MVC-AACN Newsletter
FALL 2013
Hello fellow MVC AACN members,
INSIDE THIS ISSUE
1-2
Letter from New Chapter President
2
NTI News
3-11
Neuro Program Review
11
Horizons Reminder
12
Step Forward Theme & Fall Program Reminder
13
Fall Education program reminder
13-14
Photos
Allow me to introduce myself to those of
you who don't already know me. My name is
Chrissy Cebollero, and I am the current President
of our chapter, and have been involved on the
board over the last 4 years. I currently work at
Lowell General Hospital, and have for the past 17
years. About a year ago I became an
Administrative Coordinators (nursing supervisor)
and for the 11 years prior had been a staff nurse in
the ICU. I am married (to a nurse), and we have 3
kids in 3 different schools who are involved in
more activities than I can list.
I have been thinking and thinking about a
theme for this year. If you follow the newsletters
sent out by AACN they always have a letter with
suggestions on how to apply the theme of the year
or examples of how it was applied. Last year was
DARE TO... and this year is STEP FORWARD...
I thought of combining the two but instead have
decided on BE INVOLVED!
I would like to challenge you to BE
INVOLVED in something important to you. It
can be something small like voicing your opinion
about changes on the unit where you work. It
could be something bigger like joining a
committee which could make practice changes
hospital wide. I would love to challenge anyone
of you to be involved at the board meetings, or to
help plan our next program. Your involvement
may not have anything to do with nursing, but
something else you are interested in.
(cont on page 2)
Newsletter 1
continued from page 1
One event you may start with is our fall
program... Bundles, Guidelines & Pearls: Sepsis,
PAD and ABCDE. The all day program is being
held on October 22 at the Westford Regency.
Program brochures are available for download on
the MVC AACN website (accessed through
AACN.org). We will be having our next board
meeting following the program for anyone
interested in joining us.
Another upcoming event is the 3 day
Regional Horizons Conference. This time the
venue is Portland, ME and is being held April 2,
3&4 2014. Flyers will be mailed after the New
Year. You can look at HORIZONS2014.org for
more information.
Lead through example and BE
INVOLVED in the process.
Thank you and looking forward to another great
year,
Chrissy Cebollero BSN RN CCRN
MVC AACN President
A Big Thank You to All Chapter
Members who volunteered
their time at the NTI Ribbon
Booth in Boston this past May!
(Look for photos in this newsletter and on our
AACN Chapter Website!)
Thanks to each of you our Chapter
was able to staff the Ribbon Booth for 2
days. The funds raised from NTI T-shirt sales
were divided between the three AACN
Chapters in eastern Massachusetts and
will be used to support educational
programs and philanthropic activities.
Next year NTI will be held in
It may only be October but watch
Denver, CO from May 19-22. Be sure to
stop by the Ribbon Booth in Denver to say
for an announcement about the
“Hello” to Chapter hosts and thank them
Chapter Christmas Party! Don’t
for volunteering their time to be there!
forget our annual Toys for Tots
Housing is open now for this event so
donations too!
reserve your room early!!
Newsletter 2
orientation, fear, irritability, misperception of sensory
“It’s All in Your Head:
stimuli, and sometimes visual hallucinations. Delirium
Getting AHEAD in Neuroscience Nursing”
accompanies diffuse metabolic and multifocal cerebral
disease or illness – if you have an elderly patient
A Review by Sue Ouellette RN, MVC Secretary
presenting with delirium or altered LOC consider
Our spring 2013 program was held on 4/23/13
sepsis. Dementia is an impairment of awareness due
at the Westford Regency. We were delighted to
to pathological lesions usually scattered throughout the
present Mary Kay Bader, a well-known International
cerebral hemisphere.
speaker and co-author of the Core Curriculum of
Apraxia is defined as an inability to perform
Neuro-science Nursing, which I have referenced in
planned motor acts and there are several types. One
updating neurological policies at my institution.
type is ideational, which is an inability to comprehend
Mary Kay began the program with a review of
or remember a command; a second type is dressing,
neuroanatomy, essential to understanding what your
where the patient demonstrates neglect of one side of
neurological assessment is telling you about your
the body in grooming or dressing. OT/PT/ST will
patient. Level of consciousness (LOC) is the most
assess for this abnormality as well as sensory
important indicator of neurological function. This may
recognition abnormalities such as agraphesthesia, the
be assessed by using scales such as the Glasgow
inability to discern the number or letter traced on the
Coma Scale, NIHSS (National Institute of Health
palm of the hand. The patient may also have language
Stroke Scale), or described as alert, lethargic, semi-
or communication impairment noted on your exam.
