Why is it important to check for the cough and gag reflexes?It indicates whether the patient can protect their own airwayIf a patient does not have adequate cough and gag reflexes, what is the priority?IntubationWhat two postures happen with IICP?Decorticate DecerebrateWhat is decorticate posturing?Flexion of the upper extremities and extension of the lower extremitiesWhat areas of the brain are being injured with decorticate posturing?The cerebral hemispheresWhat is decerebrate posturing?Extension and internal rotation of the upper extremitiesWhat areas of the brain are being injured with decerebrate posturing?Midbrain PonsIf a patient goes flaccid after decorticate/decerebrate posturing, what is this a sign of?Injury to the brain stemWhat are the different levels of consciousness?Full Confused Disorientated Lethargic Obtunded Stupor ComaWhat is full consciousness?Awake and alert OrientedWhat is meant by confusion with LOC?Unable to think clearly or quicklyWhat is meant by disorientation with LOC?Unable to recognize places or peopleWhat is meant by lethargic with LOC?The patient awakens easily but has limited responsivenessWhat is obtunded consciousness?Sleeps unless aroused Limited interaction with the environmentWhat is stupor?The patient requires considerable stimulation to arouseWhat is considered a coma?No motor or verbal response to stimuliWhat is normal ICP?5-15 mmHgWhen should ICP be treated?If over 20 mmHg for more than 5 minutesWhat is the Monroe-Kellie doctrine?An increase in one cranial component (blood, CSF, or brain) requires a compensatory decrease in one of the other componentsWhat percentage of skull space does brain tissue take up?85%What percentage of skull space does blood take up?10%What percentage of skull space does CSF take up?5%What are the three major components inside the skull that contribute to pressure balance?Brain tissue Blood CSFWhat happens if there is an increase in one of the three cranial components and no compensatory decrease in another component?IICPWhat is the overall method of treating IICP?Figuring out which cranial component is elevated and decreasing another component to balance out pressures in the skullWhat is there a risk for to the brain with untreated IICP?Brain herniation and tissue deathWhat happens to the vessels in the brain with decreasing CO2?They vasoconstrictWhat can happen if there is too much vasoconstriction of cerebral vessels due to low CO2?Blood flow to brain tissue is depleted causing tissue deathWhat happens to heart rate initially with IICP?TachycardiaWhat happens to heart rate late in IICP?BradycardiaWhat happens to oxygenation when CO2 levels increase?It decreasesWhat happens to oxygenation levels when CO2 levels decrease?It increasesWhat happens to the vessels in the brain with increasing CO2?They vasodilateWhy do cerebral vessels dilate with increasing CO2?Oxygenation to the brain is decreased, so dilation helps bring more oxygen to the brain tissueWhy can dilation of cerebral vessels be a negative thing with IICP?If there is already too much fluid in the skull, then dilation causes even more fluid buildup and pressure on the brain tissueWhat happens to cerebral vessels during respiratory acidosis?The vessels dilate to allow for more oxygen to get to the brainWhy do the cerebral vessels dilate with respiratory acidosis?High levels of CO2 and low levels of O2 to the brain trigger the need for increased oxygenation to the brainWhat is Cushing's triad?Bradycardia Irregular respirations Widening pulse pressureWhat is Cushing's triad a sign of?IICPIs Cushing's triad an early or late sign of IICP?Late (HAVE TO ACT FAST)What is happening to the brain stem if Cushing's triad is occurring?It is being poorly perfusedWhat causes poor brain stem perfusion with Cushing's triad?Increased fluid pressure on the brain stem, constricting the vesselsWhat does the body do to compensate for poor brain stem perfusion with Cushing's triad?It increases systolic blood pressureWhat are the most common causes of IICP?Head trauma Stroke Encephalitis Anoxic brain injury Tumor Bleeding Hydrocephalus Water intoxication HyponatremiaWhat happens to CPP as ICP increases?It decreasesWhat happens to CPP as ICP decreases?It increasesWhat happens to cerebral blood flow as ICP increases?It decreasesWhat happens to cerebral blood flow as ICP decreases?It increasesWhat happens to PaO2 