Page 165 - Critical Care Notes

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■ Maintain glycemic control. Administer IV insulin cautiously to prevent
hypoglycemia. Target serum glucose levels >60 and <140–180 mg/dL.
■ Provide either continuous ECG monitoring or Holter monitoring to detect
bradycardia →↓ cardiac output and ↓ CPP and arrhythmias especially atrial
fibrillation.
■ Treat and control fever. Administer antibiotics for pneumonia and UTIs.
Prophylactic antibiotics not recommended.
■ Avoid use of Foley catheter if possible. Monitor intake and output closely.
■ Institute seizure precautions, and administer anticonvulsants if necessary.
■ Provide enteral or PEG tube feedings, following aspiration precautions.
Elevate HOB 30°. Consider swallowing assessment.
Endovascular Interventions
■ Intra-arterial fibrinolysis
■ A combination of IV and intra-arterial fibrinolysis
■ Mechanical thrombectomy to remove offending thrombus with select
thrombus retrievers
■ Extra-intracranial bypass (EC-IC) not recommended; no benefit shown over
medical therapy
■ Use of intracranial angioplasty and/or stenting not well established
Herniation of the Brain
A brain herniation occurs when brain tissue, CSF, and blood vessels are moved
away from their usual position inside the skull. May result from brain swelling
caused by a head injury, stroke, or brain tumor. Other causes include abscess,
hemorrhage, hydrocephalus, and swelling after radiation therapy.
Brain herniation can cause a massive stroke and can quickly lead to brain
death or death.
Signs and symptoms:
■ Cardiac arrest
■ Cushing’s triad of impending herniation: an increase in pulse pressure;
bradycardia; and slow, irregular respiratory rate
■ Headache
■ Lethargy, difficulty concentrating, drowsy or agitated → stupor and coma
■ Loss of brainstem reflexes such as blinking, gagging
■ Changes in pupillary reaction, sluggish → fixed and dilated pupils
■ Hemiparesis → decortication, decerebration, flaccidity
■ Increased BP, irregular and slow HR
■ Increased BP, hyperventilation → irregular breathing → Cheyne-Stokes →
respiratory arrest

NEURO