Expressive aphasia, aka Brocca’s aphasia, is
comatose, or comatose, terms that are subjective.
Mary Kay discussed the Four Score Scale which was
characterized by speech which is very slow with great
developed to supplement the assessment capabilities
effort, poorly articulated, with inability to express
of the Glasgow Coma Scale so that the extent of the
thoughts, but comprehension is usually intact.
patient’s brain stem function may be more accurately
Receptive aphasia, aka Wernicke’s aphasia, is
gauged, even if intubated. The Four Score Scale
characterized by running speech which lacks content,
includes four tests to score separately: eye response,
inability to comprehend words spoken to them, and
motor response, brain stem reflexes, and respiration.
impaired ability to name objects.
Motor and sensory exam is an important piece
Frequent neuro checks are essential for new
pathologies and should be part of hand off
of every RN’s assessment. Both upper and lower
communication. Mary Kay made the following points
extremities should be checked for voluntary or non-
related to LOC – just because the patient follows
voluntary strength (scored 1-5 with 5 as full strength
commands does not mean their ICP (intracranial
against resistance). In the patient with spinal cord
pressure) is normal, and agitation/restlessness
injury, lumbar abnormalities will manifest as lower
precedes neurological decline, therefore do not
extremity deficit, thoracic abnormalities as lower
sedate for agitation in this case.
extremity deficit except for sensation and cervical
A mental status exam should be performed to
abnormalities, both upper and lower extremity deficit.
assess cognitive functions – two abnormalities we
In an awake, cooperative patient able to follow
frequently see are delirium and dementia. Delirium is
commands, a complete sensory assessment can be
defined as an abnormal state characterized by dis-
performed. Test with the patient’s eyes closed and
(Cont on pg 4)
Newsletter 3
compare one side of the body with the other. Sensory
Cranial nerve 4 (trochlear) palsy prevents the
function is scored using a 10-2 scale with 2 considered
eye from looking down and in. When you test the
normal or intact. Can the patient tell the difference
patient’s corneal reflex, you are assessing cranial
between dull or sharp stimuli, hot or cold?
nerve 5 (trigeminal) which also controls the muscles of
Reflex assessment is usually done by the
mastication and facial sensation. With cranial nerve 6
physician. You may note these pathologic reflexes in
(abducens) palsy, the eye looks in at the nose at rest
the course of your neuro assessment – grasp reflex in
and doesn’t move outward. The facial nerve (7)
response to palmar stimulation, sucking reflex in
controls muscles of the face, taste on 2/3 of tongue,
response to lip stimulation, and rooting reflex where
and closes the eyelid. Cranial nerve 7 dysfunction
the mouth opens and head deviates toward a stimulus
may be either central (ie stroke) , where you will see
applied to the lower lip or cheek. These are primitive
symmetric wrinkling of the forehead, or peripheral (ie
reflexes present in infants but normally absent in
Bell’s palsy) with absent wrinkling of the forehead.
adults that may reappear in association with frontal
The MD evaluates cranial nerve 8 (acoustic)
lobe impairment. Therefore, asking your patient with a
for sense of hearing and 3 ,6 and 8 with “Doll’s eyes”
decreased LOC to squeeze your hand is not a good
(oculocephalic reflex) maneuver or cold calorics
indicator of ability to follow commands.
(oculovestibular reflex). Abnormal oculocephalic reflex
Babinski’s sign is elicited by stroking the
is no eye movement or asymmetric eye movement in
lateral aspect of the sole of the foot from the heel up
response to turning the patient’s head quickly from
and across the ball causing abnormal dorsiflexion of
side to side while holding eyes open. This reflex is only
the great toe and extensor fanning of the other toes. In
tested in the comatose patient who has had c-spine
an adult, this indicates a lesion of the corticospinal
injury ruled out. Abnormal oculovestibular reflex
tract anywhere from the motor cortex to the anterior
(showing the brainstem pathways to be impaired) is
horn of the spinal cord.
