INITIAL MANAGEMENT
-GCS and ABCDE: Assessing and keeping the patient alive:
Ensuring adequate ventilation and maintaining the circulation are the immediate priorities in any patient.
- Glasgow Coma Scale
As a general rule the scores reflect the severity of the neurological status:
-13 to 15: mild
-9 to 12: moderate
-3 to 8: severe
Coma is defined as a GCS of less than 9.
- ABCDE: click here for definition.
- Critical nursing observations: blood sugar, pupillary responses, temperature, pulse, blood pressure, respiratory rate, oxygen saturations, GCS, top to toe examination and a reliable history.
Broadly there are two types of coma: medical coma, which is due to conditions such as liver failure, respiratory failure and diabetic ketoacidosis, in which the management is primarily aimed at the underlying disease; and neurological coma due to conditions such as stroke, subarachnoid haemorrhage and meningitis.
Causes of coma
- Cerebral hemisphere malfunction:
-drug and alcohol intoxication
-hypoxic brain damage
-stroke
-metabolic disorders
-infection
-post-tonic-clonic convulsion
- Brain stem damage:
-direct damage (brain stem stroke)
-indirect damage (cerebral mass or oedema)
STROKE AND STROKE-LIKE EMERGENCIES
Stroke is a syndrome of rapidly developing clinical signs of focal or global disturbance of function, with symptoms lasting 24 hours or longer with no apparent cause other than of vascular origin.
Causes:
- Cerebral infarction (cerebral embolus or thrombosis):
-Anterior circulation infarcts: which result in a variable combination of one-sided weakness (hemiparesis), one-sided sensory loss (hemianaesthesia), visual disturbance (gaze paralysis) and partial loss of the visual field. In addition, there is a variable disturbance of higher functions such as language, neglect of the affected side and incontinence.
*TACI (total anterior circulation infarct), PACI (partial anterior circulation infarct) and LACI (Lacunar anterior circulation infart).
-Posterior circulation infarcts (POCI): also termed a brain stem CVA. Symptoms affect both sides of the body and also, affect coordination in talking, swallowing, looking and balancing. These patients have combination of dysarthria (slurred speech), dysphagia (difficulty swallowing), double vision and dizziness.
- Transient ischaemic attacks (TIA): these are minor strokes caused by the passage of small emboli that negotiate the cerebral circulation without producing any permanent damage.
- Intracerebral haemorrhage
- Subarachnoid haemorrhage
- Subdural haemorrhage
- Extradural haemorrhage
Nursing the patient with a stroke: the first 24h.
-Avoiding aspiration pneumonia and assessing the swallow. Assess security of the airway and maintain oxygen saturation.
-Monitor pulse, temperature and blood pressure.
-Medical history.
-Managing urinary incontinence which suggests disordered higher cortical function and is common in anterior circulation strokes. Catheterisation causes infection and reduction of the bladder capacity so it chould be avoided.
-Communication: vision, hearing, speech and language must be evaluated and documented at an early stage so it will be possible to spot and monitor any changes.
Interventions in the first 24h
-Diagnosis: FAST (Facial drop, Arm weakness and Slurred speech Test)
The Rosier Scale shown above is used to differentiate stroke from "look-alikes" including hypoglycaemia, syncope and epilepsy.
-Imaging: head CT scan.
-Acute drug intervention.
-Monitor blood pressure, temperature and blood sugar.
-Cerebral oedema may develop after a severe stroke and produce a deterioration in the consciousness levelwithin the first day or so.
-Reversing warfarin.
-Avoiding pressure sores: click here for more information.
-Resuscitation status.
-Avoiding venous thromboembolism. stroke victims are at risk of VTE, DVT and pulmonary embolus.
MENINGOCOCCAL MENINGITIS
Nursing tasks
The signs of worsening meningitis:
Meningococcal bacteria normally live quite naturally in the oropharynx of about 10% of the healthy population. In meningococcal disease , for some unexplained reasonthe bacteria become virulent and invade the bloodstream . The result is meningicoccal septicaemia and, if the nervous system is also invaded, meningococcal meningitis.
