i bc27f85be50b71b1 (98 page)

Headache, seizure,

Headache, vomiting, altered

findings

cranial nerve palsy

brain stem reflexes

Source: D:1(:I from JV Hickey. Thc Clinical Practice of Neurological and Neurosurgical

NurSIng (41h cd). Philadelphia: Lippincott, 1997.

outlined in Table 4-2 1 . Appendix Table llI-A.5 describes the different

types of ICP monitoring systems.

Cerebral perfusion pressure (CPP), or cerebral blood pressure, is

mean arterial pressure minus ICP. It indicares oxygen delivery to the

brain. Normal CPP is 70-100 mm Hg. CPPs at or less than 60 mm

Hg for a prolonged length of time correlate with ischemia and anoxic

brain injury.46

Following are terms related to ICP:

Brain herniatioll. The displacement of brain parenchyma through an

anaromic opening; named according ro the location of the displaced Structure (e.g., lranslelltorial herniation is the herniation of the cerebral hemispheres, diencephalon, or midbrain beneath the

tentorium cerebelli)

Mass effect. The combination of midline shift, third ventricle compression, and hydrocephalus8

324 ACUTE CARE HANDBOOK FOR PHYSICAL THERAPISTS

Table 4-2 1 . Treatment Options to Decrease Intracranial Pressure (1CP)

Variable

Treatment

Blood pressure

Inotropic drugs to maintain mean arterial pressure

>90 mm Hg to aid in cerebral perfusion, or antihypertensives

Osmorherapy

Osmotic diuretic to minimize cerebral edema

Mechanical

Normocapnia· to maximize cerebral oxygen delivery

ventilation

by limiting cerebral ischemia from the vasoconstrictive effects of decreased Paco2

Cerebrospinal

Ventriculostomy to remove cerebrospinal fluid

fluid drainage

Seda tion/paral ysis

Barbiturates to decrease cerebral blood flow or ocher

medication to decrease the stress of noxious activities

Positioning

Head of the bed at 30-45 degrees to increase cerebral

venous drainage

Promote neutral cervical spine and head position

Environment

Dim lights, decreased noise, frequent rest periods to

decrease external stimulation

Seizure control

Prophylactic anticonvulsant medication

Temperature

Normothermia or induced hypothermia to 32-35°C

control

(e.g., cooling blanket or decreased room temperature)

to decrease cerebral metabolism

· Routine aggressive hyperventilation is no longer used for the control of elevated ICP.

Hyperventilarion can contribute to secondary brain injury because of a rebound

increase in cerebral blood flow and volume in response to a decreased cerebrospinal

fluid pH.

Source: Data from F Wong. Prevemion of secondary brain injury. Crit Care Nurs

2000;20, 18-27.

Midlille shift. The lateral displacement of the falx cerebri secondary

to a space-occupying lesion

Space-occupying lesion. A mass lesion, such as a rumor or hematoma,

that displaces brain parenchyma and may result in the elevation of

ICP and shifting of the brain

Another primary goal of the team is to prevent further neurologic

impairment. The main components of management of the patient with

neurologic dysfunction in the acute care setting include pharmacologic

therapy, surgical procedures, and physical therapy intervention.

NERVOUS SYSTEM

325

Phamtacologic Therapy

A multitude of pharmacologic agents can be prescribed for the patient

with neurologic dysfunction. These include anticonvulsant agents (see

Appendix Table IV.5), osmotic diuretics (see Appendix Table lV.26),

adrenocorricosteroids (see Appendix Table lV. I ), skeletal muscle relaxants (see Appendix Table lV.28), and anti parkinsonian agents (see Appendix Table IV.9). Additional pharmacologic agents for medical

needs include antibiotics (e.g., for infection or after neurosurgery), antihypertensives, thrombolytics, anticoagulants, chemotherapy and radiation for CNS neoplasm, stress ulcer prophylaxis (e.g., after SCI), pain control, and neuromuscular blockade.

Neurosurgical Procedures

The most common surgical and nonsurgical neurologic procedures

arc described below (see Table 3-8 for a description of surgical

spine procedures and Appendix I II-A for a description of ICP monitoring devices).

Allellryslll clippillg. The obliteration of an aneutysm with a surgical

clip placed at the stem of the aneurysm.

Bllrr hole. A small hole made in the skull with a drill for access to the

brain for the placement of ICP monitoring systems, hematoma

evacuation, or stereotactic procedures; a series of burr holes is

made before a craniotomy.

Cralliectomy. The removal of incised bone, usually for brain (bone

Aapl tissue decompression; the bone may be permanently removed

or placed in the bone bank Or temporarily placed in the subcutaneous tissue of the abdomen (to maintain blood supply).

Crallioplasty. The reconstruction of the skull with a bone graft or

acrylic material to restore the protective properties of the scalp and

for cosmesis.

Cralliotomy. An incision through the skull for access to the brain for

extensive intracranial neurosurgery, such as aneurysm or AVM

repair or tumor removal; craniotomy is named according to the

area of the bone affecred (e.g., frontal, bifrontal, frontotemporal

[pterional], temporal, occipital).

326 ACUTE CARE HANDBOOK FOR PHYSICAl THERAPISTS

Embolization. The use of arrerial catheterization (entrance usually at

the femoral artery) to place a material, such as a detachable coil,

balloon, or sponge, to clot off an AVM or aneurysm.

Evacuation. The removal of an epidural, subdural, or intraparenchymal hematoma via burr hole or cranioromy.

Shunt placement. The insertion of a shunt system that connects the

ventricular system with the right atrium (VA shunt) or peritoneal

caviry (VP shunt) to allow the drainage of CSF when ICP rises.

Stereotaxis. The use of a stereotactic frame (a frame that temporarily

attaches ro the patient's head) in conjunction with head CT results

to specifically localize a pretargeted site, as in tumor biopsy; a burr

hole is then made for access to the brain.

Clinical Tip

• The physical therapist should be aware of the location

of a craniectomy, because the patient should nOt have

direct pressure applied to thar area. Look for signs posted

at the patient's bedside that communicate positioning

restrictions.

•

Pay close attention to head of bed positioning restricrions for the patient who has recently had neurosurgery.