as ICP increases?It decreasesWhat happens to PaO2 as ICP decreases?It increasesWhat happens to PaCO2 as ICP increases?It increasesWhat happens to PaCO2 as ICP decreases?It decreasesWhat happens to pH as ICP increases?It decreasesWhat happens to pH as ICP decreases?It increasesWhat happens to the vessels as ICP increases?They vasodilateWhat happens to the vessels as ICP decreases?They vasoconstrictIf a patient is intubated and has increasing ICP, what can be done temporarily to fix this?Lower RR to increase CO2 retention and cause vasoconstrictionWhat is there a risk for long-term in intubated patients with IICP if their RR is turned down to increase CO2?Ischemia of brain tissueHow is CPP calculated?MAP-ICPWhat does CPP measure?Perfusion of the brainWhat is the normal range for CPP?70-100 mmHgWhat should CPP be maintained above in all patients?50 mmHgWhat should CPP be maintained above in patients with neurologic injuries?70 mmHgWhat happens to brain tissue if CPP is below 50 mmHg?Ischemia and tissue deathWhat can happen to posturing during noxious stimuli with IICP?There is a temporary shift from decorticate to decerebrate posturingWhat happens with posturing as IICP worsens?The patient shifts from decorticate to decerebrate posturingWhich is worse: decorticate or decerebrate?DecerebrateWhat posturing will be seen first with IICP?Decorticate posturingIs decorticate posturing an early or late sign of IICP?EarlyWhat causes a shift from decorticate to decerebrate posturing with IICP?Increased pressure on the brain stemWhat should happen to posturing after noxious stimuli is removed with IICP?The patient shifts back to decorticate posturing from decerebrate posturingWhat causes a shift in posturing with noxious stimuli?A temporary increase in ICPWhat are the most common types of noxious stimuli that cause temporary IICP?Suctioning Repositioning Daily caresWhat is the overall goal with posturing with IICP?Decreasing stimuli as much as possible to prevent surges in IICPIs Cushing's triad a medical emergency?Yes (HAVE TO ACT NOW)What are the three major goals of treatment with IICP?Reducing the volume of CSF Preserving cerebral function Avoiding situations that increase ICPWhat are the two main ways CSF is reduced with IICP?Ventriculostomy ShuntsWhat is a ventriculostomy?A catheter placed into the ventricle of the brain to monitor ICP and drain CSFWhat is the main external shunt used with IICP?Extraventricular drainage device (EVD)Is a ventriculostomy and an EVD the same thing?YesWhat is the main way of preserving cerebral function with IICP?Maintaining proper oxygenation and perfusion to the brain tissuesWhat usually is given in order to maintain brain perfusion with IICP?IV fluidsWhat two pressures are constantly monitored when treating IICP?ICP pressure CPP pressureWhat is important for positioning with the head with IICP?Keep the head in a neutral position to prevent increases in ICPHow does the Valsalva maneuver and IICP relate?You need to prevent anything that can cause vagal stimulationWhy are stool softeners given to with IICP?It helps prevent straining and vagal stimulationWhy do you have to use caution when suctioning with IICP?It can cause vagal stimulationWhy is vagal stimulation with IICP dangerous?It increases ICPWhat is a major safety intervention that should always be done with IICP?Seizure precautionsWhy do you have to be careful when giving analgesics for pain related to IICP?Too many opioids can mask the signs of IICPWhat may be done if a patient is on opioids for pain related to IICP?Weaning the patient off of opioids in order to do an accurate neurological check and then increasing opioids againWhy is maintaining fluid balance and nutrition important with IICP?The sooner gut feedings can be started the faster the patient will healWhy is it important to keep temperature under control with IICP?High temperature can cause increased oxygen consumption by the brain (vasodilation), worsening IICPWhy may a Foley catheter be used in a patient with IICP?To get accurate body temperature readingWhat are the main ways of controlling temperature with IICP?Wraps/pads IV fluids MedicationsWhy should shivering be avoided with IICP?It is used to control shiveringHow does an external shunt work?It inserts into the ventricle of the brain to drain fluid and will drain fluid once pressure increases above a set limitIs an