that the eyes stay in mid-position when the ear is
irrigated – awake patients may also experience
Part of the ongoing neuro assessment is
cranial nerve function. Cranial nerve 1 (olfactory) is
vertigo, nausea, and vomiting.
only able to be assessed in the conscious patient –
Cranial nerves 9 & 10 (glossopharyngeal and
each nostril should be tested separately by asking the
vagus) control sensation to posterior tongue and
patient to identify familiar, nonirritating odors such as
palate, motor control to palate, swallowing/gag reflex,
coffee or perfume.
and vagal simulation. Cranial nerve 11 (spinal
Nerves 2 & 3 (optic and oculomotor) assess
visual acuity, visual field, pupillary light reflex, elevate the
eyelid, and move the eye in various directions. Mary Kay
accessory) controls shoulder shrug and number 12
(hypoglossal) tongue movement. As you can see,
neuro assessment involves a lot that you are already
noted that 10 – 20% of the population have unequal pupils
doing in your patient assessment with vital signs also
normally. With a cranial nerve 3 palsy, the eye looks out
an integral part and the importance of hand-off report
toward the ear at rest and does not move inward.
on current neuro status cannot be over emphasized to
ensure changes are quickly noticed.
(Cont on pg 5)
Newsletter 4
Mary Kay next presented a brief presentation
on coma, differentiating between deep coma, where
understand the consequences of these factors and
adhere to their treatment programs.
the patient does not respond to pain or light coma
Patients may experience a TIA, defined by the
where there is a response to noxious stimuli. There are
AHA as a transient episode of neurological dysfunction
multiple etiologies but she asked us to keep in mind
caused by focal brain, spinal cord, or retinal ischemia
that unilateral hemispheric lesions do not result in
without acute infarct. Symptoms generally resolve in
coma. The main interventions are to secure airway,
less than 24 hours and there is no radiographic
establish IV access, consider dextrose or narcan, and
evidence of insult on CT scan. These episodes need to
MONITOR THE PATIENT.
be taken seriously however as 10 – 15% of TIA
Care of the ischemic stroke victim was the
next topic reviewed. Stroke is defined as an abrupt and
patients will have a stroke within 3 months (1/2 within
48 hours).
dramatic development of a focal neurological deficit
Ischemic stroke may be thrombotic, related to
caused by either an occlusion of an artery or rupture of
atherosclerosis or embolic in origin, related to DVT or
the artery with blood escaping into the brain and/or
atrial fibrillation. Thrombotic events are associated with
subarachnoid space. Stroke is the 4th leading cause of
sleep, while embolic are more associated with activity.
death in the U.S. 20% of survivors still require
Lacunar or subcortical strokes (small vessel disease)
institutional care after 3 months and 25 – 30% are
are very common in diabetic patients. The classic
permanently disabled.
signs and symptoms of stroke are weakness of an
The Stroke Chain of Survival encompasses 4
arm/leg, difficulty speaking, headache, droopy smile,
steps that involve the participation and cooperation of
visual problems, and or numbness/tingling on one side
EMS providers:
of body.
1. Detection : understand the stroke
The specific blood vessel affected in the brain
signs/symptoms and determine TIME LAST
and whether this is located in the dominant or non-
SEEN NORMAL
dominant hemisphere determines the symptoms. Once
2. Dispatch: public needs to understand the
importance of 911
a vessel is occluded, systemic arterial blood pressure
influences cerebral perfusion pressure (CPP) and
3. Delivery: initial patient stabilization and
collateral blood flow during ischemia. Permanent
exclusion of other alternative etiologies
ischemic cell death ensues after thirty minutes –
4. Door: patients should be delivered to a
continued ischemia (<50% of baseline CBF) will kill the
rest of the vessel territory. Edema and increased ICP
hospital competent to deal with stroke
occurs as the natural evolution of insult and will be
There are non-modifiable risk factors for ischemic
vascular events, such as age, sex, race, ethnicity, and
family history of stroke/TIA. Many risk factors are
modifiable however and the public needs to be
There are 3 pathophysiological issues related to stroke
– blood pressure (B/P), blood glucose, and
temperature. Brain perfusion is dependent on mean
educated about factors such as HTN, cigarette
arterial pressure (MAP). Increase in B/P may be the
smoking, diabetes, dyslipidemia, atrial fibrillation, and
cardiovascular disease. We, as nurses can educate
our patients and the public so they can better
minimized if perfusion is restored.
