This document discusses neuromonitoring and cerebral protection strategies for patients with brain injuries. It covers the physiology of the central nervous system, intracranial pressure monitoring, pathophysiology of brain injury, and various methods of central nervous system monitoring including intracranial pressure, brain oxygenation, metabolism, hemodynamics, and electrical activity. Continuous monitoring can help detect secondary insults like hypoxia and ischemia early to guide treatment and minimize further brain damage.
Neuromuscular monitoring, also known as train of four monitoring, is a technique used during recovery from the application of general anesthesia to objectively determine how well a patient's muscles are able to function. It involves the application of electrical stimulation to nerves and recording of muscle response using, for example, an acceleromyograph. Neuromuscular monitoring is typically used when neuromuscular-blocking drugs have been part of the general anesthesia and the doctor wishes to avoid postoperative residual curarization (PORC) in the patient, that is, the residual paralysis of muscles stemming from these drugs.
Scalp block is simple and easy to perform. It has the advantages of minimizing cardiovascular effects and decreasing intraoperative analgesia requirements.
New GCS, the GCS-P was adopted in 2018 by the same person who proposed GCS. It gives better prognosticate outcomes compared to GCS.
This presentation introduces medical professionals and allied healthcare associates to the fundamental rationale, objectives, techniques, and utilizations of intraoperative neurophysiologic monitoring (IONM).
Neuromuscular monitoring, also known as train of four monitoring, is a technique used during recovery from the application of general anesthesia to objectively determine how well a patient's muscles are able to function. It involves the application of electrical stimulation to nerves and recording of muscle response using, for example, an acceleromyograph. Neuromuscular monitoring is typically used when neuromuscular-blocking drugs have been part of the general anesthesia and the doctor wishes to avoid postoperative residual curarization (PORC) in the patient, that is, the residual paralysis of muscles stemming from these drugs.
Scalp block is simple and easy to perform. It has the advantages of minimizing cardiovascular effects and decreasing intraoperative analgesia requirements.
New GCS, the GCS-P was adopted in 2018 by the same person who proposed GCS. It gives better prognosticate outcomes compared to GCS.
This presentation introduces medical professionals and allied healthcare associates to the fundamental rationale, objectives, techniques, and utilizations of intraoperative neurophysiologic monitoring (IONM).
SUMMARY:
- Neurophysiologic monitoring not universally adopted but in many centers has become routine monitor for some surgical procedures
- Ideal neurophysiologic monitoring in the neurosurgical procedure should be: non-invasive (v.s invasive), high sensitivity & specificity, cost effective, easy to use, simple instrumentation, and real time or continous monitoring.
I've relaunched my website http://intraoperativeneuromonitoring.com. To kick things off, I am doing "30 Days Of Neuromonitoring" where I post an IONM article every business day for 30 days starting Oct 3rd. I've also released my CNIM Crash Course Oct 1st. A DABNM Crash Course should be done by December.
Nursing management of the client with increased intracranial pressureANILKUMAR BR
The rigid cranial vault contains brain tissue (1,400 g), blood (75 mL), and CSF (75 mL)
The volume and pressure of these three components are usually in a state of equilibrium and produce the ICP.
ICP is usually measured in the lateral ventricles; normal ICP is 10 to 20 mm Hg. Increased ICP is a syndrome that affects many patients with acute neurologic conditions.
This is because pathologic conditions alter the relationship between intracranial volume and pressure. Although an elevated ICP is most commonly associated with head injury, it also may be seen as a secondary effect in other conditions, such as brain tumours, subarachnoid haemorrhage, and toxic and viral encephalopathies
Acute scrotum is a general term referring to an emergency condition affecting the contents or the wall of the scrotum.
There are a number of conditions that present acutely, predominantly with pain and/or swelling
A careful and detailed history and examination, and in some cases, investigations allow differentiation between these diagnoses. A prompt diagnosis is essential as the patient may require urgent surgical intervention
Testicular torsion refers to twisting of the spermatic cord, causing ischaemia of the testicle.
Testicular torsion results from inadequate fixation of the testis to the tunica vaginalis producing ischemia from reduced arterial inflow and venous outflow obstruction.