external shunt mechanical flow?No; it is gravity flowWhy is it critical to make sure an external shunt is balanced at 0?It has to be level in order to drain fluid in proper amountsWhat can happen if an external shunt is set too high?It will under-drain fluid from the brainWhat can happen if an external shunt is set too low?It will over-drain fluid from the brainWhat happens if too much fluid is removed by an external shunt?Perfusion to the brain is decreasedHow long will an external shunt be used with IICP?Until the infection or trauma has resolvedAt what level should 0 be on the collection container for an external shunt?At the level of the tragus of the earWhat should you do to an external shunt when doing cares/noxious stimuli?Turn it off to prevent excess drainage of CSF related to a temporary increase in ICPWhat is needed before an external shunt can be placed?A physician's orderWhat is critical to put on the door and bed of a patient who has an external shunt?A sign indicating not to reposition the patient unless absolutely necessaryWhat should be checked regularly with an external shunt?The dressing and insertion site Pressure level Drainage amountWhich type of ICP monitor is the most accurate?Inter-parenchymalDoes the inter-parenchymal monitor drain CSF?No; it just monitors ICP levelWhat is a bolt?An ICP monitor that enters the subarachnoid spaceDoes a bolt drain CSF?No; it just monitors ICP levelWhy is it uncommon to see both a bolt and an EVD together?There is increased risk of infection with two invasive devicesWhen is the ONLY time a bolt needs to be zeroed?Right after insertion into the subarachnoid spaceWhere can any type of ICP monitoring system be placed?At bedside In the ORWhat is there an increased risk of with an EVD after 7 days?InfectionHow often should neuro checks be done with ICP?Every 1-2 hoursWhat are the major fluids used to treat IICP?Mannitol Hypertonic saline (3%)What should be watch for when giving Mannitol for head injuries?Rebound cerebral edemaHow do sodium levels relate to ICP management?Sodium levels should be kept slightly higher than normalWhy should sodium levels be kept slightly higher than normal with ICP management?It is easier to lower sodium levels than increase themWhat lab should be checked frequently when giving Mannitol?Serum osmolalityWhy should serum osmolality be checked frequently when giving Mannitol?To watch for dehydrationWhat should an EVD tubing be primed with?Preservative free normal salineWhat can air bubbles in the EVD line cause?Inaccurate waveform on the monitorShould an EVD line be flushed by a nurse?NeverHow is an EVD line and an arterial line different?An EVD line is NOT pressurized; an arterial line IS pressurizedWhen should an EVD be zeroed?Immediately after insertionIf monitoring with an EVD, what should happen with the transducer?It should be on and closed to drainageIf draining with an EVD, what should happen with the transducer?It should off and open to drainageIf an EVD is currently draining, what will the waveform on the monitor look like?It will be a flat lineIf an EVD is currently monitoring, what will the waveform on the monitor look like?It will have an accurate waveformWhat can blood in the EVD tubing cause?Inaccurate waveform on the monitorAre nurses allowed to do anything with an EVD line?No; any tampering must be done by someone with a higher level of educationWhat is the expected amount of drainage from an EVD?5-7 ml/hrWhat should happen to the amount of drainage from an EVD overtime?It should decreaseWhen would Mannitol not be given for IICP?If serum osmolality is above 320 mOsm/kgWhat can happen if Mannitol is given and serum osmolality is above 320?It can cause acute kidney injury (AKI)When should the blood sample for serum osmolality be drawn?Within 1-2 hours of giving MannitolWhat should serum osmolality be maintained under?320 mOsm/kgWhat should sodium level be maintained at with IICP?145-160 mEq/LHow often should sodium levels be measured with IICP?Every 4-6 hoursWhat should the head of the bed be elevated to with IICP?At least 45 degreesWhat should PaCO2 levels be maintained at with IICP?30-35What are the three major intracranial surgeries done related to IICP?Craniotomy Craniectomy CranioplastyWhat is a craniotomy?A surgical opening into the skullWhat is a craniectomy?Surgical removal of a portion of the skullWhat is a