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Saraf, Bedah Saraf
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Neurosurgical Emergencies
Neuroscience Nursing Concepts
Adi Sulistyanto MD
Scope
• Traumatic Brain Injury
• Spine Injury
• Stroke
• Brain Tumor
• Pediatric Emergencies
Traumatic Brain Injury
• ATLS Classification•Mild GCS 14-15•Moderate GCS 8-13• Severe GCS 3-8
Glasgow Coma Scale
Trauma -> ATLS
• A = Airway with Cervical Control
• B = Breathing
• C= Circulation
•D = Neurologic Assesment
Neurologic Assesment
Nursing Management
• A-> B -> C
• Maintain cerebral venous outflow -> Head elevation 30 degrees
• Management of pain and agitation
• Urgent CT Scan (Non Contrast)
CT Scan
Spine Injury
• Prevention of further injury• Cervical Collar• Spine Board
• Urgent Radiological Assesment• Management of Autonomic
Dysfunction• Prevention of Pressure Sore• Prevention of TE complication
Spine Imaging
• NEXUS Criteria :• Fully alert• No spinal pain• No neurologic deficit• No alcohol or drug intoxication• No distracting injuries
American Spinal Injury Association Scale
A = CompleteB = Sensory FunctionC = Motor < 3D = Motor > 3E = Normal
Stroke
• Ischemic Stroke
• Hemorrhagic Stroke
• Aneurysmal Subarachnoid Hemorrhage (SAH)
Stroke
Time Is Brain
• Maximum intervals recommended by NINDS
• Door-to– doctor first sees patient 10 min
• Door-to–CT completed 25 min
• Door-to–CT read 45 min
• Door-to–thrombolytic therapy starts 60 min
• Physician examination 15 min
• Neurosurgical expertise available* 2 h
• Admitted to monitored bed 3 h
Hemorrhagic Stroke
• Blood Pressure Control
• Reverse Coagulopathy
SubArachnoid Hemorrhage
Subarachnoid Hemorrhage
Complications
• Rebleeding
• Hydrocephalus
• Vasospasm
• Seizure
• Hyponatremia
• Cardiac Abnormalities
• Fever
NeuroOncology Emergencies
• Increased ICP• Edema • Hemorrhage• Hydrocephalus
• Spinal Cord Compression• Seizure
Pediatric
VP Shunt Malfunction
Altered Consciousness
• Extracranial / Medical : Drug/Alcohol Intoxication, Metabolic (electrolyte, hypo/hyperglycemia, uremia), Infection (Sepsis), Psychiatric
• Intracranial / Structural (Surgical) : Hematoma, Tumor, Hydrocephalus
IntraCranial Pressure
• Volume inside the skull is constant (Monroe-Kellie) consist of :• Brain• Blood• CSF
• Cerebral Perfusion Pressure = Mean Arterial Pressure – IntraCranial Pressure
CPP = MAP – ICP
Keep MAP > 90 ICP < 20
Increased ICP
• Signs and symptoms of increasing ICP–a medical emergency
• Early signs: decreased level of consciousness, deterioration in motor function, headache, visual disturbances, changes in blood pressure or heart rate, changes in respiratory pattern
• Late signs: pupillary abnormalities, more persistent changes in vital signs
• Intervention: thorough neurological assessment, notify physicianimmediately, emergency brain imaging, maintain ABCs
Cushing Reflex
• Hypertension
• Bradycardia
• Abnormal Respiration
Increased ICP
• General measures to prevent elevation of ICP
• HOB up 30° or as physician specifies; reverse Trendelenburg position may be used if blood pressure is stable. Head position may be one of the single most important nursing modalities for controlling increased ICP
• Good head and body alignment: prevents increased intrathoracic pressure and allows venous drainage.
• Pain management: provide good pain control on a consistent basis
• Keep patient normothermic
ICP Monitoring
Herniation
Status Epilepticus
A-B-C
THANK YOU