The prevalence of testicular torsion in adult patients hospitalized with acute scrotal pain is approximately 25 to 50 percent
Recomendações da OMS sobre cuidados maternos e neonatais para uma experiência pós-natal positiva.
Em consonância com os ODS – Objetivos do Desenvolvimento Sustentável e a Estratégia Global para a Saúde das Mulheres, Crianças e Adolescentes, e aplicando uma abordagem baseada nos direitos humanos, os esforços de cuidados pós-natais devem expandir-se para além da cobertura e da simples sobrevivência, de modo a incluir cuidados de qualidade.
Estas diretrizes visam melhorar a qualidade dos cuidados pós-natais essenciais e de rotina prestados às mulheres e aos recém-nascidos, com o objetivo final de melhorar a saúde e o bem-estar materno e neonatal.
Uma “experiência pós-natal positiva” é um resultado importante para todas as mulheres que dão à luz e para os seus recém-nascidos, estabelecendo as bases para a melhoria da saúde e do bem-estar a curto e longo prazo. Uma experiência pós-natal positiva é definida como aquela em que as mulheres, pessoas que gestam, os recém-nascidos, os casais, os pais, os cuidadores e as famílias recebem informação consistente, garantia e apoio de profissionais de saúde motivados; e onde um sistema de saúde flexível e com recursos reconheça as necessidades das mulheres e dos bebês e respeite o seu contexto cultural.
Estas diretrizes consolidadas apresentam algumas recomendações novas e já bem fundamentadas sobre cuidados pós-natais de rotina para mulheres e neonatos que recebem cuidados no pós-parto em unidades de saúde ou na comunidade, independentemente dos recursos disponíveis.
É fornecido um conjunto abrangente de recomendações para cuidados durante o período puerperal, com ênfase nos cuidados essenciais que todas as mulheres e recém-nascidos devem receber, e com a devida atenção à qualidade dos cuidados; isto é, a entrega e a experiência do cuidado recebido. Estas diretrizes atualizam e ampliam as recomendações da OMS de 2014 sobre cuidados pós-natais da mãe e do recém-nascido e complementam as atuais diretrizes da OMS sobre a gestão de complicações pós-natais.
O estabelecimento da amamentação e o manejo das principais intercorrências é contemplada.
Recomendamos muito.
Vamos discutir essas recomendações no nosso curso de pós-graduação em Aleitamento no Instituto Ciclos.
Esta publicação só está disponível em inglês até o momento.
Prof. Marcus Renato de Carvalho
www.agostodourado.com
Knee anatomy and clinical tests 2024.pdfvimalpl1234
This includes all relevant anatomy and clinical tests compiled from standard textbooks, Campbell,netter etc..It is comprehensive and best suited for orthopaedicians and orthopaedic residents.
Couples presenting to the infertility clinic- Do they really have infertility...Sujoy Dasgupta
Dr Sujoy Dasgupta presented the study on "Couples presenting to the infertility clinic- Do they really have infertility? – The unexplored stories of non-consummation" in the 13th Congress of the Asia Pacific Initiative on Reproduction (ASPIRE 2024) at Manila on 24 May, 2024.
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The prostate is an exocrine gland of the male mammalian reproductive system
It is a walnut-sized gland that forms part of the male reproductive system and is located in front of the rectum and just below the urinary bladder
Function is to store and secrete a clear, slightly alkaline fluid that constitutes 10-30% of the volume of the seminal fluid that along with the spermatozoa, constitutes semen
A healthy human prostate measures (4cm-vertical, by 3cm-horizontal, 2cm ant-post ).
It surrounds the urethra just below the urinary bladder. It has anterior, median, posterior and two lateral lobes
It’s work is regulated by androgens which are responsible for male sex characteristics
Generalised disease of the prostate due to hormonal derangement which leads to non malignant enlargement of the gland (increase in the number of epithelial cells and stromal tissue)to cause compression of the urethra leading to symptoms (LUTS
These lecture slides, by Dr Sidra Arshad, offer a quick overview of physiological basis of a normal electrocardiogram.