normal homeostatic response to stroke and usually
falls spontaneously within 24 hours to several days. If
the patient has not received thrombolytics, do not treat
MVC-AACN Newsletter 5
B/P in acute ischemic stroke unless systolic > 220 mm
Intravenous TPA is indicated for the treatment
Hg, diastolic B/P >120 mm Hg, or MAP >130 mm Hg. If
of acute ischemic stroke if patient symptoms began
thrombolytic therapy is to be used, do not treat unless
<4.5 hours prior to arrival, CT scan excludes
systolic B/P >185 mm Hg (after TPA, 180 mm Hg),
hemorrhage, NIHSS 4 OR <, AGE >18, or isolated
diastolic B/P >110 mm Hg (after TPA, 105 MM Hg).
aphasia present. The exclusions for use of 3 – 4.5 hour
Regarding blood glucose and stroke, when
IV TPA are age > 80, patient taking oral
level exceeds 180, begin strategies to lower serum
anticoagulants, NIHSS > 25, or combination of prior
glucose. The New England Journal of Medicine
stroke and diabetes. If the treatment decision is IV
published the results of a clinical trial stating a blood
TPA, a second IV line should be initiated for
glucose target of 180 mg or < /deciliter resulted in
thrombolytic, NIHSS q15 minutes needs to be
lower mortality than did a range of 81-108 mg/deciliter.
continued, obtain/estimate weight, and avoid invasive
Hyperthermia has been found to increase mortality and
tubes. IV TPA 0.9 mg/kg is given, 10% as IV bolus
length of stay (LOS) in the stroke patient. Temperature
over 1-2 minutes followed by 90% over 60 minutes.
should be maintained 98.6 or <, IV Acetaminophen 1
gm q6 hours may be used to achieve this goal.
Post IV TPA care continues in the ICU.
Neurological checks and vital signs are checked q15
Hospitals must have an organized Stroke
minutes x 2 hours, q 30 minutes x 6 hours, then q 1
Intervention Program in place to ensure rapid
hour. Labetalol or Nicardipine are the drugs of choice
identification and work up once the patient presents
to control B/P if needed. Nipride should not be used as
with possible stroke. Time of symptom onset is crucial
it increases ICP. No invasive tubes should be inserted
and will direct course of treatment. Once the Stroke
x 24 hours. Antithrombotic/antiplatelet drugs should not
Team is activated and patient arrives in the ED,
be given (ASA, Heparin, Warfarin, Ticlid, Lovenox,
primary/secondary survey is completed. A complete
Plavix, Aggrenox, Fragmin are examples). Antiplatelet
NIHSS must be done by ED MD or primary nurse. Mini
therapy may be started 24 hours after TPA. Also keep
NIHSS and vital signs should be done q 15 minutes x1
the patient NPO until a swallow evaluation is done,
hour. Notification of Neurologist should be done within
monitor blood glucose levels q 4 hours x2, maintain
15 minutes of arrival in ED.
normothermia, and initiate TED hose/ compression
Immediate diagnostic studies for the patient
with suspected stroke include non-contrast CT Scan
boots for DVT prophylaxis.
Intra-arterial thrombolytic therapy to the
(CT scan within 25 minutes of patient arrival with
occluded cerebral vessel may be a treatment option if
interpretation within 45 minutes of arrival) or MRI of the
the time window is < 6 hours from onset of symptoms.
brain, Blood glucose, O2 saturation, serum
This requires availability of cerebral angiogram and a
electrolytes/renal function tests, CBC, platelets,
trained Interventional Radiologist. Removal of the intra-
PT/INR, PTT, EKG, and cardiac markers if necessary.
cerebral vessel clot may be done utilizing the Merci
There are conditions that mimic stroke which need to
device especially if TPA cannot be given secondary to
be ruled out, such as ICH, Todd’s paralysis (post
contraindications. This would generally be done in a
seizure), hypoglycemia, complicated migraine, brain
tertiary health center.
tumor, brain abscess, encephalitis, conversion
disorder, or malingering.
