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Management of Neurologic
Trauma
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Is the pressure exerted in the cranium by itscontents: The brain The blood The Cerebrospinal Fluid
Is measured with a monitor in either a ventricle,
the brain parenchyma, or a subarachnoid space Normal = 5-15 mm Hg Pressures over 20 increased ICP that impairs
cerebral perfusion
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Cerebral Perfusion Pressure (CPP) Is the amount of blood flow from the systemic
circulation that is required to provide adequateoxygenation and glucose for brain metabolism
CPP = MAP - ICP
Mean Arterial Press
ure (MAP) Represents the average pressure during the cardiac
cycle
Calculated by: (systole + 2 diastole) /3
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ETIOLOGY Space occupying lesion
Cerebral infarction
Obstruction of outflow of CSF
Abscess
Ingested or accumulation of toxins Impaired blood flow to or from the brain
Vasodilation from increased paCO2 or decreased PaO2
Increased intrathoracic pressure
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Risk factors
Head injury
Brain tumors
Cerebral bleeding
Hydrocephalus
Edema from surgery or injury
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MUNRO Theory
States that because the bony skull cannot expand, whenone of the three components expands, the other twomust compensate by decreasing in volume in order forthe total brain volume and pressure to remain constant
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Munro theory As an intracranial mass enlargesCompensatory:
1st: displacement of CSF into the spinal canal COMPLIANCE = ability of the brain to adapt to an increasing
pressure without increasing ICP When exceeded = ICP rises
2nd: reduction of blood volume in the brain When reduced by 40%, brain tissues become acidotic. When 60%,
alters cerebral metabolism leading to brain tissue hypoxia andareas of brain tissue ischemia 3rd: Displacement of Brain tissue
Across the tentorium, under the falx cerebri, or through foramenmagnum into the spinal canal
HERNIATION = may result to DEATH
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HERNIATION SYNDROMES
Supratentorial Herniation Syndromes Transcalvarial Herniation Occurs with open head injuries when brain tissue is extruded through an
unstable skull fractures Central Transtentorial Herniation
Is the end result of the downward displacement of diencephalon throughthe tentorial notch
Caused by injuries or masses in the cerebral cortex or on the outwardperimeter of the cerebrum
RAPID CHANGE on LOC = early indication As pressure increases, 1st: cheyne stokes; then centra neurogenichyperventilation; later, apneustic and ataxic breathing (Biots); finally,
apnea Pupils become small with progression to a dilated and fixed state Babinski sign followed by abnormal flexion extension posturing Dolls eye reflex
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HERNIATION SYNDROMES Supratentorial Herniation Syndromes
Lateral Transtentorial Herniation (Uncal herniation) Displacement of masses in or along temporal lobe
Pupils become sluggish first, then become unresponsiveipsilaterally, then contralateral 2o to third cranial nerve
compression at the midbrain Cingulate Herniation
Occurs when frontal lobes of the cerebrum are compressed
Cerebral artery compression = ischemia, congestion, edema,increased ICP
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INFRATENTORIAL (Tonsilar) Herniation
a.k.a Cerebellar herniation occurs when the cerebellartonsil shifts throught the foramen magnum,compressing the medulla and upper portion of thespinal cord.
Increasing pressure in the posterior fossa 2 tocerebellar bleeding underlying problem
Erratic changes on BP, PR, breathing, dec LOC, anarched stiff neck and quadriparesis
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OUTCOME MANAGEMENT
Decrease Intracranial Pressure
ABC
Hyperventilation CO2 causes cerebral blood vessel todilate. Hyperventilate to cause hypocarbic blood level
creation. PaCO2 30-35 results in vasoconstriction of thecerebral blood vessels, leading to decrease blood flow andthus decreasing ICP. PaO2 must be kept at 90-100 mm Hg
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OUTCOME MANAGEMENT
Decreased ICP
MANNITOL hyperosmotic agent, does not cross an intactblood-brain barrier. Increases intravascular pressure bydrawing fluid from the interstitial spaces and from braincells. If the blood-brain barrier is damaged, the medicationenters the brain and increasesswelling. DIURESIS isexpected, risk for dehydration
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OUTCOME MNGT Decrease ICP
Cerebral Perfusion Give vasoactive medication to maintain CPP at a normal level.
CPP at more than 70 mm Hg
Prevention of Complications
Antibiotics Infection increases metabolism, thus increased ICP Anti-seizure phenytoin, barbiturates, diazepam) Seizures
increase metabolism
Hypertonic IV solutions are avoided because of the risk ofpromoting cerebral edema
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