Learning objectives:
1. Define an electrocardiogram (ECG) and electrocardiography
2. Describe how dipoles generated by the heart produce the waveforms of the ECG
3. Describe the components of a normal electrocardiogram of a typical bipolar leads (limb II)
4. Differentiate between intervals and segments
5. Enlist some common indications for obtaining an ECG
Study Resources:
1. Chapter 11, Guyton and Hall Textbook of Medical Physiology, 14th edition
2. Chapter 9, Human Physiology - From Cells to Systems, Lauralee Sherwood, 9th edition
3. Chapter 29, Ganong’s Review of Medical Physiology, 26th edition
4. Electrocardiogram, StatPearls - https://www.ncbi.nlm.nih.gov/books/NBK549803/
5. ECG in Medical Practice by ABM Abdullah, 4th edition
6. ECG Basics, http://www.nataliescasebook.com/tag/e-c-g-basics
Flu Vaccine Alert in Bangalore Karnatakaaddon Scans
As flu season approaches, health officials in Bangalore, Karnataka, are urging residents to get their flu vaccinations. The seasonal flu, while common, can lead to severe health complications, particularly for vulnerable populations such as young children, the elderly, and those with underlying health conditions.
Dr. Vidisha Kumari, a leading epidemiologist in Bangalore, emphasizes the importance of getting vaccinated. "The flu vaccine is our best defense against the influenza virus. It not only protects individuals but also helps prevent the spread of the virus in our communities," he says.
This year, the flu season is expected to coincide with a potential increase in other respiratory illnesses. The Karnataka Health Department has launched an awareness campaign highlighting the significance of flu vaccinations. They have set up multiple vaccination centers across Bangalore, making it convenient for residents to receive their shots.
To encourage widespread vaccination, the government is also collaborating with local schools, workplaces, and community centers to facilitate vaccination drives. Special attention is being given to ensuring that the vaccine is accessible to all, including marginalized communities who may have limited access to healthcare.
Residents are reminded that the flu vaccine is safe and effective. Common side effects are mild and may include soreness at the injection site, mild fever, or muscle aches. These side effects are generally short-lived and far less severe than the flu itself.
Healthcare providers are also stressing the importance of continuing COVID-19 precautions. Wearing masks, practicing good hand hygiene, and maintaining social distancing are still crucial, especially in crowded places.
Protect yourself and your loved ones by getting vaccinated. Together, we can help keep Bangalore healthy and safe this flu season. For more information on vaccination centers and schedules, residents can visit the Karnataka Health Department’s official website or follow their social media pages.
Stay informed, stay safe, and get your flu shot today!
Tom Selleck Health: A Comprehensive Look at the Iconic Actor’s Wellness Journeygreendigital
Tom Selleck, an enduring figure in Hollywood. has captivated audiences for decades with his rugged charm, iconic moustache. and memorable roles in television and film. From his breakout role as Thomas Magnum in Magnum P.I. to his current portrayal of Frank Reagan in Blue Bloods. Selleck's career has spanned over 50 years. But beyond his professional achievements. fans have often been curious about Tom Selleck Health. especially as he has aged in the public eye.
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Introduction
Many have been interested in Tom Selleck health. not only because of his enduring presence on screen but also because of the challenges. and lifestyle choices he has faced and made over the years. This article delves into the various aspects of Tom Selleck health. exploring his fitness regimen, diet, mental health. and the challenges he has encountered as he ages. We'll look at how he maintains his well-being. the health issues he has faced, and his approach to ageing .
Early Life and Career
Childhood and Athletic Beginnings
Tom Selleck was born on January 29, 1945, in Detroit, Michigan, and grew up in Sherman Oaks, California. From an early age, he was involved in sports, particularly basketball. which played a significant role in his physical development. His athletic pursuits continued into college. where he attended the University of Southern California (USC) on a basketball scholarship. This early involvement in sports laid a strong foundation for his physical health and disciplined lifestyle.
Transition to Acting
Selleck's transition from an athlete to an actor came with its physical demands. His first significant role in "Magnum P.I." required him to perform various stunts and maintain a fit appearance. This role, which he played from 1980 to 1988. necessitated a rigorous fitness routine to meet the show's demands. setting the stage for his long-term commitment to health and wellness.