cranioplasty?Surgical repair of the skull using a plastic or metal plateWhat are Burr holes?Circular openings made in the skullIs intracranial surgery usually a first line treatment or last line treatment for IICP?Last lineWhat are Burr holes used for?They allow for catheters to be inserted into the skull to monitor ICPWhen catheters are placed into the skull through Burr holes, do they drain fluid?No; they just monitor ICPWhere is the piece of skull stored with a craniectomy?In a tissue pocket or tissue bankWhat is the dura replaced with in a craniectomy?Synthetic materialWhat does synthetic material with a craniectomy do?It allows for brain tissue expansion and watertight closure of the meningeal layerWhat should be avoided with positioning the patient who had a craniectomy?Placing them on the operative sideWhat can direct pressure on the operating site after a craniectomy lead to?Injury of brain tissue and IICPWhat will a patient have to wear consistently after a craniectomy?A helmetHow often should temperature be taken with IICP?Every 1-2 hoursWhy should temperature be watched carefully with IICP?Neurologic damage can cause troubles with regulating body temperatureWhat is often used for sedation with IICP?ProfololWhy is Profolol used instead of Versed for sedation with IICP?It wears off much faster to allow for more frequent neurological assessmentsWhy is it critical to give fluids before giving Mannitol?It prevents cardiovascular collapseWhat can happen if Mannitol is given to an already dehydrated patient?It will cause cardiovascular collapseWhat is the maximum amount of doses of Mannitol that can be given?3 dosesWhat can happen if more than 3 doses of Mannitol are given?Rebound cerebral edemaWhat is pentobarbital used for?To induce a comaWhat does pentobarbital do to brain activity?It stops all brain activityWhy can it be helpful to stop brain activity with pentobarbital?It allows the brain to healWhat is Nimodipine used for?To treat SIADHWhy would SIADH occur with IICP?IICP puts pressure on the pituitary gland causing abnormal ADH releaseWhat is Nicardipine used for?To decrease blood pressureWhat is Levetiracetam (Keppra) used for?To prevent seizuresWhat is hemorrhagic stroke?A stroke caused by bleeding into the brainWhat are the major risk factors for hemorrhagic stroke?Hypertension Smoking Heavy alcohol use SNS stimulantsWhat is a subarachnoid hemorrhage often caused by?A ruptured aneurysmWhat are the most common complications of hemorrhagic stroke?Ischemic stroke Cerebral edema Pulmonary edema Myocardial ischemiaWhat is the most common type of hemorrhagic stroke?Subarachnoid hemorrhageWhat is the second most common type of hemorrhagic stroke?Intracranial hemorrhageWhat causes an intraventricular hemorrhage?Veins and arteries come together without a capillary bed causing too much pressure in the veinsWhat is there a high risk of with a burst aneurysm?Neurological deficits and/or deathWhen.a patient presents to the ER with an aneurysm, what is usually the first medication given?NicardapineWhy is Nicardapine given quickly to patients with an aneurysm?It lowers blood pressure to prevent the aneurysm from burstingWhat should blood pressure be decreased to if a patient presents with an aneurysm?Under 140 systolicWhat diagnostic test is done to look for an aneurysm?CT angiogramWhat may be placed if there is bleeding from an aneurysm?An EVDWhat type of CT angiogram is commonly done to look for an aneurysm?Four vessel angiogramWhat are the two primary treatments for an aneurysm?Coil ClippingWhat is the coil treatment for an aneurysm?A small wire is stuff into the aneurysm to prevent blood from filling the vessel outpouchingWhen would the coil treatment not be done for an aneurysm?If the neck of the outpouching is too wide to hold the coiling in the outpouchingWhich treatment for an aneurysm does NOT require a craniotomy?CoilingWhich treatment for an aneurysm DOES require a craniotomy?ClippingWhat is the clipping treatment for an aneurysm?A clip is placed over the neck of the outpouching to cut off blood flowWhat ideally happens to the aneurysm over time with clipping?It decreases in sizeWhich treatment for an aneurysm is the preferred treatment?CoilingWhere do cerebral aneurysms often happen?At the circle of willisWhat is the circle of willis?The point where the four main cerebral arteries come togetherHow is blood evacuated