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Mod C Exemplars

Terms in this set (32)

ROP Retinopathy of Prematurity
abnormal vessel growth and retinal detachment in premature newborns

most often due to over-oxygenation

can lead to blindness in newborns
Risk factors
Premature <32 weeks
Oxygen therapy! With high levels. Ventilator support
Low birth weight
Poor weight gain
Blood transfusions


Apnea
Heart Disease
Elevated Carbon Dioxide in the blood
Infection
Low blood acidity
Low blood oxygen (too much AND too little can cause issues)
Respiratory distress
Bradycardia
Clinical manifestations
ONLY LATE SIGNS

abnormal eye movement
strabismus (cross-eyed)
severe near-sightedness
leukocoria (white pupils)
ROP Stages
I mildly abnormal vessel growth
II moderate growth
III severe growth
IV severe w partial retinal detachment
V total retinal detachment

I-II usually resolve and don't require tx

III-IV tx varies based on severity

V requires immediate tx to prevent blindness!
Diagnosis
Exams/Tests
sleeping baby is beneficial during examRetinal exams required for high risk babies (premature!)
Born prior to 30 weeks gestation
Weighs less than 1500 grams or 3 lbs
Born after 30 weeks but weigh 3-4.5 lbs

First retinal exam occurs 4-7 weeks after birth depending on the gestational age
Need to allow time for vascular completion (typically occurs 6-23 weeks gestation)
Prior to 27 weeks - exam later
After 27 weeks - exam at 4 weeks of age

Sleeping baby is beneficial during exam
Pupillary dilators and analgesics

Follow-up exams based on initial exam results
Normal development in both retinas = no need for second exam
Ensure parent are aware of need for follow-up
ROP Treatment
Early detection and treatment is key, also prevention of premature birth!
Tx within 72 hours of indicative exam

Laser therapy "photocoagulation" - prevents formation of new vessels and complications; must be done prior to scarring or retinal detachment

Antibody injection to block VEG-F

Cryotherapy - extreme cold to freeze and remove abnormal tissue

Surgery if retinal detachment occurs
Nursing care
Avoid premature birth

Use lowest (but safest) concentration of oxygen therapy (FiO2) possible
Keep O2 sats between 88-94%
Try to allow baby to compensate prior to turning up oxygen flow (unless able to compensate! mottled skin, HR drop, further O2 sat drop)

Admin pupillary dilators and analgesics prior to eye exam
Phenylephrine 2.5%
Cyclopentolate 0.25%
administered prior to the eye exam to dilate the pupils

typically prepared by nurse and admin by doc

store in fridge
minimum of 2 doses
first dose 60 mins prior, second dose 10-20 mins after initial dose (third dose 10-20 mins after second for dark-eyes)
Analgesics
Amethocaine, Hydrochloride, Tetracaine
admin just prior to OR during the exam to help calm the baby (exam itself is not painful but can cause distress)

Tetracaine - topical eye drops

another option is oral sucrose. should give prior since its not as effective if administered during. don't admin in sleeping infant!

small risk of eye injury if baby is stimulated during exam
sleeping baby is beneficial during exam
Complications
Severe near-sightedness
Blindness
Retinal detachment
Plus disease
Plus Disease
large, twisting blood vessels on the back part of the eye

indicates severe ROP!
often followed by rapid progression to retinal detachment
may require immediate tx!

s/s - haze, engorged iris vessels, poor dilation of pupil
Eye Trauma
Injury to the eye sustained as the result of sharp or blunt trauma, chemicals or heat; visual impairment can occur

Main priorities = preventing long-term damage, relieving pain, preventing infection

