Page 149 - Critical Care Notes

4223_Tab05_141-174 29/08/14 8:28 AM Page 143

143
■ Administer diuretics such as furosemide (Lasix).
■ Insert Foley catheter to monitor output. Monitor fluid intake.
■ Administer IV hypertonic saline (>0.9% NaCl). Administer fluid boluses only
with hypertonic or isotonic fluids. Avoid hypotonic dextrose solutions.
■ Institute mechanical ventilation according to ABGs.
■ Maintain patent airway, suction cautiously (can ↑ ICP), oxygenate, and
avoid PEEP (can ↑ ICP).
■ Assess respiratory status, and monitor ABGs and oxygenation.
■ Perform hyperventilation maneuvers or aggressive “bagging” to ↓ PaCO 2
and ↓ ICP.
■ Consider neuromuscular blocking agents: pancuronium, atracurium,
cisatracurium.
■ Assess neurological and mental status by Glasgow Coma Scale or FOUR
Score coma scale, including reflexes, pupils, motor and sensory function,
and cranial nerve function (extraocular movements, peripheral facial droop,
tongue deviation, gag reflex, corneal reflex, cough reflex, doll’s eyes).
■ Assess for meningeal signs such as headache, nuchal (neck) rigidity, photo-
phobia.
■ Assess response to verbal and painful stimuli.
■ Monitor vital signs, CPP, and ICP, and control fever with antipyretics. Avoid
shivering, which ↑ ICP. For every 1ºC rise in body temperature → 5%–6%
↑ cerebral blood flow.
■ Consider therapeutic hypothermia to ↓ cerebral edema. Hypothermia use is
controversial.
■ Keep head in midline position (HOB 30°–60°).
■ Avoid extreme rotation of neck and neck flexion.
■ Avoid extreme hip flexion.
■ Monitor serum glucose and administer insulin as indicated as metabolic
changes may occur.
■ Administer stool softeners to avoid straining at stool and prevent Valsalva
maneuver.
■ Maintain cardiac output using inotropes such as dobutamine (Dobutrex)
and norepinephrine (Levophed).
■ Administer IV sedation cautiously. Consider midazolam (Versed), diazepam
(Valium), lorazepam (Ativan), propofol (Diprivan), and dexmedetomidine
(Precedex). Consider haloperidol (Haldol) if delirium present. Refer to tab 1,
Basics.
■ Administer analgesics as needed. Consider morphine, fentanyl, and
hydromorphone.
■ Administer high doses of barbiturates to ↓ ICP and ↓ metabolic demands.
Consider pentobarbital (Nembutal), phenobarbital, and thiopental
(Pentothal)).
■ Institute seizure precautions; administer anticonvulsants as necessary.
Consider phenytoin (Dilantin) or carbamazepine (Tegretol). Monitor
therapeutic drug levels.
NEURO