridostigmine

• Stomach cramps

• Diarrhea

• Increased secretions

• Nausea

• Bradycardia

• Muscle twitches

Side effects of AChE inhibitors

• Shorter acting AChE inhibitor given IV prior to surgery

• Can cause life-threatening bradycardia or cardiac arrhythmias

• IV site must be monitored frequently to ensure patency due to increased risk of infiltration

• PO pyridostigmine must be given 1 hour before stopping the IV neostigmine

Neostigmine

• Prednisone

• Azathioprine

• Cyclosporine

• Mycophenolate mofetil

• Cyclophosphamide

Immunosuppressants for myasthenia gravis

• Complement inhibiting monoclonal antibody

• Given to patients unresponsive to traditional treatments

• Ensure patient has received meningococcal vaccine at least 2 weeks before the medication administration due to increased risk

Eculizumab

Donor antibody therapy that destroys anti-MuSK and anti-ACh receptor antibodies

IVIG

• Myasthenic crisis

• Cholinergic crisis

Complications of myasthenia gravis

Acute episode of respiratory failure often caused by a respiratory infection from viral or bacterial agents

Myasthenic crisis

• Respiratory distress

• Bulbar weakness

• Tachycardia

• Flaccid muscles

• Pale and cool skin

S/S of myasthenic crisis

• IVIG or plasmapheresis

• Intubation and mechanical ventilation

Treatment for myasthenic crisis

Caused by excessive AChE medication

Cholinergic crisis

• Fasciculations

• Bradycardia

• Sweating

• Pallor

• Excessive secretions

• Small pupils

S/S of cholinergic crisis

Used to distinguish between myasthenic and cholinergic crisis because they present with similar S/S

Tensilon test

• Myasthenic crisis result: Muscle strength improvement

• Cholinergic crisis result: Fasciculations and muscle weakness

Results of tensilon test

• Discontinuing AChE inhibitors

• IV Atropine

Treatment for cholinergic crisis

• Respiratory assessment

• Vital capacity measurement

• Muscle strength

• Cranial nerve assessment

• Dysphagia, dysarthria

• Nutritional intake, Is & Os, daily weights

• S/S of infection

Nursing assessment for myasthenia gravis

• Maximum amount of air exhaled following maximal inhalation

• Normal is 65 mL/kg

• Mechanical ventilation is required when it falls below 15 mL/lg or 1 L

Vital capacity measurement

• Administer medications at prescribed times and prior to activities requiring swallowing

• Elevate HOB for eating or drinking to decrease risk for aspiration

• Establish effective communication method with the patient such as a board

• Plan meals when medications are at peak levels to decrease risk for aspiration

• Offer soft foods and thickened liquids as recommended by the speech language pathologist

• Plan for rest periods between ADLs to minimize fatigue and muscle weakness

• Use equipment like a gait belt or wheeled walker when ambulating patient to prevent falls due to muscle weakness or vision changes

Nursing interventions for myasthenia gravis

• Importance of taking medications as prescribed

• Spare med doses should be kept in car, carry-on luggage, and at job to never a miss a dose of pyridostigmine

• Wear a MedicAlert bracelet

• Avoid large gatherings of people in the winter due to increased risk of infection

• Obtain vaccines to prevent the flu and pneumonia to prevent myasthenic crisis

• Prevent fatigue with frequent rest periods

• Plan activities during peak energy periods

• Don’t take OTC meds without first checking with provider or pharmacist

Client education for myasthenia gravis

Acute inflammatory demyelinating polyneuropathy that occurs after an infection and causes a rapidly progressing flaccid paralysis

GBS