Critical Care of Patients with Neurologic Emergencies

Critical Concepts in Neurologic Emergencies

• Perfusion: Refers to the flow of blood to tissues, crucial for maintaining function in the brain.
• Cognition: The mental processes involved in gaining knowledge and comprehension.

Interrelated Concepts

• Mobility: The ability to move freely and easily.
• Sensory Perception: The process of receiving and interpreting sensory information.

Transient Ischemic Attack (TIA)

• Definition: A short episode of neurologic dysfunction caused by temporary interruption in cerebral blood flow.
• Characteristics:
  • Often referred to as a “warning sign” for a future stroke.
  • Symptoms resolve within a short duration.
• Causes: Commonly related to carotid stenosis.
• Assessment Tools: NIH Stroke Scale (NIHSS), ABCD2 assessment tool.

Stroke

• Pathophysiology:
  • Critical interruption of blood flow to the brain leading to tissue infarction.
  • Considered a medical emergency.
• Types:
  • Acute Ischemic Stroke (AIS): Caused by thrombotic or embolic blockage.
  • Hemorrhagic Stroke: Includes Intracerebral Hemorrhage (ICH) and Subarachnoid Hemorrhage (SAH).
  • Aneurysm and Arteriovenous Malformation (AVM).

Etiology and Risk Factors

• Genetic Factors: Family history can increase risk.
• Modifiable Factors: Smoking, obesity, hypertension, diabetes mellitus, elevated cholesterol levels.

Incidence and Prevalence

• Statistics:
  • Fifth leading cause of death in the U.S.
  • Higher incidence in women due to longer life expectancy.

Prevention and Health Promotion

• Healthy People 2030 Goals:
  • Control blood pressure.
  • Manage cholesterol levels.
  • Promote smoking cessation.
• ABCs of Prevention: Aspirin use when appropriate, Blood pressure management, Cholesterol management.

Recognizing Cues: Assessment

• Immediate Actions:
  • Ensure timely transport to a stroke center.
  • Conduct a thorough physical assessment.
  • Utilize the NIHSS for neurologic examination.
• Laboratory Assessments: Check elevated H&H, WBC, blood glucose, and coagulation parameters (PT, INR, aPTT).
• Imaging: Consider CTP, CTA, MRA, and Ultrasound.

Analyzing Cues & Prioritizing Hypotheses

• Clinical Analysis:
  • Evaluate inadequate perfusion to the brain and the potential increase in intracranial pressure (ICP).
  • Assess for decreased mobility and impaired cognition, which may impact ADLs.
  • Monitor for aphasia and/or dysarthria due to altered brain circulation.
  • Identify sensory perception deficits related to neurologic changes.

Planning and Implementation

• Immediate Focus:
  • Improve cerebral perfusion.
  • Promote patient mobility and assist with activities of daily living (ADLs).
  • Enhance effective communication strategies.
  • Manage sensory perception changes as they occur.

Outcomes Evaluation

• Expected Goals for Patients:
  • Maintain adequate cerebral perfusion.
  • Control blood pressure and blood glucose levels within prescribed ranges.
  • Perform self-care and mobility tasks independently.
  • Adapt to changes in sensory perception and develop communication strategies.
  • Achieve adequate nutrition and avoid aspiration.

Traumatic Brain Injury (TBI)

• Definition: Damage to the brain caused by an external mechanical force.
• Types of Brain Injury:
  • Primary: Occurs at the moment of impact (focal/diffuse, open/closed).
  • Secondary: Develops or worsens outcomes after the initial injury (e.g., post-concussion syndrome).

Hematomas

• Epidural Hematoma: Located outside the dura mater; usually arterial bleeding.
• Subdural Hematoma (SDH): Venous bleeding between the dura and arachnoid, often due to torn bridging veins; slower bleeding compared to epidural hematomas.

Epidemiology and Risk Factors

• Injury Causes: Falls, self-harm, vehicular accidents, and assaults often contribute. Alcohol use may exacerbate risks.

Health Promotion and Safety Prevention

• Strategies:
  • Promote safe driving and helmet usage.
  • Prevent falls through environmental adjustments.
  • Avoid alcohol and drugs.

Recognizing Cues: Assessment

• Key Signs:
  • Amnesia, loss of consciousness (LOC), seizures.
  • Physical signs include increased ICP and vital sign changes (hypotension, hypoxia).
  • Conduct a thorough neurologic and psychosocial assessment.

Imaging Assessments

• Use CT and MRI to evaluate brain injuries.

Analysis of Findings

• Hypotheses:
  • Address potential decreased cerebral perfusion and secondary injury impacts, including cognitive and sensory deficits.

Planning and Implementation for TBI

• Care Goals:
  • Ensure adequate perfusion.
  • Prevent secondary injuries.
  • Address cognitive, sensory, and mobility management.

Outcome Evaluation for TBI

• Patient Goals:
  • Maintain cerebral tissue perfusion.
  • Adapt to mobility and sensory perception changes.
  • Minimize cognitive impairments.

Brain Tumors

• Pathophysiology:
  • May be primary (originating in the CNS) or secondary (metastatic from other parts of the body).

Symptoms and Assessment

• Common Symptoms:
  • Headaches, nausea, seizures, sensory impairments, balance issues.
  • Cognitive changes, speech difficulties, personality alterations.

Interventions

• Management:
  • Non-surgical: Drug therapy and stereotactic radiosurgery.
  • Surgical: Craniotomy as indicated.

Care Coordination and Management

• Ensuring quality of life and safety; monitoring for seizure activity and providing a supportive environment.