Page 159 - Critical Care Notes

4223_Tab05_141-174 29/08/14 8:28 AM Page 153

153
■ Serum chemistry panel
■ CBC
■ PT, PTT
■ Cardiac enzymes
■ ABGs
■ Baseline CXR
■ ECG
■ CT scan of brain or MRI of brain
■ TCD studies
■ Single proton emission computed tomography (SPECT)
■ PET scan
■ ECG (changes in ST segment and T wave, prominent U wave)
■ Lumbar puncture and CSF analysis if CT inconclusive and no ↑ ICP present
■ CSF clear and colorless, with no organisms present; normally tests positive
for protein and glucose
■ Cerebral angiography: cerebral digital subtraction angiography (DSA),
multidetector computed tomography angiography (CTA)
Management
■ For patients with an unavoidable delay in obliteration of aneurysm, a signif-
icant risk of rebleeding, and no compelling medical contraindications,
short-term (72-hr) therapy with tranexamic acid or aminocaproic acid is
reasonable to reduce the risk of early aneurysm rebleeding.
■ Neurological assessment: LOC, papillary reaction, motor and sensory
function, cranial nerve deficits, and speech and visual disturbances.
■ Assess for headache and nuchal rigidity.
■ Provide intubation and mechanical ventilation as needed; assess ABGs and
pulse oximetry.
■ Monitor end-tidal CO 2 if indicated.
■ Assess BP, HR, RR, and Glasgow Coma Scale frequently.
■ Monitor and control fever.
■ Initiate cardiac monitoring.
■ Control BP with a titratable antihypertensive. Administer nicardipine
(Cardene) or clevidipine (Cleviprex), preferred over nitroprusside and
labetalol. Keep SBP <160 mm Hg. Balance risk or rebleeding, stroke, and
CPP levels. Keep BP <160 mm Hg.
■ Avoid nitrates such as NTG and vasodilators such as nitroprusside (can
elevate ICP).
■ Monitor and control ICP. Monitor CSF drainage systems for cloudy
(infection) or bloody (rebleeding) drainage.
■ Calculate and monitor CPP = MAP – ICP.
■ Administer osmotic agents (mannitol), loop diuretics (Lasix).
■ Consider IV steroids (controversial).
NEURO