Assessment

• Goals:

  • Airway control
  • Cardio stabilization & support
  • Intervention to interrupt ongoing cerebral injury
  • Protection of pt from further harm
• Primary Assessment:

  • Pt's LOC
  • Ensure patent airway
  • If pt is unconscious & c-spine suspected, open airway w/ spinal precautions
  • Immobilize cervical spine
  • Give ventilatory support & O2
• Physical Assessment

  • Airway adjuncts/tracheal intubation - taken with spinal precautions
  • Closely monitor pt for respiratory arrest
  • Respiratory arrest may be from ICP & vomiting/aspiration
  • Inc. PCO2 or dec. PO2, results in dilation of blood vessels presumably in response to greater cerebral metabolic needs.
  • PCO2 lowered - blood volume & flow to brain reduced
  • Controlled hyperventilation may be indicated to maintain PCO2 abt 30mmHg & PO2 greater than 80mmHg
• Physical Examination:

  • Patient history
  • History of events
  • Vital signs
  • Respiratory patterns
• History:

  • Chief complaint
  • Details of presenting illness
  • Underlying medical problems: cardiac, lung, neurological, previous stroke, diabetes, HTN, chronic seizures, drug/alcohol use, recent injury
  • If LOC, obtain events that happened before
• Vital Signs: change rapidly

  • Monitor ECG for dysrhythmias - are common
  • Cushing triad in early stages of inc. ICP
  • In terminal stages of inc. ICP, brain tissue is compressed -
  • Body temperature remains elevated
  • Pulse dec.
  • BP falls
• Cushing Triad:

  • Inc. systolic BP (widening pulse pressure)
  • Dec. PR
  • Irregular respiratory pattern
• Respiratory Patterns: abnormalities may give clues to mechanism responsible for neurological emergency & lvl of neurological dysfunction

  • Acute respiratory arrest usually from the medullary respiratory center (brainstem compression or infarct)
  • Neural pathway involvement (from cortex down to medulla) often associated with disturbances of respiratory rhythm not respiratory arrest
• Cheyene-Stokes: RR & TV inc. followed by gradual dec.

  • Lesion location: bilateral cortical & forebrain
• Apneustic: prolonged, gasping inhalation followed by short, inadequate exhalation

  • Lesion location: mid-lower pons
• Ataxic: irregular breathing pattern characterized by a series of inhalations & exhalations

  Lesion location: medulla respiratory center
• Centreal hyperventilation: deep rapid ventilation, similar to Kussmauls

  • Lesion location: midbrain - upper pons
• Decorticate: abnormal flexor response of one or both arms (arms are bent), with extension of legs - from impairment of certain cortical regions of brain
• Decerebrate: abnormal extensor of the arms (arms extended with wrists flexed) with legs extended. Worse prognosis - results from impairment of certain subcritical regions of the brain.
• Flaccidity: usually caused by brainstem or cord dysfunction - involved a poor prognosis - may result in abnormal reflexes

  • Reflexes include Babinski & Sphincter (when relaxed it can empty bowels & bladder)
• Positive Babinski sign - loss of or diminished achilles tendon reflex - toes stretch outward

  Negative Babinski sign - toes stretch inward
• Both pupils are dilated & do not react to light:

  • brainstem has probably been affected
  • pt has suffered severe cerebral anoxia
• • Pupillary constriction controlled by parasympathetic fibers that originate in midbrain & accompany oculomotor nerve
  • Pupillary dilation controlled by fibers that go into brainstem & into cervical sympathetic chains
• • Conjugate gaze: both eye in the same direction - structural lesion
  • Irritative focus: eyes look away from lesion
  • Destructive focus: eyes look toward lesion
  • Dysconjugate gaze: deviation of eyes to opposite side - structural brainstem dysfunction