Includes:
Corneal abrasion - superficial abrasion due to disruption of the superficial epithelium ie. contact, eyelash, small foreign body
Thermal burns - chemicals, heat, radiation, burns/flashes, UV
Alkaline burns - more serious due to high pH and lipophilic (lets in)! ulceration and tissue necrosis with 5-15 mins
Acid burns - less serious; body cells defend against acids better
Penetrating injuries - layers spontaneosly reapproximate (may be difficult to visualize)
Blunt trauma
Subconjunctival hemorrhage
Periorbital ecchymosis
Foreign body on conjunctiva
Detached retina - retina separated from chorea; usually spontaneous. Painless with drawn curtain effect. Must reattach to prevent permanent loss of vision
Clinical manifestations
Corneal abrasion - TEARS, very painful, redness, irritation
Burns - swollen eyelids, swelling, decreased vision (cloudy/hazy cornea), red/sloughing/charred skin (eyelids, face, lips), red conjunctiva
Penetrating trauma - pain, vision loss, bleeding, leaking eye contents
Blunt trauma - pain, redness, ecchymosis, subconjunctival hemorrhage, hyphema (blood pooling in between cornea/iris aka ant. chamber), sunken eye
Subconjunctival hemorrhage - redness in conjunctiva
Detached retina - painless, drawn curtain effect, floaters in vision, flashes light
Diagnosis
Visual acuity test
Test cranial nerves; extraocular movement eval
PERRLA
Red reflex w ophthalmoscope
CT, ultrasonography
Facial x-ray to visualize bones
Slit lamp or florescent stain to visualize corneal defects or abrasions/injuries
Treatment
Corneal abrasion, subconjunctival hemorrhage, black eye - typically no surgery, treat symptoms, abx (gentamycin, neomycin)

Thermal burn, acid burn - saline irrigation/rinse, cyclopegics for dilation (Atropine, Tropicamide, Cyclopentolate), anesthetics (Tetracaine, Proparacaine)
Aklaline burn - copious saline rinse; NO BUFFERES ie. saline flush, cyclopegics, anesthetics
Severe chemical burns - debridement, eye washing, tissue grafting, corneal transplant

Penetrating - ophthalmic surgery, irrigate, abx, anesthetics, sedatives, antiemitics
Blunt - vary w type/cause, Brinzolamine (eye drops), carbonic anhydrase inhibitor to reduce fluid production and decrease intraocular pressure (oral acetazolamide)

Foreign bodies - typically nonsurgical removal in ED, may req specialist

Retinal detachment - medical emergency! cyrotherapy, laser photocoagulation, pain management for procedure, surgery w contrast, steroids post-op to reduce inflammation
Lifespan considerations
Common causes of eye injury in children:
Blunt trauma from ball or fist
Sharp trauma from projectiles, sticks
Chemical trauma from household chemicals
Burns from fireworks

Two black eyes = sign of abuse

Most frequent cause of eye injury for geriatrics = falling!
Increased risk due to poor eyesight, decreased cognition, altered depth perception due to bifocals
Subarachnoid hemorrhage
bleeding in the arachnoid space
Dx and Tx
CT and cerebral angiography

Lumbar puncture; do NOT do if s/s of IICP
Risk for herniation

Tx: primary therapy = direct aneurysm clipping
surgical candidate if mild/intermediate SAH (Hunt and Hess score 1-3, must be less than 3)

Surgical AMV excision
Embolization

Calcium channel blocker Nimodipine to decrease incidence/severity; monitor for hypotension

Keep systolic BP less than 150 to prevent re-bleeding
Amicar to prevent fibrinolysis and prevent re-bleeding

For SAH and ICH - Frequent GCS, CCP 70, keep temp down, pH 7.4-7.45, BP management due to elevated BP
Complications of SAH
Re-bleeding - typically occurs 1st day after initial bleed

Vaso-spasm due to vessel being aggravated by blood in subarachnoid space, usually 3-5 days after initial bleed; monitor for ischemic stroke

Seizure
Intracranial hemorrhage
bleeding directly into the cerebral tissue

destroys brain tissue and causes cerebral edema
IICP

2x more common than SAH
typically caused by small artery bleed

Also may be due to hypertensive rupture of cerebral artery, atherosclerosis and vessel burst, anticoagulant therapy, coagulation disorder, bleeding into infarct or tumor
Clinical manifestations
early loss of consciousness, usually very sick
HTN
IICP
HA
vomiting
rapid neurological deterioration
Dx
CT and cerebral angiography
Traumatic brain injuries TBI
various shapes, sizes, levels of severity

Main priorities:
Identify early signs of IICP
Prevent and manage secondary injuries

Patients often experience life-long cognitive impairment and post-injury deficits

Goal = minimize damage and preserve brain function
Want to minimize damage in the penumbra (area affected around primary injury with viable tissue)
Decrease CBF and ischemic damage
TBI Dx and Labs
CT
Angiography
Cerebral Blood Flow Studies via cerebral doppler
X-Rays
MRI