If the acute ischemic stroke patient presents to
the ED > 6 hours after symptom onset,
primary/secondary assessment is performed and ASA
MVC-AACN Newsletter 6
325 mg PR may be administered after hemorrhage is
If the patient has decreased LOC, unable to
ruled out by CT scan. B/P management is done as
maintain a patent airway, motor score < 5, or PaCo2 >
previously discussed and the patient is kept NPO until
45, rapid sequence intubation (RSI) should be
dysphagia screen performed. Admission to a
performed. Do not hyperventilate the patient - keep
telemetry/ stroke unit for the first 24 hours is
PaCo2 >35. B/P management may require placement
appropriate.
of an arterial catheter for closer monitoring – systolic
Hemorrhagic stroke accounts for 10 -20% of
B/P should be kept < 150 mm Hg. IV Labetalol or
all strokes and has a 30 day morbidity rate of 43%.
Nicardipine are the agents of choice. Mannitol or 200
Hemorrhagic stroke may be intracerebral or
ml hypertonic saline (3%) over 20 minutes can be
subarachnoid (secondary to aneurysm or vascular
administered if patient exhibits signs of posturing,
malformations). Systemic HTN is the number 1 risk
blown pupil, or increasing ICP by monitor.
factor of intracranial hemorrhage (ICH) – other
When monitoring ICP, be aware of CPP (MAP
etiologies include brain tumors (commonly malignant),
–ICP) as this can reflect increased brain ischemia.
and cerebral amyloid angiopathy (pathological deposits
Normal CPP range is 50 – 70. The patient needs to be
of beta amyloid protein within the walls of small
kept euvolemic – do not dehydrate. Prophylactic
meningeal and cortical vessels – common in folks >
anticonvulsant treatment is not recommended.
70, with anticoagulant use, vasculitis, venous
Treatment with benzodiazepines is appropriate for
infarction, and drug abuse such as cocaine or
actual seizures, also consider EEG monitoring if the
amphetamines). The hematoma releases toxins into
patient’s LOC is worse than likely explained by the size
brain tissue causing a local decrease in perfusion and
and location of the hemorrhage.
cellular changes. Cerebral edema develops over 24 –
Aneurysmal subarachnoid hemorrhage (SAH)
72 hours and ICP increases because of the space
occurs when a sacular outpouching of a cerebral artery
occupying blood clot. Intraventricular ICP
ruptures into the subarachnoid space. The 30 day
monitoring/drainage may be utilized in the course of
mortality rate with this bleed is 45%, with 30% of
treatment.
survivors left with a major disability. Associated risk
The patient with an ICH may present with the
factors are current smoking, HTN, women affected >
sudden onset of focal deficit, severe headache, n/v,
men, African- American descent, family history, older
and/or decreased LOC.ICH in the cerebellum usually
age, excess alcohol intake/drug use. Higher risk of
presents with severe headache, nuchal rigidity, n/v,
aneurysm formation and rupture are also associated
balance/coordination problems and may progress to
with trauma to the vessel, polycystic kidney disease,
posturing and coma - this is best emergently treated in
connective tissue disease, and Ehler Danlos
the OR. Coagulopathy may need to be reversed, and
Syndrome, Type 4. The patient presents with the
is managed depending on anticoagulant or antiplatelet
abrupt onset of “the worst headache of my life”,
agent used. If CT scan confirms hemorrhage,
photophobia, stiff neck secondary to meningeal
treatment will be determined by several factors such as
irritation, cranial nerve dysfunction, motor weakness to
patient age, pre-morbid condition, location and size of
posturing, decreased LOC to coma (that can change in
ICH, and patient’s advanced directive. If aggressive
a second!).
interventions are warranted, Mary Kay advised getting
the Neurosurgeon involved.
Aneurysmal SAH is graded most commonly
using the Hunt and Hess scale (1-4 depending on
MVC-AACN Newsletter 7
symptoms). Good outcomes are correlated with scores
hypotension, 30 mg q 2 hours x 21 days.” Double H”
of 1 – 2 and worse outcomes with scores of 3 and 4.
therapy is now used (hypertension and hemodilution),
CT scan is the initial diagnostic study of choice. CT
not “Triple H” (patient should be kept euvolemic).