Fitness Regimen
Workout Routine
Tom Selleck health and fitness regimen has evolved. adapting to his changing roles and age. During his "Magnum, P.I." days. Selleck's workouts were intense and focused on building and maintaining muscle mass. His routine included weightlifting, cardiovascular exercises. and specific training for the stunts he performed on the show.
Selleck adjusted his fitness routine as he aged to suit his body's needs. Today, his workouts focus on maintaining flexibility, strength, and cardiovascular health. He incorporates low-impact exercises such as swimming, walking, and light weightlifting. This balanced approach helps him stay fit without putting undue strain on his joints and muscles.
Importance of Flexibility and Mobility
In recent years, Selleck has emphasized the importance of flexibility and mobility in his fitness regimen. Understanding the natural decline in muscle mass and joint flexibility with age. he includes stretching and yoga in his routine. These practices help prevent injuries, improve posture, and maintain mobilit
Prix Galien International 2024 Forum ProgramLevi Shapiro
June 20, 2024, Prix Galien International and Jerusalem Ethics Forum in ROME. Detailed agenda including panels:
- ADVANCES IN CARDIOLOGY: A NEW PARADIGM IS COMING
- WOMEN’S HEALTH: FERTILITY PRESERVATION
- WHAT’S NEW IN THE TREATMENT OF INFECTIOUS,
ONCOLOGICAL AND INFLAMMATORY SKIN DISEASES?
- ARTIFICIAL INTELLIGENCE AND ETHICS
- GENE THERAPY
- BEYOND BORDERS: GLOBAL INITIATIVES FOR DEMOCRATIZING LIFE SCIENCE TECHNOLOGIES AND PROMOTING ACCESS TO HEALTHCARE
- ETHICAL CHALLENGES IN LIFE SCIENCES
- Prix Galien International Awards Ceremony
Lung Cancer: Artificial Intelligence, Synergetics, Complex System Analysis, S...Oleg Kshivets
RESULTS: Overall life span (LS) was 2252.1±1742.5 days and cumulative 5-year survival (5YS) reached 73.2%, 10 years – 64.8%, 20 years – 42.5%. 513 LCP lived more than 5 years (LS=3124.6±1525.6 days), 148 LCP – more than 10 years (LS=5054.4±1504.1 days).199 LCP died because of LC (LS=562.7±374.5 days). 5YS of LCP after bi/lobectomies was significantly superior in comparison with LCP after pneumonectomies (78.1% vs.63.7%, P=0.00001 by log-rank test). AT significantly improved 5YS (66.3% vs. 34.8%) (P=0.00000 by log-rank test) only for LCP with N1-2. Cox modeling displayed that 5YS of LCP significantly depended on: phase transition (PT) early-invasive LC in terms of synergetics, PT N0—N12, cell ratio factors (ratio between cancer cells- CC and blood cells subpopulations), G1-3, histology, glucose, AT, blood cell circuit, prothrombin index, heparin tolerance, recalcification time (P=0.000-0.038). Neural networks, genetic algorithm selection and bootstrap simulation revealed relationships between 5YS and PT early-invasive LC (rank=1), PT N0—N12 (rank=2), thrombocytes/CC (3), erythrocytes/CC (4), eosinophils/CC (5), healthy cells/CC (6), lymphocytes/CC (7), segmented neutrophils/CC (8), stick neutrophils/CC (9), monocytes/CC (10); leucocytes/CC (11). Correct prediction of 5YS was 100% by neural networks computing (area under ROC curve=1.0; error=0.0).
CONCLUSIONS: 5YS of LCP after radical procedures significantly depended on: 1) PT early-invasive cancer; 2) PT N0--N12; 3) cell ratio factors; 4) blood cell circuit; 5) biochemical factors; 6) hemostasis system; 7) AT; 8) LC characteristics; 9) LC cell dynamics; 10) surgery type: lobectomy/pneumonectomy; 11) anthropometric data. Optimal diagnosis and treatment strategies for LC are: 1) screening and early detection of LC; 2) availability of experienced thoracic surgeons because of complexity of radical procedures; 3) aggressive en block surgery and adequate lymph node dissection for completeness; 4) precise prediction; 5) adjuvant chemoimmunoradiotherapy for LCP with unfavorable prognosis.
micro teaching on communication m.sc nursing.pdfAnurag Sharma
Microteaching is a unique model of practice teaching. It is a viable instrument for the. desired change in the teaching behavior or the behavior potential which, in specified types of real. classroom situations, tends to facilitate the achievement of specified types of objectives.