from the brain if an aneurysm bursts?EVD Nimodipine/fluidsWhat does blood on the outside of cerebral vessels cause?Vasospasms and ischemiaWhat should blood pressure be maintained at if an aneurysm bursts?140-160 mmHgWhy is blood pressure allowed to be high if an aneurysm bursts?It prevents vasospasming of the cerebral vesselsWhat is the gold standard medication for cerebral vasospasms caused by an aneurysm?NimodipineWhy would fluids need to be given when giving Nimodipine for a burst aneurysm?Nimodipine lowers blood pressure, so the fluids help maintain blood pressure above 140What vasopressor is often given alongside Nimodipine with a burst aneurysm?NorepinephrineHow long is Nimodipine typically given for?For 25 daysWhy is Nimodipine given for such a long period after a hemorrhagic stroke?The risk of vessel vaspospams and brain ischemia is increased for roughly 21 daysAre there usually symptoms with an aneurysm before it ruptures?NoWhat is an intercranial hemorrhage often caused by?A subarachnoid hemorrhageWhat is an intracranial hemorrhage?Bleeding within the skullWhat are the two most common causes of an intracranial hemorrhage?Hypertension Oral anticoagulantsWhat are the two main focuses when treating an intracranial hemorrhage?Manage ICP Prevent seizuresWhat is the main way of treating an intracranial hemorrhage?Evacuation of the bloodIs Nimodipine given for intracranial hemorrhage?NoWhat is often given to manage blood pressure with an intracranial hemorrhage?NicardipineIf a patient is already on Nimodipine for a subarachnoid hemorrhage, will they also be given Nicardipine?NoWhat is fentanyl used for with hemorrhagic strokes?SedationWhen would pentobarbital be used to treat hemorrhagic strokes?When all other measures have failedWhat assessments should be done with hemorrhagic stroke?Neurological (Q1-2H) Vitals Neurovascular EKG Electrolytes I&OWhat is a primary head injury?Initial damage to the brain that can't be changedWhat is a secondary head injury?The consequence of a primary head injuryWhat are the four major types of brain injuries?Concussion Contusion Coup Contrecoup Diffuse Axonal InjuryWhat is a concussion?A mild traumatic brain injury caused by an impact to the head or whiplashWhat is a contusion?Blood underneath the brain tissue due to trauma causing a bruiseWhat is a coup contrecoup?A contusion present at both the site of impact of the brain and exact opposite end of the impactWhat is a diffuse axonal injury?Widespread shearing damage to the axons of the brainWhat is an acceleration injury?An external force contacting the head, placing the head in motionIs the head stationary or moving right before an acceleration injury?StationaryWhat is a deceleration injury?The moving head is suddenly stopped or hits a stationary objectIs the head stationary or moving right before a deceleration injury?MovingWhich is more severe: acceleration or deceleration injury?Deceleration injuryHow is a coup contrecoup injury different than an acceleration/deceleration injury?There is no external contact to the skull with a coup contrecoup injuryWhich is the most severe type of brain injury?Diffuse axonal injuryIf the front of the brain is hit, which is affected more: white or gray matter?White matterIf the back of the brain is hit, which is affected more: white or gray matter?Gray matterHow long does it typically take for swelling in the brain to reach its maximum point after a brain injury?72 hoursWhat happens after 72 hours with a brain injury?Brain swelling begins to decreaseWhy is important to wait the full 72 hours after a brain injury before making any major decisions?The true extent of the injury won't be seen until after swelling begins to go downWhich type of head injury IS preventable/changeable?Secondary head injuryWhich type of head injury is NOT preventable/changeable?Primary head injuryWhat are the most common secondary injuries caused by primary head injuries?Hypoxia Hypercapnia IICP Anemia Hyperglycemia Infections SeizuresWhat is the goal of treatment with head injuries?To prevent/control secondary injuries as much as possibleWhat is a basilar skull fracture?Fracture at the base of the skullWhat are the most common signs of a basilar skull fracture?CSF leakage Battles sign Orbital bruisingWhat is Battles Sign?Bruising behind the earWhere does CSF leakage occur with a basilar skull fracture?From the ears