Aneurysms

Pathology:
A cerebral aneurysm is an area of arterial vessel wall (obviously located in the brain) that is locally dilated causing weakening and is at increased risk of rupture.


Just in case you want to show off your mad brain skills remember that most aneurysms occur at Circle of Willis. The circle of who you ask? Willis! No, Bruce Willis does not not receive royalties for the use of his name. The circle of Willis is a bifurcation (splitting) of large arteries at the base of the brain. Here is where you say: “Ohhhhhh, now I understand why an aneurysm is bad!”. When an aneurysm ruptures it commonly ruptures into the subarachnoid space of the basal cisterns (i.e. creating a subarachnoid hemorrhage), but it can rupture into the ventricles or into brain tissue itself.

And This Is A Problem Why?

    While in the PICU you probably won’t see a patient PRIOR to their aneurysm rupturing, but you just never know!
“Pre” Aneurysm s/s:
- Localized Headaches
- Stiff neck (i.e. nuchal rigidity)
- pain above and behind the eye
- photophobia (sensitivity to light)
- Dilated pupil(s)
- Extraocular deficit (the eye can’t move normally or is altered in gaze)
- Ptosis (‘cause you’re really smart this term comes from a Greek word meaning to “fall”. Ptosis is when either the upper or lower eyelid droops).

“Post” Aneurysm
- “The worse headache of my LIFE!”
- Photophobia
- Vomiting
- Decreased level of consciousness, even unresponsiveness
- Nuchal rigidity
- If your Neurosurgeons are on the ball and have placed some form of ICP monitoring you may see Increased ICPs.
- Hemodynamic instability
- Cognitive changes.

Tests And Bodily Fluids

    First, hopefully the ED has done their job and got your patient’s lab work, head CT,. and IV access. But, that doesn’t always happen. Here is a little list of what you patient should or will need.
*Emergent head CT (without contrast)
*possible EKG - Especially if there has already been some disrhythmias
*Complete Blood Count/platelet count; PT/PTT (clotting studies)/INR, BMP
*MRI
*possible Arteriography or an Angiograph (both will look extensively at the vessels in the head)

There Ain’t No Going Back Now

    What do you as a nurse need to know, and watch for?
- Q1 hour neurologic checks. Look out for s/s of cerebral herniation especially around 72 hours post bleed.
- If you have an ICP monitor in you will see increasing ICP.
- Decreased level of consciousness (LOC) or altered LOC
- Pupillary changes (dilation on the side of herniation)
- Respiratory pattern changes (i.e. altered rate, decreased pO2, increased CO2, decreased pH)
- Headache
- Nausea and/or vomiting
- Posturing or Seizures
- Sudden bulging or tense fontanel
- Cushing’s Triad (the combined s/s are seen late) - “Danger Will Robinson, danger!”
- Widening Pulse Pressure
- Bradycardia
- Abnormal Respirations
- Keep the patient NPO, it’s always bad ju ju to eat before the OR, and if possible Neurosurgery will want to take the patient to evacuate the bleed.
- Make sure your patient has enough oxygen (i.e. for starters your pulse ox should be >95%)

- If your patient is already in a bad spot they may be intubated.

- Remember the point is to make as much oxygen available to the brain as we can. Did you know: brain cells survive only about 3-4 minutes when deprived of blood and oxygen? That said every element of care given to a patient increases their O2 consumption. Even poor sedation increase O2 requirements!!!

- Keep them normothermic
- You may need the head of bed flat if the patient’s blood pressure won’t tolerate.
- Maintain fluid balance with Saline baby, none of the LR crap!
- Drug them! Antiepileptics, sedation, or even possibly Pentobarbital coma.

Speaking of Drugs...


- Mannitol - Think of it like Lasix for the brain - remember there are three main components within the skull, and only so many ways to moderate them.


- 3% Saline - This is also a brain diuretic of sorts...it promotes osmotic diuresis. Keep an eye on your patient's serum sodium levels as 3% increases it!


- Analgesia/Anethetics/Barbiturates - i.e. Morphine/Fentanyl/Ativan/Pentobarbital


Please remember that depenting on what else is happening with your patient the medications they require will vary. Also, for most neurologic diagnosis you will use the same drugs.