Angiogram affords rapid visualization of arterial
Statins may also be used to counter act vasospasm.
anatomy, a 3 dimensional image that assists in
Another potential complication of aneurysmal
determining the shape of the aneurysm prior to
SAH is myocardial stunning or Tako-tsubo
therapeutic intervention.
cardiomyopathy and neurogenic pulmonary edema
The greatest risk of re-bleeding occurs in the
related to increased catecholamine release from a
first 24 hours and at 7 – 10 days after initial SAH when
huge bleed. The treatment is supportive with goal of
clot lysis occurs. Early surgical or endovascular repair
unloading the left ventricle – use contractility agents if
is the most effective intervention to prevent re-bleed.
possible such as dobutamine and a diuretic.
Surgical repair can be accomplished by clipping of the
Mary Kay next discussed studies that have
aneurysm neck or aneurysms not amenable to clipping
shown the negative impact of fever in acute brain injury
may be resected or wrapped to reinforce the vessel
and ICH. Hyperthermia increases metabolic rate, blood
wall. Interventional Neuro-radiologists may insert
velocity, cerebral blood flow, and O2 consumption,
devices such as coils detachable balloons, and/or
which in turn will increase ICP. The use of mild
stents to occlude the aneurysm. A Ventriculostomy
hypothermia can ameliorate the cascade of ischemic
tube may be placed for high grade SAH,
insult. Patients with refractory increased ICP, stroke
hydrocephalus, or increasing ICP enabling CSF
with impending herniation (usually <60 years old), or
drainage.
vasospasm refractory to medical/interventional therapy
Cerebral vasospasm is a potential
can benefit from hypothermia therapy. The method
complication of aneurysmal rupture. Narrowing of
used may vary according to different institutions but
cerebral arteries around the Circle of Willis causes an
must be readily available, must have feedback loop, be
increase in velocities of arteries, decreasing blood
able to rapidly cool to target temperature, prevent
delivery to cerebral tissue and may cause brain
overcooling (not <32 degrees C), control slow
ischemia and infarct. Incidence and degree of vaso-
rewarming, and not hurt the patient. Cooling may begin
spasm are directly related to amount of blood in the
with ice packs while awaiting cooling machine
subarachnoid space. This can occur 4 - 14 days post
application.
rupture. Neurological symptoms may not occur or there
Temperature may be monitored utilizing an
may be subtle or dramatic deterioration in neurological
esophageal sensor that is placed in the lower third of
function. Transcranial Doppler studies (TCD), usually
the esophagus which will allow the sensor to be closer
done daily for 14 days after SAH may detect
to the heart and aorta and will accurately reflect core
vasospasm. Cerebral angiography is used to diagnose
temperature. It also indicates changes in core
or confirm vasospasm, or in the comatose patient brain
temperature significantly faster than peripheral sites.
tissue partial pressure of oxygen or CBF decrease if
Bladder sensors require a urinary catheter with a
sensor is in the region fed by the spastic vessel.
thermistor tip to be inserted into the bladder. Bladder
Nimodipine is given immediately after SAH diagnosis
temperatures track core temperature changes better
to reduce vasospasm and improve long term
than rectal but the readings may be altered secondary
outcomes. Dosage is 60 mg q 4 hours or if
MVC-AACN Newsletter 8
to urine volume or if the patient is receiving bladder
pectoralis muscle, neck, and mandible region –
irrigations.
HUMMING OR VIBRATION IS AN EARLY
The patient should be on the ventilator with
hemodynamic monitoring – central IV access and
arterial lines should be placed prior to induction.
INDICATION OF SHIVERING. Extra anti-shivering
medication may be necessary.
Hypothermia slows the heart rate – normal
ICP/Brain Tissue O2 monitoring may be utilized
heart rate at core temperature 32 degrees C is 34 - 40
depending on your institutions’ capabilities. If your
bpm. The patient generally remains asymptomatic but
institution is doing therapeutic hypothermia, a protocol
if treatment is deemed necessary use Isuprel or
should be in place to guide safe and effective
Dopamine infusion. Atropine is ineffective for
treatment. A few bullet points to this therapy – the
hypothermia induced bradycardia. Be aware that
patient should be comatose and/or sedated (propofol if
Neosynephrine and Precedex cause bradycardia.
the patient is hemodynamically stable, midazolam if
Arrhythmias secondary to hypothermia only occur with
unstable). Consider Fentanyl infusion for analgesia.
core temperature < 30 degrees. If core temperature is
The goal is to get patient temperature to 33 degrees C
>30 degrees, arrhythmias do not require any change in
ASAP. MD should be notified if not reaching goal
cooling therapy. Treat arrhythmias with standard
within 6 hours. Infusion of cold fluids (4 degrees C)
antiarrhythmic meds but be aware of possible
such as NS with a pressure bag as rapidly as possible,
decrease in clearance of Amiodarone during
2000-2500ml is usually required but may need up to 4
hypothermia. Keep in mind the potential for decubiti
liters.
secondary to skin vasoconstriction and immobilization.