Clinical features of meningococcal infection:
-fever
-haemorrhagic rash
-altered level of consciousness
Septicaemia: influenza, vomiting, muscle pain and drowsiness.
Meningitis: photophobia, headache, neck stiffness and coma.
Clinical deterioration can be extremely rapid, the causes of death in meningitis are septicaemic shock and increased Intracranial Pressure (ICP).
Nursing tasks
-Assessment of ABCDE and vital signs every half an hour. Including fluid balance.
-ECG monitoring.
-Give oxygen and secure IV access.
-Administer immediate IV antibiotics (ceftriaxone or cefotaxime).
-Measurement of GCS.
-Note any rash.
-Discuss isolation for 24 hours with Control of Infection.
Other important nursing tasks are:
-detain any relatives for further history and advice on contacts,
-ensure there are no drug allergies and ensure immediate specimens are taken for bacteriology (blood cultures, urgent PCR, clotted sample for meningococcal serology and oral or nasal posterior pharyngeal wall swab. Also, preparations should be made for a lumbar puncture if needed to confirm diagnosis.
-rapidly progressing rash
-poor peripheral circulation: capillary refill > 4 seconds, systolic blood pressure < 90mmHg and falling urinary output
-respiratory rate < 8 or > 30 breaths/min
-pulse < 40 or > 140 beats/min
-falling (less than 12) or fluctuating (by more than 2) GCS
-development of a focal limb weakness
-fitting
-falling pulse and climbing blood pressure.
SUDDEN LOSS OF CONSCIOUSNESS: FAINTS AND FITS
Sudden loss of consciousness followed by a recovery is usually due to a faint (syncope) or a fit (tonic-clonic convulsion). The history will differentiate fits and faints in most cases, as well as knowing the triggers, onset, the attack and the recovery details.
SYNCOPE
Syncope is due to a sudden reduction in the blood supply to the brain, in most cases, if the patient stays horizontal there is a full and rapid recovery. If the patient is upright, the blood supply does not return rapidly and the syncope may progress to an anoxic convulsion (convulsive syncope).
The reduction in cerebral blood supply has two possible causes:
-sudden change in heart rate (heart block, ventricular tachycardia)
-sudden change in blood pressure (reflex syncope, acute gastrointestinal haemorrhage, acute pulmonary embolus, drug side effect).
-Cardiac syncope
-Reflex syncope
-Situational syncope
EPILEPTIC SEIZURES
Click here for a detailed explanation.
- Patients who have regained consciousness:
-primary assessment ABCDE
-measure blood sugar and sitting/standing blood pressure
-12-lead ECG and cardiac monitor/telemetry for arrhythmias
-look for injuries, painful areas, bruising and swelling especially in wrists, ankles, hips and shoulders
-look for signs of upper gastrointestinal blood loss (coffee-ground vomit or melaena)
-look for signs of DVT
-obtain drug history and detain relatives or witnesses for more information.
- Patients who are fitting:
-primary assessment ABCDE (especially airway and good venous access)
-ensure the patient cannot injure himself and place him in the recovery position
-give high concentration oxygen with a non re-breathing mask at 15L/min
-carry out blood sugar measurement and bloods for drug levels, biochemistry, clotting, etc.
-take a full history, especially concerning drugs and alcohol.
- Patients with status epilepticus: status epilepticus is defined as fits that continue for 30 min or more without intervening periods of recovery and is a medical emergency. The management is the same as for a single fit but there is a risk of drug-induced respiratory depression. Close monitoring is needed and if the patient´s conculsions cannot be stopped within an hour, the patient needs ITU care.
ACUTE PARALYSIS OF THE LOWER LIMBS
Possible causes:
-spinal cord disorders: acute diseases of the spinal cord are compressive (urgent surgery), inflammatory (specific drug therapy) or vascular. Urgent MRI will differentiate between the three groups.
-Guillain-Barré syndrome: is an ascending paralysis that starts in the feet and moves progressively up the body, to an extent that the respiratory muscles are often involved. The disease can progress rapidly over a matter of hours and put the patient´s breathing at risk.
Respiratory monitoring is the key for the management of the syndrome.
Source:
-A nurse´s survival guide to acute medical emergencies, R. Harrison and L. Daly, Elsevier 2011
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