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.