Hypotension should be avoided with
Rewarming is the most dangerous time. The
maintenance of MAP 80 MM Hg. The patient may
duration of rewarming phase is usually 12- 24 hours –
shiver at 35 degrees C causing increased metabolic
warming speed is 0.1 – 0.3 degrees C/hour with
rate and reduced cooling benefits – Demerol, propofol,
absolute maximum 0.5 degrees C/hour. Perform
and magnesium may be used to control or single dose
controlled rewarming using a cooling device with a
paralytic in case of refractory shivering. Diuresis will
feedback mechanism. B/P drops may occur secondary
occur during initial cooling. Potassium, magnesium,
to vasodilation and fluid shifts. Electrolyte disturbances
calcium, sodium, phosphorus are driven into the cell
occur as potassium,, magnesium, calcium, sodium,
during induction, therefore electrolytes should be
and phosphorus now leave the cell – especially
checked q1 hour, PT/INR, PTT, lactate, and cardiac
beware of hyperkalemia and hypoglycemia (due to
enzymes q 4 hours or as ordered. Maintain blood
increased insulin sensitivity during rewarming).
glucose 180.
Shivering may resume. Rewarming is complete when
Hypothermia should be maintained for 18
hours after reaching the desired temperature (33
degrees C) or 24 hours total. During maintenance,
core temperature reaches 36.5 degrees C. Maintain
normothermia for 48 hours.
Therapeutic hypothermia may need to be
diuresis slows and urine output normalizes.
terminated early (or increase core temp by 1 degree
Temperature should never decrease < 30 degrees C, if
and hold at 34 degrees C) in the case of hemodynamic
temperature increases to 1 degree or > above target
instability, when the patient is adequately resuscitated,
cause is usually shivering. Use the Bedside Shivering
if there are unstable arrhythmias resistant to meds,
Assessment Scale (BSAS) to screen. Palpate the
severe bleeding, or platelet drop < 50,000. The
MVC-AACN Newsletter 9
American Heart Association (AHA) recommends that
Karyn reviewed the signs and symptoms of
duration of observation > 72 hours after ROSC (return
increased ICP which may be treated in the ED with 30
of spontaneous circulation) should be considered
degree HOB elevation, osmotic therapy (mannitol),
before predicting poor outcome in patients treated with
sedation, or hyperventilation if other measures are
therapeutic hypothermia. No technology has been
unsuccessful. If the facility does not have
specifically approved for use in children.
neurosurgical coverage, the patient should be
Our second speaker for the day, Karyn
Stremmenos is a member of MVC AACN and one of
our former Publications chairs – she is currently a
transferred to a Tertiary care center with these
services available as soon as stable.
An epidural hematoma may develop with a TBI
Family Nurse Practitioner in the ED at Wing Memorial
- this is bleeding in the space between the dura and
Hospital in Palmer. MA.
skull usually related to an arterial injury There is a
Karyn’s presentation was titled Head Injuries in
transient loss of consciousness followed by a lucid
the ED: Wrapping Your Brain Around It. She discussed
period that may last from minutes to hours, followed by
statistics such as 1.4 million traumatic brain injuries
a rapid deterioration in neuro status. This is a
(TBI) occur each year resulting in 50,000 deaths. The
neurological emergency, in many cases requiring
two leading causes of TBI are motor vehicle/traffic
surgical intervention.
related accidents and falls. A coup injury refers to
Subdural hematomas result from bleeding in
injury on the same side as impact and contra coup
the space between the dura and arachnoid
injury is on the opposite side of impact. There may be
membranes usually related to venous bleeding and
associated ocular, maxillofacial, or cervical spine
may be acute, sub-acute, or chronic. These do not
injuries. Ongoing support of airway, breathing, and
always require surgical intervention.
circulation begins in the field with spinal
The 3 types of skull fractures are linear,
stabilization/immobilization, continued monitoring of
depressed, and basilar. Because considerable force is
vital signs, and neuro assessment. Baseline lab
required to fracture the skull, concurrent injury to the
studies include CBC, electrolytes, blood glucose,
brain and C-spine should always be considered.
coags, blood ETOH level, and urine tox screen.
