MENINGITIS Patho: Inflammation of the inner meninges Usually caused by: 1. Autoimmune reaction 2. Adverse reaction to medication or procedure (Spinal or Brain) direct route of entry 3. Infecti... on: a. Bacterial: Most common Strep. Pneumoniae and Neisseria Meningitids Highly contagious (see risks) b. Viral: Most common herpes, Varicella (chicken pox/shingles) c. Fungal: Usually seen in pts w/ AIDs Risks: - Infections of eye, ear, mouth (like a tooth abscess) and neck are at increased risk a/r close anatomic proximity - Pts ages 16-21 at highest risk for bacterial meningitis. Vaccinate @11-12 y/o then booster @16. - Pts living in high density populations (dorms, barracks, crowded living areas) have increased risk for bacterial meningitis as well. Initial or booster vaccination is advised for these adults. - Pts who are immunocompromised AIDs, Cancer Rx tx, or pts receiving immunosuppressant tx for organ transplant or autoimmune disease. S/S: - Classical Triad: Headache, Fever, Neck pain (nuchal rigidity) - Kerning’s sign (may or may not be present) back pain when flexing knee beyond 90 degrees w/ pt in supine position - Brudzinski’s sign (may or may not be present) flexing the head when pt is in supine position results in automatic flexion of legs and/or hips - Photo and Phonophobia - Rhinorrhea (nasal discharge of CSF basal skull fracture) or Otorrhea (ear discharge same as rhinorrhea) - ICP changes in mental status/LOC and/or orientation can progress to seizures - Systemic Inflammatory response Coagulopathy changes in vascular status if thrombi forms DIC, gangrene - Other usual s/s of infection may or may not be present (like tachycardia, fever, chills etc.) Dx: CT – if pt is >60, immunocompromised, or have s/s of ICP then CT first all other LP. LP – If viral CSF is usually clear and if bacterial usually cloudy. All other findings such as glucose, WBC and protein are usually the same. Management: - Priority = Airway Breathing and Circulation + Monitoring + documenting neuro status (q2-4h) - Seizure precautions - BS AB tx until LP results then specific Rx tx. - Managing ICP Mannitol and Antiepilectic rx - If bacterial meningitis DROPLET + STANDARD - prophylaxis tx for close contact - Decrease stimuli + keep HOB elevated at 30 degrees. ENCHEPALITIS Patho: Inflammation of the brain and surrounding meninges. Most commonly caused by viral infections such as Herpes (HSV1) and Varicella S/S: -Changes in mental status such as agitation, acute confusion, irritability or personality/behavioral changes -ICP -Neurological deficits vision loss, seizures, muscle weakness, and paralysis. **these changes may last for weeks and may be permanent. - photo and phonophobia Management: -Priority = Airway. Turn cough and deep breathe q2h UNLESS ICP present. If on vent and s/s of ICP suction -Monitor Neuro Status: -Glasgow Coma Scale max score of 15, min of 3 (totally dependent) Any change >2 notify MD -Any change in neuro status such as increasingly dilated pupils or decreased responsiveness to light, new onset of bradycardia, widening pulse pressure (basically s/s of increasing ICP) or irregular resp effort notify MD -Medication viral = acyclovir INCREASED INTRACRENIAL PRESSURE (ICP) A quick A&P note: Monro-Kellie Hypothesis: the Cerebral Spinal Fluid (CSF), brain blood and brain tissue all work together to regulate Cerebral pulse pressure. If there is an increase in one structure the other two will attempt to compensate by: 1. Shunting of blood to spinal subarachnoid space, 2. Decrease in CSF production or 3.Increase in CSF absorption. A normal CPP is 60-100 mm Hg; CPP = MAP-ICP. Normal ICP is between 10-15mm Hg. Patho: ICP results in a decrease in cerebral perfusion = cerebral ischemia. To compensate for this ischemia the body increases systolic blood pressure to increase blood flow to brain, this results in additional increase in ICP swelling/edema of cerebral tissue. The edema can cause compression of brain stem affects breathing = CO2 retention CO2 retention causes arterial dilation decreased cerebral venous return to heart = increase in ICP. ICP is usually caused by head trauma, high CSF, cerebral hemorrhage/tumor, infection inflammation = ICP Other factors that affect ICP: -Body temperature hyperthermia increases ICP -Oxygenation Status increase in CO2 hypercapnic increased vasodilation decreased venous flow from brain = increase in ICP -Body position -Intra-abdominal/intra-thoracic pressure S/S: - Changes in mental status FIRST and EARLIEST sign of ICP (agitation, restlessness etc.,) - Irregular breathing as brain stem is compressed Cheyne-Strokes: Periods of hyperventilation followed by apnea (LATE SIGN) - Optic and oculomotor changes: -Papilledema (ALWAYS a sign of ICP) -double vision -unequal pupils (normal is 6 mm) report any change >2mm -fixed non responsive pupils indicates brainstem damage report immediately - Posturing: - Decoricate hands adducted to chest, arms flexed and feet flexed and rotated inwardly - Decerebrate hands adducted to side, arms extended w/ protonation and feet flexed -Cushing’s Triad LATE SIGN - Increase in Systolic BP - Widening pulse pressure - Decreased HR -Vomiting (may be projectile) Management: Priority #1 Maintain patent airway -Prevent Hypoxia and hypercapnia vent patients CO2 should be lower than normal (around 35-38mm Hg) (see oxygenation status in ICP patho) - Suction as needed, assess ABGs Priority #2 Decrease ICP - Temperature management -Therapeutic hypothermia – rapid cooling of body may be started even if pt is afebrile. -febrile pts cooling blankets, cool baths etc - Low PEEP. A high PEEP can increase intra-thoracic pressure decrease in cerebral venous return = ICP - HOB elevated 30-35 degrees. **If pt becomes hypotensive when HOB is elevated, position pt so that CPP >70 mm Hg** - Keep head midline pt must be log rolled to move or repositioned. - Avoid any flexion of head, neck or hips as flexion increases ICP - Mannitol Osmotic diuretic, will pull water extracellularly. -Give in BOLUS not as effective if continuous -Give through a FILTERED IV or draw up using FILTERED needed -Contraindicated if pt has no urine output. -Thirst is expected, monitor I&O expect folley. Monitor for s/s dehydration. - Lasix often given w/ mannitol. Helps decrease production of CSF. Priority #3 Monitor and Assess Neuro status - Monitor and assess LOC. Any change in LOC is an indicator of worsening neuro status report to MD. - GCS - Monitor for CSF leakage any nose or ear drainage, can distinguish by yellow ring around blood on absorbent paper or linen. Other interventions: - Avoid over sedation used short acting rx such as propofol, precede, dexdor, these have short T1/2 and can be stopped for daily neuro exam. - Safety seizure precautions. -Surgical: - Decompressive craniectomy: Don’t lye on side of fragment removal; have to use protective head gear when out of bed. - Craniotomy (see craniotomy) LUMBAR PUNCTURE IS CONTRAINDICATED IN PTS W/ ICP TRAUMATIC BRAIN INJURY Patho: Damage to brain from external mechanical force that is not caused by neuro-degenerative or congenital conditions. -Primary Injury Injury occurs at the time of impact -Focal: damage to specific part of brain -Diffuse: damage to multiple areas or throughout the brain -Open: Skull integrity compromised dura exposed to environmental contaminants (caused by fracture or pierce) -Closed: Skull integrity is not compromised. -Secondary Injury Physiological, vascular, biochemical event that is an extension of primary injury: - Hemorrhage hematoma -Epidural Hematoma: Arterial bleeding into space between dura and inner skull. (lucid then unconscious) -Subdural Hematoma: Venous bleeding into space beneath dura and above arachnoid -Chronic 2wks to several months after TBI -Acute 24hrs after TBI - Traumatic Intra-cerebral Hemorrhage blood in brain tissue - Hydrocephalus: Abnormal increase in CSF -Brain herniation: Either one notify MD. -Uncal temporal shift pressure on cranial nerve III dilated/nonreactive pupils, drooping eyelids -Central herniation downward shift of brainstem. resp distress, pinpoint nonreactive pupils S/S: -Changes in mental status, and LOC -s/s hypovolemic shock a/r hemorrhage - s/s of ICP Management: Priority # 1: Airway -pt on vent, use humidified air and collaborate w/ RT Priority # 2: Preventing & detecting secondary brain injury - Neutralizing head and neck: - Cervical collar until definitive dx tests r/o spinal injury - Spinal board to transport remove asap once in health care setting (ER/ICU) Once removed, strict bed rest, no elevation of HOB, (reverse trendelenburg ok) No pillow, no roll etc., Log roll to reposition or move pt. - Monitor for s/s ICP (see ICP management) - Thermal regulation: Central fever - effective management includes cool air, cool sponge baths. Tylenol other antipyretic agents not as effective - Therapeutic hypothermia rapidly cool after primary injury Priority # 3: Neuro Assessments Other interventions: -Surgical (see craniotomy) -At home management for TBI: -NO sedatives x24 hr unless MD okays it. -ASA q4 prn h/a ok. Go to ER ASAP if severe or worsening h/a, persistent vomiting, drainage from ear/nose, excessive or CRANIOTOMY Pre Op: -Reassurance re disturbed/altered body image -ensure NO NSAIDS, ASA, EtOH , anticoagulation tx x5 days before procedure Post Op: -Assess neuro status + VS xq15-30 mins x4-6 hr -Report and document immediately any deficits, changes in LOC, motor weakness or paralysis, changes in speech or sensory perception -Periorbital edema and ecchymosis are expected cold compress for swelling, irrigate w/ saline or artificial tears -Strict I&O - Expect fluid restriction if pituitary involvement (SIADH/DI) - turn and repos but not onto operative side -Anti-thrombi measures SCDs. Active + passive ROM -Brainstem (infactentorial): -Lay flat and side lying x24-48 hrs, rotate sides q2 - NPO x24h post op -Supratentorial: -Elevate HOB @30 degrees or as tolerated -ICP prevention no thoracic pressure, no flexion of head, neck or hips, keep head midline and neutral -Assess dressing -Normal drainage 30-50mL/q8h -report saturated or drainage >50mL/8hr -Assess for hypovolemic shock -Monitor electrolytes -Hypernatremia may occur muscle weakness, restlessness, extreme thirst + dry mouth report -Hypokalemia EKG changes -Hydration status decreased or increased UOP SIADH or DI depending on s/s + UOP -Monitor for cerebral salt wasting possible volume depletion -Monitor for s/s of hematomas severe h/a, rapid decrease in LOC. SPINAL CORD INJURY Mechanisms of Injury: -Hyperflexion -Hyperextension -Axial Loading (vertebral compression) -Rotation -Penetrating S/S & Assessment of patient with SCI -Priority # 1is maintaining a patent airway. Patients w/ SCI of C3-C5 have a high probability of respiratory compromise as these vertebrae control the diaphragm. -Priority # 2 is cardiovascular assessment and maintenance: Assess pulse, BP and peripheral perfusion. Injuries at or above T6 are likely to affect cardiovascular status. The loss of sympathetic input may result in bradycardia, hypotension and hypothermia. A systolic BP <90 mm Hg or MAP <65, requires immediate intervention as this may result in a lack of perfusion to spinal cord and can worsen the injury. Notify MD STAT Assess for any s/s of hemorrhage. These include tachycardia + hypotension + weak thready pulse. -Priority # 3 is preventing secondary spinal cord injuries. this includes spinal cord mobilization and stabilization. (see management) -Assessing Neuro status: GCS to assess LOC. Assess level of motor function a six-point scale is best w/ 0=no movement and 5=normal strength against full resistance. -Assessing GI/GU: Assess abdomen for any s/s of internal bleeding such as abdominal distention or paralytic ileus. Paralytic ileus may develop w/in 72h. Assess for any abdominal pain and bowel sounds. Complications of SCI: Spinal Shock, or Spinal Shock syndrome. -Spinal shock syndrome occurs IMMEDIATELY after injury. -There is complete but temporary loss of motor function, sensory reflex and autonomic function. Spinal shock duration is usually less than 48h but may last for several weeks. Major concerns are ventilation, hypotension, hypotonic bowel (if paralytic ileus is unresolved) and poilkilothermia (body cannot regulate temperature so it assumes room temp) -Indicators of spinal shock resolution include muscle spasticity, reflex activity and return of bladder function. Management: 1: Preventing Secondary spinal cord injury - Spinal immobilization and stabilization: C Collar & Halo Fixator - Never move or turn pt by holding or pulling on halo device - Do NOT adjust screws - Ensure that wrench is attached to vest - Monitor screw sites for any s/s of infection - Teach and encourage pts to stay as active as possible however contact sports should be avoided - Teach pt that driving is discouraged as the device impairs vision. - Osteomyelitis is a risk. 2: Airway Management: - Jaw thrust instead of head-tilt - Early trach if necessary 3: Circulation Management: - Atropine to treat bradycardia if HR <50-60 - Dextran plasma expander will help w/ hypotension as well as perfuse spinal cord. - If hypotension is severe manage w/ continuous IV of dopamine or other vasoactive agent. 4: Muscle Spasms: - ITB/Intrathecal baclofen (Lioresal) - Infused directly into the CSF - May cause sedation, dizziness and changes in mental status. - Should not be d/c abruptly as this may result in seizures and hallucinations. 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