Page 498 - ACCCN's Critical Care Nursing

Neurological Alterations and Management 475

Research vignette, Continued
TBI, for which intraparenchymal pressure tipped catheters were In terms of study design and methodological implications, there
most commonly used. It should be noted that since then were limitations relating to the missing elements in the data set.
improvement has been noted in an Australasian study with the However, this resulted in minor quantitative, rather than major
72
SAFE study in patients with TBI demonstrating higher ICP qualitative changes to the findings. Similar degrees of missing data
monitoring rates more in line with the TBI guidelines, using ven- were reported in the European historical controls study, which
tricular catheters (~75%) and conversely lower mortality (24.56%) emphasises the difficulties inherent in assessing the epidemiology
overall and (29.24%) in severe TBI. of TBI.

Learning activities

1. What clinical signs are indicative of a fractured base of skull? ● What are the clinical signs of coma?
Are the injuries noted on CT focal or diffuse? ● Where does the source of coma localise in the brain?
2. Reading the Case Study, interpret Sam’s vital signs in relation ● Which complications of TBI might lead to coma?
to cerebral perfusion. Are management changes required? ● What are the key treatment options to prevent cerebral
3. Ischaemia prevention requires a PbtO 2 >20. How can this be ischaemia?
achieved? 7. A child is taken to the emergency room with lethargy, fever and
4. What is the pathophysiological basis for the rise in ICP? How a stiff neck on examination.
would this manifest on the ICP waveform? ● What findings on initial lumbar puncture indicate bacterial
5. A 20-year-old man suffered spinal cord injury at the C2–C3 versus viral meningitis?
level as the result of a motorcycle accident. Explain the ● In the case of bacterial meningitis, what are the most likely
effects of this man’s injury on ventilation and communica- organisms?
tion; sensorimotor function; autonomic nervous system func- 8. Your patient had symptoms of an ischaemic stroke approxi-
tion; bowel, bladder and sexual function; and temperature mately 2 hours ago and is undergoing a confirmatory CT scan
regulation. in 30 minutes. You know tPA must be administered within 3
6. A 25-year-old-man is an unbelted driver involved in a motor hours of the symptoms. What actions would you take? What is
vehicle accident and presents in a coma. your rationale for these actions?

ONLINE RESOURCES National Stroke Foundation of Australia publication: Did you know that? http://
www.strokefoundation.com.au
American Association of Spinal Cord Injury Nurses (AASCIN),http:// Neurological Foundation of New Zealand, http://www.neurological.org.nz/
www.aascin.org Post Coma Unresponsiveness Guidelines, http://www.nhmrc.gov.au/_files_
The Brain Trauma Foundation, http://www.braintrauma.org nhmrc/file/publications/synopses/e81.pdf
Centers for Disease Control: Traumatic Brain Injury, www.cdc.gov/ Spinal Injury Log Roll Protocol, http://intensivecare.hsnet.nsw.gov.au/five/doc/
traumaticbraininjuy/index.html logroll_guideline_R_cp_rnsh.pdf
Cerebral Spinal Fluid Drainage, http://intensivecare.hsnet.nsw.gov.au/five/doc/ Spinal Injury Methylprednisolone Protocol, http://intensivecare.hsnet.nsw.gov.au/
evd_csfspecimen_S_n_liverpool.pdf five/doc/methylprednisolone_spinalcord_D_svh.pdf
Cervical Collars, http://intensivecare.hsnet.nsw.gov.au/five/doc/cervical_collars_ Stroke Foundation of New Zealand, http://www.stroke.org.nz/
care_fitting_S_n_stgeorge.pdf Stroke Management Guidelines, http://www.strokesociety.com.au/index.
Australian Institute of Health and Welfare publication: Stroke, www.aihw.gov.au/ php?option=com_docman&Itemid=196
cvd/stroke.cfm Stroke Thrombolytic Protocol, http://www.mja.com.au/public/issues/187_10_
Australian & NZ Traumatic Brain Injury Study Results (ATBIS), www.anzics.com.au/ 191107/bat11279_fm.pdf,
ctg/completed-studies/50-atbis- or Brain Injury Association, Inc., http:// Sports injuries: head and spine, www.injuryupdate.com.au/injuries/head_&_neck/
www.biausa.org. spinal_injuries.php
Cervical Traction, http://intensivecare.hsnet.nsw.gov.au/five/doc/cervical_ Traumatic Brain Injury National Data Centre, http://www.tbindc.org/
traction_S_n_nepean.pdf
Ethical guidelines for the care of people in post-coma unresponsiveness, http://
www.nhmrc.gov.au/_files_nhmrc/file/publications/synopses/e81.pdf REFERENCES
External Ventricular Drains, http://intensivecare.hsnet.nsw.gov.au/five/doc/evd_
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