RECOGNIZING THE SIGNS OF A NEURO EMERGENCY

Noorin Darvesh BScN, RN, CNN (C)

Clinical Nurse Educator, Unit 58

South Health Campus

Department of Clinical Neurosciences

DISCLOSURES

• None

WHO AM I?

WHO ARE YOU?

Source: Retrived from URL. https://www.google.ca/search?q=who+are+you%3F&rlz=1C5CHFA_enCA768CA768&source=lnms&tbm=isch&sa=X&ved=0ahUKEwizy72kvbTeAhUjhOAKHTbnDqAQ_AUIDigB&biw=1440&bih=721#imgrc=1aRj08uriEj0lM:

OUTLINE

• Case

• Objectives

• Discussion

CASE STUDY

On January 26th, 2018, a 76-year-old male patient was admitted to the inpatientneurology ward with a diagnosis of an ischemic posterior inferior cerebellar artery(PICA) stroke. His primary deficit was ataxia, but could still ambulate with stand-byassistance to the bathroom.

Source: Retrived from URL. https://www.researchgate.net/figure/A-B-Cerebellar-infarct-in-the-distribution-of-the-posterior-inferior-cerebellar-artery_fig18_288579276

• On the night of January 27th at approximately 0200, the patient’s daughterrang the patient’s call bell, as her father verbalized that he needed to go tothe bathroom.

• As the primary nurse was ambulating the patient, she noticed an increase inhis gait disturbance, and he required the assistance of 2 nurses to go to thebathroom. The patient reported unspecific visual disturbances, a low-gradeheadache, and appeared more confused in conversation.

a) Let the patient sleep. He’s probably just tired.

b) Nothing. It is normal to have worsening of symptoms after an acute stroke due to cerebral edema.

c) Phone the on-call physician. Something is not right.

As the primary nurse, what would be your intervention for this patient?

OBJECTIVES

• Analyze the anatomy and pathophysiology of the signs and symptoms present

• Identify the signs and symptoms of increased intracranial pressure (ICP) following a PICA stroke

• Outline the most anticipated nursing interventions utilized

• Hopefully influence your decision to choose C in the future

ANATOMY

Posterior Circulation Diagram. Retrieved from URL:https://www.google.ca/search?q=posterior+circulation+stroke&rlz=1C5CHFA_enCA768CA768&source=lnms&tbm=isch&sa=X&ved=0ahUKEwi44oqB_bDeAhVzKH0KHXBkDwwQ_AUIDigB&biw=1440&bih=721#imgrc=hlewarlgb-nhtM:

https://www.google.ca/search?q=posterior+circulation+stroke&rlz=1C5CHFA_enCA768CA768&source=lnms&tbm=isch&sa=X&ved=0ahUKEwi44oqB_bDeAhVzKH0KHXBkDwwQ_AUIDigB&biw=1440&bih=721#imgrc=hlewarlgb-nhtM

COMMON SYMPTOMS

• Headache

• Nausea/Vomiting

• Dysphagia/Dysarthria

• Horizontal Nystagmus

• Ataxia

• Vertigo

(Nouh, A., Remke, J., Ruland, S. (2014).

WHY ARE WE WORRIED?

MONROE-KELLIE HYPOTHESIS

Source:Retrieved from URL:https://canadiem.org/tiny-tips-ich-for-ich-brain-herniation/Source:Retrieved from URL: http://www.trauma.org/archive/neuro/icp.html

HEADACHE

Source:(2016). Retrieved from URL: http://freeofpain.org/occipital-neuralgic-headaches/

When the full PICA cerebellar territory is involved, headache is usually present in the occiput or high neck on the ipsilateral side. (Caplan, L.R. (2018).

PUPILLARY & OCULAR ABNORMALITIES

Source:Retrieved from URL:https://www.researchgate.net/figure/Clinical-manifestations-of-medial-pontine-syndrome-A-Body-representation-of-the_fig8_308065354

• CN III – originates from the midbrain

• CN IV – originates from the pons

• CN V1 – originates from the pons

• Cerebellum

EMESIS

Source: (2011). Retrieved from URL: http://benbbrave.blogspot.com/2011/10/vomiting-centre.html

• Fourth ventricle located in the medulla

DETERIORATION IN LOC

Source: Retrieved from URL:http://health-and-medicine.wikia.com/wiki/Brain

POSTURING

Source: Retrieved from URL: http://betterpicf.pw/Decorticate-vs-Decerebrate-Posturing-posturing-Easy-read.html

NURSING INTERVENTIONS

Notify MRHP:

Patient may require transfer to a hyper-acute neurological unit for further monitoring or surgical intervention

Source: Retrieved from URL: https://allnurses.com/first-year-after/50-things-new-982436.html

OUTCOME

Source: Retrived from URL. https://journals.lww.com/neurotodayonline/blog/breakingnews/Pages/post.aspx?PostID=363

QUESTIONS?

Source:Retrieved from URL:https://www.shutterstock.com/search/hands+up

REFERENCES

• Caplan, L.R. (2018). Posterior circulation cerebrovascular syndromes. UpToDate, Inc.

• Hickey, J.V. (2014). The clinical practice of neurological and neurosurgical nursing. Philadelphia, PA:Lippincott Williams & Wilkins.

• Majid, A., Kassab, M. (2018). Pathophysiology of ischemic stroke. UpToDate, Inc.

• Nouh, A., Remke, J., Ruland, S. (2014). Ischemic posterior circulation stroke: a review of anatomy, clinicalpresentations, diagnosis, and current management. Frontiers in Neurology, 5(30). 1-16.

• Sharifi, M., Cisczek, B. (2013). Bilaterally absent posterior inferior cerebellar artery: case report. Surgicaland Radiologic Anatomy (2013). 35 (7). 623-625.

Recognizing the signs of a neuro emergency DisclosuresWho am i?Who are you?OutlineCase StudySlide Number 7Slide Number 8ObjectivesAnatomy Common SymptomsWhy are we worried?Monroe-Kellie Hypothesis HeadachePupillary & Ocular abnormalitiesEmesisDeterioration in LOCPosturingNursing interventionsoutcomeQuestions?References