Neurocritical Care Overview

Overview

Week 12 nursing lecture covering spinal cord injuries, craniotomy case studies, increased intracranial pressure (ICP) management, delegation principles, ventilator adjustments, and medication administration protocols for neurocritical care patients.

Spinal Cord Injury Assessment

• Always assess patient first; however, with suspected spinal injury, see spine before proceeding to ABCs
• Use jaw thrust maneuver (not head tilt chin lift) for cervical injuries to open airway
• If question does not specify complete vs. incomplete injury, assume complete (affects both motor and sensory)
• Know general dermatome locations: cervical (C1-C8), thoracic (T1-T12), lumbar, sacral
• T6 or higher injuries increase risk for neurogenic shock and autonomic dysreflexia
• T3 injury example: patient has arm function but no function below thorax or in legs
• Quad coughing: manually assist intercostal muscle movement by pushing up and in on ribcage during cough

Increased Intracranial Pressure (ICP)

• All roads lead to Rome: bleeding, infection, inflammation, or trauma ultimately cause increased ICP
• Normal ICP: less than 20 mmHg; notify provider when exceeds this threshold
• Most serious post-craniotomy complication is increased ICP leading to herniation
• Cushing's Triad (late sign): bradycardia, Cheyne-Stokes breathing, severe hypertension with widened pulse pressure
• Early sign: change in level of consciousness (LOC)
• Monitor ICP waveforms continuously; watch for trends and spikes

Cerebral Perfusion Pressure (CPP)

• CPP = Mean Arterial Pressure (MAP) – ICP
• Goal CPP: 70–80 mmHg
• CPP below 50 indicates risk of anoxic brain injury
• Rising ICP or dropping MAP reduces CPP, causing poor brain perfusion

Intraventricular Catheter Management

• Level transducer at foramen of Monroe (where lateral ventricles meet third ventricle)
• External landmark: tragus of the ear (small ear cartilage point)
• Use aseptic technique when setting up device
• Monitor ICP continuously and report values exceeding 20 mmHg
• Administer prophylactic antibiotics and antiseizure medications (e.g., Keppra)

First 24 Hours Post-Craniotomy Interventions

• Prevent and treat increased ICP
• Implement seizure precautions
• Prevent infection (wound care, monitor for signs)
• Monitor ventilator settings closely
• Provide postoperative care (assess dressing, drains, vital signs)
• Watch for anesthesia complications
• Assess neurological status frequently (Glasgow Coma Scale)

Delegation Principles

• Key verb in question determines delegation: monitor, assess, analyze → RN only
• "Perform" capillary glucose = UAP; "Monitor" capillary glucose = RN

Gas Exchange and ICP Connection

• Low oxygen and high CO₂ cause vasodilation of brain blood vessels
• Vasodilation increases ICP by expanding blood vessel diameter in brain
• Normal PaO₂: 80–100 mmHg; normal PaCO₂: 35–45 mmHg
• Hypoxia and hypercapnia worsen ICP and alter level of consciousness

Ventilator Adjustments for ICP Management

• Increase FiO₂ to correct low oxygen levels
• Increase respiratory rate (breaths per minute) to blow off excess CO₂
• Consider increasing PEEP to improve alveolar expansion and gas exchange
• Caution: excessive PEEP raises intrathoracic pressure, which can increase ICP

Mannitol Administration

• Osmotic diuretic that pulls fluid from brain tissue into vascular space
• Fluid then excreted via urine, reducing ICP
• Effectiveness measured by: decreased ICP or improved level of consciousness
• Side effect: electrolyte imbalances (potassium and sodium drop)

Potassium Replacement Safety

• Never push IV potassium; lethal if given rapidly
• Administer as primary infusion only (not secondary/piggyback)
• Maximum rate: 10 mEq/hour
• Dilute in 100–250 mL saline depending on central vs. peripheral line
• Monitor urine output (minimum 30 mL/hour) before and during infusion
• Obtain ECG before notifying provider of hypokalemia to assess for arrhythmias

Key Terms & Definitions

• Cushing's Triad: Late sign of increased ICP; includes bradycardia, irregular breathing, and severe hypertension with widened pulse pressure
• Cerebral Perfusion Pressure (CPP): Pressure needed to perfuse brain tissue; calculated as MAP minus ICP
• Foramen of Monroe: Connection point between lateral and third ventricles; landmark for ICP catheter leveling
• Quad Coughing: Manual technique to assist coughing in patients with high spinal cord injuries by compressing ribcage during cough
• Mannitol: Osmotic diuretic used to reduce ICP by pulling fluid from brain tissue
• Complete Spinal Cord Injury: Loss of both motor and sensory function below injury level
• Incomplete Spinal Cord Injury: Partial loss of motor or sensory function below injury level

Action Items / Next Steps

• Review all class videos and concept maps for exam preparation
• Study risk factors for spinal cord injury, traumatic brain injury, and stroke
• Practice NextGen case study format (one will appear on exam)
• Review delegation standards and practice identifying correct delegation based on task verbs
• Understand flow sheets and case studies provided in course materials
• Email instructor or schedule Zoom session for any remaining questions