Neurological Case Study #1

 

A 28-year-old client with a Past Medical History of seizure disorder that is controlled with Tegretol® (last seizure was 5 years ago), hypothyroidism that is controlled with Synthroid®, and has had a recent urinary tract infection slipped and fell hitting her head while on a family outing. She experienced loss of consciousness at the scene. She was taken to a local hospital where a CT scan revealed a Left Subdural hematoma. She has been transferred to your regional medical center, which has neurosurgeon on call.

 

  1. The ED RN gives you the above information during a phoned report. What other information do you need to prepare for this patient?

 

The RN needs to assess about the patient’s current LOC, medications, and plan of treatment at this time. What are the pt’s most current VS, cardiac rhythm/rate, and oxygen requirements? Lab work also needs to be assessed to ensure the patient’s F/E status are within expected limits.  Psychosocial parameters also need to be addressed. Is the patient married? Partnered? Is there family that will also be helping to care for the patient?

 

 

 

  1. Because you always have trouble remembering the layers of the brain and different hematomas, you look up subdural hematoma before this client arrives. What do you find?

 

Subdural hematoma (SDH) is the most common extra-axial collection and is seen in 5% of head trauma patients. SDH occurs between the dura and the arachnoid membrane, most often due to venous bleeding from the "bridging" subdural veins which connect the cerebral cortex to the dural sinuses. However, SDH may also result from disruption of the penetrating branches of superficial cerebral arteries. These collections tend to conform to the shape of the brain and the cranial vault, exhibiting concave inner margins and convex outer margins. Occasionally, SDH may be straight or even concave in appearance.

Patients with SDH commonly present after acute deceleration injury from a fall or motor vehicle accident, but are rarely associated with skull fracture. More rarely, coagulopathies, tumors, or aneurysms may be responsible for SDH.

SDH may be classified as hyperacute (low density) if less than 12 hours from the acute event, acute (high density) if less than few days, subacute (isodense) from a few days to 2-3 weeks, and chronic (low density) if more than 3 weeks after the time of injury.

  1. This client’s Subdural is considered acute because symptoms appeared with 24 hours of injury. What are the other classifications of subdural hematomas?

 

SDH may be classified as hyperacute (low density) if less than 12 hours from the acute event, acute (high density) if less than few days, subacute (isodense) from a few days to 2-3 weeks, and chronic (low density) if more than 3 weeks after the time of injury.

 

 

  1. What are common signs and symptoms of an acute subdural hematoma?

 

 

 

  1. Why are the elderly and alcoholics at risk for chronic subdural hematoma?

 

Risk factors include:

 

 

  1. How would you monitor for neurological change?

 

Any change in the patient’s level of consciousness (LOC) needs to be monitored closely. The RN would want to follow unit protocol to ensure that the patient’s neurological status is being regularly assessed (at least every 2 hours). Sudden changes in LOC, confusion, dizziness, vertigo, slurred speech, or drowsiness indicates a possible increase in ICP (normally 10-15 mm Hg). Late and ominous findings of increased ICP include Cushing’s Triad (Widening Pulse Pressure with acute HTN, Erratic Respirations, and Bradycardia).

 

 

 

  1. Why is it especially important to make sure that the client is taking her Tegretol and has a therapeutic serum level?

 

Tegretol® is an antiepileptic medication that should be kept at a constant serum level to help control seizure activity by increasing the threshold of excitation at neuronal synaptic clefts through alteration of Na+ channels in neurons.  Seizure activity can lead to potentially lethal effects in this patient as tonic-clonic associated movements can result in further tearing of the vascular network and cause increased hemorrhage, increased ICP, and death.

 

Faculty Note: Discuss the role of seizure precautions, a brief history of antiepileptic medications (Dilantin® = Hyperplasia of Gingiva; Phenobarbitol® = Decreased Intelligence Quotient).  Ataxia and Drowsiness are most common adverse effects of Tegretol®.

 

 

 

  1. The decision was made in this client’s case not to do a craniotomy. When would a neurosurgeon decide to treat medically versus performing surgery?

 

 

Large hematomas or solid blood clots may need to be removed through a larger opening in the skull (craniotomy). The decision not to perform this procedure on this patient indicates that the Subdural Hematoma isn’t significant enough to require craniotomy. Small Subdural Hematomas can reaborb into the vasculature tree of the brain without complications. Subacute and chronic subdural hematomas have good outcomes in most cases, with symptoms going away after drainage of the blood collection. There is a high frequency of seizures following subdural hematoma; however, these seizures are usually well controlled with medication.

 

 

  1. Burr holes work only for subdural hematomas.  A craniotomy must be done for subacute and chronic subdurals. Why?

 

The reasoning for this stems from the amount of blood collection that presents during these various bleeds. Acute Subdural Hematomas typically have smaller amounts of collecting blood compared to subacute and chronic. Additionally, there is Less frequent association of chronic intracranial Subdural Hematoma evacuation with cerebral edema than for acute Subdural Hematoma (cerebral edema frequently associated).  Risk of herniation is lower than with acute. The chronic subdural hematoma is completely liquefied and can be evacuated through a tube (craniostomy) or through small trephinations. It is difficult to treat an acute subdural hematoma with burr holes because the clot cannot be evacuated well).

 

 

 

  1. Why would hypotonic IV solutions such as D5W be avoided?

 

Hypotonic fluids will increase cerebral edema—Fluid is pulled into the cell to help create an isotonic environment for both sides of the cellular membrane resulting in an increased cerebral edema. Maintain euvolemia, using normotonic rather than hypotonic fluids, to maintain brain perfusion without exacerbating brain edema.

 

 

 

  1. How would you position this client in bed and why?

 

The patient should have the HOB elevated about 45 degrees to help decrease ICP and help facilitate reabsorption of blood.

 

 

  1. If this client’s LOC started to decrease, what information would you give the neurosurgeon when you call?

 

You would want to explain the current clinical picture to the neurosurgeon. What have the precise changes in LOC been? What are the patient’s current vital signs?  What is the client’s affect at THIS time? If an ICP monitor is being used, what is the exact ICP measurement at this time?

 

 

  1. How would provide support to the family?

 

Families need information! Studies indicate that families of patients in ICU lack information; that is the most important intervention the RN can perform for family members. Also, explaining the course of Tx and expectations of the patient and family is an important psychosocial intervention for both the family and the patient.

 

 

  1. The neurosurgeon has ordered codeine IV as a pain medication. Why did he order codeine?

 

Codeine works as a cough suppressant. Coughing can increase ICP so at this time, both decreasing nervous stimuli in the coughing reflex of the carina while controlling pain is most beneficial.