and noseIs there usually brain damage with a basilar skull fracture?Not alwaysWhat is there a high risk of with a basilar skull fracture?CSF infectionWhy is there a high risk of CSF infection with a basilar skull fracture?Bacteria enters the CSF the same way CSF is leaking outWhat medication will a trauma patient with a basilar skull fracture be put on prophylactically?AntibioticsShould a patient with a basilar skull fracture be allowed to blow their nose?NoWhat should be put under the nose to soak up CSF drainage with a basilar skull fracture?A gauze padWhat brain infection is there a high risk of with basilar skull fractures?MeningitisWhat is a hematoma?An accumulation of blood underneath the skullWhich type of hematoma is associated with artery damage?EpiduralWhich type of hematoma is associated with vein damage?SubduralWhat is an epidural hematoma often caused by?Temporal fracturesWhat happens with LOC with epidural hematomas?It rapidly declinesWhat happens with the pupils with an epidural hematoma?There is ipsilateral (same side) pupil dilationWhat happens with motor function with an epidural hematoma?There is contralateral (opposite side) motor weaknessWhat is the primary treatment for an epidural hematoma?Surgical evacuation of the pooled bloodWhy are effects seen much faster in epidural hematomas rather than subdural hematomas?Epidural hematomas are caused by an arterial bleedAre subdural hematomas usually acute or chronic?AcuteWhat is meant by an acute subdural hematoma?It occurs with 24 hours of a head injuryWhat is meant by a chronic subdural hematoma?It occurs within 2 weeks of a head injuryWhat is the primary treatment for subdural hematomas?Surgical evacuation of the pooled bloodWhy are subdural hematomas more dangerous than epidural hematomas?The signs can be delayed for several hours after the injuryWhat happens to consciousness with a diffuse axonal injury?There is immediate loss of consciousnessHow long does loss of consciousness occur with a diffuse axonal injury?Days to weeksWhat does diffuse axonal injury cause in the brain?Neurologic dysfunction White matter degenerationWhat type of brain injury occurs with diffuse axonal injury?Coup ContrecoupIs there a treatment for diffuse axonal injury?NoWhy does diffuse axonal injury often cause death?Life-sustaining nerve conduction stopsWhat are the signs of sympathetic storming?Tachycardia Tachypnea Hyperthermia Motor posturingWhat is sympathetic storming a sign of?Diffuse axonal injuryWhat is brain herniation?IICP pushes the brain into the brainstemWhy is brain herniation deadly?Brain function can't be sustained once herniation occursHow is brain herniation diagnosed?Via CT scanDoes brain function ever come back once herniation has occurred?NoIs brain herniation reversible?NoWhat are the two most severe types of brain herniation?Central TonsillarWhat is central herniation?Downward shift of the cerebral hemisphere compressing the brainstemWhat happens to the extremities with central herniation?Abnormal posturingWhat happens to the eyes with central herniation?Bilateral pupillary dilation Abnormal eye movementsWhat abnormal reflex occurs with central herniation?Babinski reflexWhat happens with the vital signs with central herniation?Cushing's triadWhat happens to LOC with central herniation?ComaWhat is tonsillar herniation?Downward shift of the bottom portion of the cerebellum, damaging the medullaWhat happens to the extremities with tonsillar herniation?Abnormal posturingWhat happens to the eyes with tonsillar herniation?Bilateral pupillary dilationWhat abnormal reflex occurs with tonsillar herniation?Babinski reflexWhat happens to LOC with tonsillar herniation?ComaWhat happens to vital signs with tonsillar herniation?Cushing's triadWhich type of brain herniation is worse?Tonsillar herniationHow does a transcranial doppler study help with diagnosing brain herniation?It measures for cerebral blood flow cessationWhat type of angiography might be done to diagnose brain herniation?Four vessel angiographyWhat is the best way to prevent brain herniation?Managing IICPWhat may need to be done with severe skull fractures?Wound debridement and removal of bone fragmentsWhat can bone fragments in brain tissue cause?Infection of the CNS

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anatomy and physiology

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