CT scan of the brain is the preferred method of
Concussion is defined as a trauma induced
alteration in mental status that may or may not involve
imaging in the ED for acute head trauma. A CT scan of
loss of consciousness. It is usually associated with
the neck should be done if there is any suspicion for a
normal neuro imaging studies. There is increased
C- spine injury. Not all head traumas require a CT
incidence secondary to contact sports. The hallmark
scan! The Canadian CT Head Injury/Trauma Rule
signs and symptoms of concussion are confusion,
determines who may need CT Brain imaging after a
retrograde or antegrade amnesia, headache,
trauma – GCS score of 13 - 15 with witnessed loss of
dizziness, or n/v. Hours to days later the patient may
consciousness, suspected open or depressed skull
have mood disturbances, sleep disturbances, or
fracture, any signs of basilar skull fracture, two or more
difficulty concentrating. If the patient with a concussion
episodes of vomiting, 65 years of age or older,
is to be discharged home from the ED they need
amnesia before impact of 30 minutes or >, or
observation for 24 hours by a responsible person who
dangerous mechanism of injury.
has been educated on monitoring and warning signs.
MVC-AACN Newsletter 10
Seven days without any activity is required with
post concussive syndrome symptoms may last for
graduated return to play guidelines.
several weeks or months – headaches, dizziness,
Second Impact Syndrome is a fatal
neuropsychiatric symptoms, and cognitive impairment.
complication of mild head injury and occurs after a
Karyn wrapped up by providing the following 3
second concussion while the patient is still recovering
websites she has found helpful – www.uptodate.com,
from the initial concussion – this is extremely rare. In
www.mdcalc.com, and www.ena.org.
Horizons
Save the dates of April 2-4, 2014 to attend Horizons at Inn by the
Bay in Portland, Maine!
For more info go to www.horizons2014.org and watch for a
brochure in your mail in January.
MVC-AACN Newsletter 11
2013-14 AACN Theme
(Submitted by Ellen Stokinger – MVC Membership Chair)
In May of 2013 “Step Forward” was announced at NTI as the new theme for AACN. Each year the
incoming president of AACN presents a theme to carry forth in her year as president.
Last year’s theme of “Dare to” … leads into this years’ theme “Step Forward”. Think of your own
practice/ profession, many days as a patient advocate you have dared to step forward and say your gut
feeling and you have pushed for further testing or further observation of your patient. In the rush to make
beds available in ICU how often do patients get pressed to move on to step down units. Are you there to
step forward and say they are not ready yet? I am sure there are many more situations to which we can
carry this theme.
In 1985 the Merrimack Valley Chapter started with 20 members. Now there are 120 members and
growing each year. Please Step Forward and exercise your ability to show leadership traits. There are
opportunities in the chapter to join a committee, attend board meetings (the Oct. meeting is after the
program). Then once you are familiar with the board activities you can and should run for office. Many
chapter officers have transitioned from staff to management positions possibly because they have “dared
to” “step forward” “with confidence”.
P.S. membership dues age 55 years and five years are reduced to $59/year; Also Submit four members for
AACN renewal together and save $10 off each - see forms on AACN website.
Don’t forget to renew your annual Chapter membership! Go to the AACN.org website to
obtain a MVC application.
MVC-AACN Newsletter 12
Be sure to join us for the Fall Education program on October 22nd at the Westford
Regency from 8am to 4pm
Bundles, Guidelines and Pearls: Sepsis, PAD & ABCDE
Presented by: Lisa M. Soltis, MSN, APRN, PCCN, CCRN-CSC, CCNS, FCCM and Leanne
Boehm, MSN, RN, ACNS-BC
To register for this class contact Diane Meagher at dianemeagher@comcast.net
* Annual House of Hope Collection * Bring an item or monetary donation and be entered in a raffle.
If you wish to bring an item, see the House of Hope web site (www.hopelowell.org), and open the HOH
Newsletter to see the HOH needs list.
MVC-AACN Newsletter 13
Have a great Fall and Holiday Season and don’t
forget to Be Involved and Step Forward!!
MVC-AACN Newsletter 14