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 = Complete
B = Sensory Function
C = Motor < 3
D = Motor > 3
E = 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-toCT completed 25 min
Door-toCT read 45 min
Door-tothrombolytic 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 ICPa 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