Neurosurgical Emergencies

Neuroscience Nursing Concepts

Adi Sulistyanto MD

Scope

• Traumatic Brain Injury

• Spine Injury

• Stroke

• Brain Tumor

• Pediatric Emergencies

Traumatic Brain Injury

• ATLS Classification•Mild GCS 14-15•Moderate GCS 8-13• Severe GCS 3-8

Glasgow Coma Scale

Trauma -> ATLS

• A = Airway with Cervical Control

• B = Breathing

• C= Circulation

•D = Neurologic Assesment

Neurologic Assesment

Nursing Management

• A-> B -> C

• Maintain cerebral venous outflow -> Head elevation 30 degrees

• Management of pain and agitation

• Urgent CT Scan (Non Contrast)

CT Scan

Spine Injury

• Prevention of further injury• Cervical Collar• Spine Board

• Urgent Radiological Assesment• Management of Autonomic

Dysfunction• Prevention of Pressure Sore• Prevention of TE complication

Spine Imaging

• NEXUS Criteria :• Fully alert• No spinal pain• No neurologic deficit• No alcohol or drug intoxication• No distracting injuries

American Spinal Injury Association Scale

A = CompleteB = Sensory FunctionC = Motor < 3D = Motor > 3E = Normal

Stroke

• Ischemic Stroke

• Hemorrhagic Stroke

• Aneurysmal Subarachnoid Hemorrhage (SAH)

Stroke

Time Is Brain

• Maximum intervals recommended by NINDS

• Door-to– doctor first sees patient 10 min

• Door-to–CT completed 25 min

• Door-to–CT read 45 min

• Door-to–thrombolytic therapy starts 60 min

• Physician examination 15 min

• Neurosurgical expertise available* 2 h

• Admitted to monitored bed 3 h

Hemorrhagic Stroke

• Blood Pressure Control

• Reverse Coagulopathy

SubArachnoid Hemorrhage

Subarachnoid Hemorrhage

Complications

• Rebleeding

• Hydrocephalus

• Vasospasm

• Seizure

• Hyponatremia

• Cardiac Abnormalities

• Fever

NeuroOncology Emergencies

• Increased ICP• Edema • Hemorrhage• Hydrocephalus

• Spinal Cord Compression• Seizure

Pediatric

VP Shunt Malfunction

Altered Consciousness

• Extracranial / Medical : Drug/Alcohol Intoxication, Metabolic (electrolyte, hypo/hyperglycemia, uremia), Infection (Sepsis), Psychiatric

• Intracranial / Structural (Surgical) : Hematoma, Tumor, Hydrocephalus

IntraCranial Pressure

• Volume inside the skull is constant (Monroe-Kellie) consist of :• Brain• Blood• CSF

• Cerebral Perfusion Pressure = Mean Arterial Pressure – IntraCranial Pressure

CPP = MAP – ICP

Keep MAP > 90 ICP < 20

Increased ICP

• Signs and symptoms of increasing ICP–a medical emergency

• Early signs: decreased level of consciousness, deterioration in motor function, headache, visual disturbances, changes in blood pressure or heart rate, changes in respiratory pattern

• Late signs: pupillary abnormalities, more persistent changes in vital signs

• Intervention: thorough neurological assessment, notify physicianimmediately, emergency brain imaging, maintain ABCs

Cushing Reflex

• Hypertension

• Bradycardia

• Abnormal Respiration

Increased ICP

• General measures to prevent elevation of ICP

• HOB up 30° or as physician specifies; reverse Trendelenburg position may be used if blood pressure is stable. Head position may be one of the single most important nursing modalities for controlling increased ICP

• Good head and body alignment: prevents increased intrathoracic pressure and allows venous drainage.

• Pain management: provide good pain control on a consistent basis

• Keep patient normothermic

ICP Monitoring

Herniation

Status Epilepticus

A-B-C

THANK YOU