Neuro ICU Nurse Tips for Newbies, Part 2: Disease Processes

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Who You’ll Hear

Kati Kleber, MSN RN – Nurse educator, former cardiac med-surg/stepdown and neurocritical care nurse, author, and speaker.

Melissa Stafford, BSN RN CCRN SCRN – highly experienced and currently practicing nationally certified neurocritical care nurse.

Elizabeth Mills, BSN RN CCRN – highly experienced neurocritical care nurse, current Stroke Navigator for a Primary Stroke Center.

What You’ll Learn:

• Subdural hematoma
• Epidural hematoma
• Seizure
• Brain Tumors
• CPM
• Diffuse axonal injury

This episode discusses a few disease processes that are typically seen by the neuro ICU nurse as well as a neuro floor. We chat about subdural hematomas, epidural hematomas, seizures, brain tumors, and diffuse axonal injury.  And as always, this episode is hosted by three neuro ICU nurses!

Subdural hematoma

• SHD is not a stroke
• Dura = covering of the brain… blood is under the dura but on top of the brain
• Often a tear in a vein, which results in a slow blood accumulation
• Happens often with elderly; brain atrophies and creates space
• Acute – blood is new, the blood isn’t thin. Quite thick… if it’s large enough they’ll go to the OR for an evacuation
• If it’s older (subacute) 1-2 weeks… but blood thins out and become easier to treat. Some surgeons will do a bedside procedure to remove the clot

Epidural hematoma

• Above the dural layer of the covering the brain
• Typically the result in an artery tear, which results in a very fast accumulation of blood in the epidural space
• Appears quickly, enlarges quickly, and is often a surgical emergency
• Common place is around the temporal bone near the eye… meningeal artery… may not lose consciousness
• Liam Neeson’s wife died of this – here is a short article from Advanced Neurological Associates
• Change in HOB with lots of pressure

Seizure

• Patients with neurological injury are at risk for seizures
• You cannot tell just by looking at a patient that they are having a seizure or not; only the EEG can absolutely confirm that
• Safety and maintaining an airway is of utmost importance
• Must get seizures under control
• Antiepileptic drugs (AED’s)
  • Looks like they’re having a seizure, but when you look at an EEG they are not actually having one
• Status epilepticus
  • Maybe one long seizure, or multiple seizures with minimal breaks
  • Must stop the brain from seizing! Brain electricity is going bananas – rescue drugs and airway protection (intubation) is frequently necessary because they cannot maintain their airway while seizing that frequently
• Subclinical seizures
  • Not evident from CT or assessment

Brain tumors

• Many kinds of tumors
• Some are cancer, some are not – must get a biopsy, which is incredibly invasive (craniotomy), to definitively say if it is cancerous or not
• Watch Na+ and for CSF leak (clear fluid out of nose, ear)
• Typically, an incision is made through the nares
• Coughing/sneezing precautions
• Usually benign
• Diabetes Insipidus is something to watch for
• Watch urine output closely

Central Pontine Myelinolysis (CPM)

• Medscape article
• Overcorrection of serum sodium – cannot correct too fast (more than 8-10 in 24 hours)
• Must watch closely when administering hypertonic saline
• Essentially, it’s a stripping of the myelin sheath
• Irreversible
• Can be mild, moderate, severe, and fatal
• This is a big deal!
• You won’t get an alert from the lab for overcorrection unless it is over their threshold for hypernatremia.
  • For example, if you correct from 125 to 135 in 24 hours, it won’t alert the lab because technically the 135 is normal. However, this is a HUGE change in 24 hours and concerning for demyelination.

Diffuse axonal injury

• Wikipedia article
• Seen with trauma patients
• The force of traumatic shearing causes this
• Global deficits rather than deficits with a stroke that’s one-sided; most (roughly 90%) never regain consciousness
• Ranges from mild to severe

More resources

• Becoming Nursey
  • First Edition
  • Second Edition
• How I Deal With Seeing Patients Die Frequently – YouTube
• Brene brown’s daring greatly
• Secondary trauma