CBC
CMP: Na, K, Cl, Ca, Mg, Cr, BUN
Serum & Urine Osmolality
ABG's want to keep patient slightly alkalotic to decrease metabolic demand (but not over 7.45; risk for cerebral ischemia and further secondary injuries)
TBI Tx
Temperature control to decrease metabolic demand - antipyretics, cooling blanket, induced hypothermia
Pain control and sedation
Barbituate coma (sedative, sleep-induced)
Paralytics to cause neuromuscular blockade

Avoid positions that decrease venous return from head ie. Trendelenburg (feet up, head down)
Reverse Trendelenburg, HOB 30
Maintain head alignment
Decreased intra-abdominal and intra-thoracic pressure

Blood glucose management
Fluid balance
Seizure precautions Levetiracetam
Neuro-checks q15-60

Maintain CO2 "potent vasodilator"
1 mm Hg increase = 3% increase in cerebral blood flow!
Normal = 35-45
Maintain 30-35

PaO2 at or around 100
Manage vent
Slight alkalosis 7.4-7.45

GCS less than 8 = intubate
GCS less than 6 = call organ procurement

No opioids due to risk for respiratory depression unless intubated

Keep ICP below 20
Keep CPP at least 60, typically ordered higher
Coup-contrecoup
Force of a blow causes the head to strike an object - the brain hits the skull on side of blow

Force of the brain moving in the skull causes the brain to strike the opposite side of the skull

BOTH (blow and counter blow) are PRIMARY injuries.
Basilar skull fracture
Fracture of the FLOOR of the Skull
Very common and usually not fatal

CSF Leak from the Nose/Ears (opens the meninges up to potential pathogens!)

S/S -
Raccoon Eye, Battles Sign (bruising behind ear), Halo Sign (dried CSF on cloth, blood in middle with CSF tint around it)

Abx infection prophylaxis due to increased risk of meningitis
Assess for s/s of infection ie. fever, Kernig, Brudzinski

Don't blow nose! nothing in the nose!
Oral gastric tube only
Penetrating injury
Object (sharp or otherwise) penetrates skull and enters the brain

Low velocity: stable object (pipe, knife, dart, etc...)

High velocity: bullet, flying, spinning object
Diffuse axonal injury
Shaking of the head on the body causes bouncing and rotation of the brain inside the skull leading to twisting, ripping, tearing, and breaking of axons.

Cerebral Edema (cytotoxic from cell damage)
IICP and Decreased CPP

Ex: Shaken Baby Syndrome

Diffuse white spots on CT show areas of axonal injury

Assess MAP Frequently - may be high since the heart is pumping up to overcome the swelling brain pushing down
Outcomes of altered level of consciousness (RT to brain death)
Optimal - full recovery w/o long-term residual effects

Recovery w residual damage like learning deficits and impaired judgement

Persistent vegetative state "irreversible coma"
- Completely unaware of self and environment
- Loss of all cognitive function
- Sleep-wake cycle
- Can chew, swallow, cough

Locked-in syndrome
- Alert and aware
- Intact cognitive abilities
- Unable to communicate via speech/movement

Brain death
- Irreversible cessation of ALL brain function
Recognized criteria for brain death
Unresponsive coma with absent motor and reflex movements
Apnea; no spontaneous respiration
Pupils fixed (unresponsive to light) and dilated
Absent ocular responses to head turning and caloric stimulation
Flat EEG and no cerebral blood circulation present on angiography
Persistence of these manifestations for 30 minutes to 1 hour and for 6 hours after onset of coma and apnea
Brain death testing notes
Criteria for tesiting:
Normotensive
Normothermic
Euvolemic
Eucapnic
Not hypoxic

Apnea testing: All supplemental support (ventilator) is removed and humidified oxygen is provided for 10 mins.
Attain ABG prior to and after trial.

In adults, the patient must be off all paralytics, sedation and pain medication for usually 48 hours prior to brain death testing being performed.

Pediatrics: MUST have at least 2 negative neurologic examinations
Performed 24 hours apart for 37 weeks to 30 days
Performed 12 hours apart for 31 days to 18 years of age
By 2 different, qualified physicians without conflict of interest
No responsiveness
Absent brainstem reflexes

GCS less than 6 = organ procurement
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