3. INTRODUCTION
• Primary aim mx – minimize secondary injury by
maintaining cerebral perfusion and oxygenation
• Mech of secondary injury – triggered by secondary
insults, subtle and remain undetected by the usual
systemic physiological monitoring
• Continuous monitoring can serve 2 functions :
1) Early detection
2) Monitor therapeutic interventions
4. CNS PHYSIOLOGY
• Brain
• 2% body weight
• 15% CO
• Energetic tissue, utilize
• 3-5 mls O2/min/100gm
• 5mg glucose/min/100gm
• Brain energy
• 60% sustain synaptic function
• 40% maintain cellular integrity
5. • CBF 50ml/min/100gm
• Any disruption to CBF, produce rapid demise
to brain tissue
• The magnitude of reduce CBF and its duration
– primary determinant of ischemic injury and
neurological outcome
6. INTRACRANIAL PRESSURE
• The pathophysiology of brain injury are complex
• Major factors influencing outcome in patients with acute
brain injury are the secondary cerebral insults – hypoxia and
ischemia
• These secondary insults cause permanent neurological
damage and worsening outcome if undetected and
untreated
• The purpose of continuous brain monitoring is to detect
these insults and inform approach to treatment
• CT scan and MRI – useful info but not continuous and bed
side investigation
7. RELATIONSHIPS BETWEEN CBF AND
CHANGES IN BP, PaO2 AND PaCO2
CBF remains constant over a
range of BP but varies with
• Age – shifted to left in
newborns
• Chronic hypertension – to the
right
CBF varies linearly with PaCO2
• Doubling PaCO2 doubles CBF
• Halving PaCO2 halves CBF
CBF is affected with severe
hypoxemia
9. Primary brain damage
• Many etiologies:
• Vascular insufficiency or disruption
• Trauma
• Infection or inflammation
• Tumour
• Metabolic and nutritional derangement
10. Global brain injury
• Hypoxemia, cardiovascular insufficiency or arrest lead to
hypoxic and low or no flow states or complete
hypoperfusion of entire organ
• No potential for recruitment of collateral flow
• Recovery depend on severity and duration of insult
• After 5-6 min have permanent histological damage and
neurological deficit in survivors
• Outcome worsens significantly after 15 min
11. Focal brain injury
• Occlusion of an arterial distal to circle of willis
• Permit some collateral flow
• Dense ischaemic core with a partially perfused
surrounding penumbral zone and tissue more
salvageable and target for neuroprotection
• The time course for infarction and irreversible
damage around 30-60 mins
12. Area of ischemia and damage
• Area of infarction/ damage =
zero CBF
• Penlucida = ischemic area,
cerebral function is abolished
• CBF < 6ml/100g/min
• Penumbra = ischemic area
potential for restoration of
cerebral function
• CBF + 6-15ml/100g/min, maintain
cellular integrity but no synaptic
function
13. CBF (ml/min per 100g brain) CHANGES
50 Normal
25-30 Abnormal EEG
15-25 Loss of electrical activity (i.e;
isoelectric EEG)
10-15 Sufficient to maintain ATP to
support ionic pump funtion
≤10 Membrane failure due to a critical
loss of ATP, which causes ionic
imbalance between the cell and
the extracellular
<10 + prolonged (min) + worsened Permanent neurological
impairment due to cell death
14. Secondary brain damage
• As a sequence of primary insult
• Reflect physiological consequence of ischemia reduction in
CBF & metabolism, hydrocephalus & herniation, shift vital
structures & axonal disruption pressure effects to underlying
brain region
• Neural injury is worsen by
• Hypoxemia
• Hypercapnia
• Hyperglycemia
• Hypotension
• Hypothermia
• Anemia
• Electrolyte imbalance
15. CNS MONITORING
• General monitoring brain injury patient
include;
• Continuous IABP – ABG analysis and blood
glucose
• Pulse oxymeter
• ETCO2 – early correction of hypercapnia induce
high ICP
• CVP
• Temperature
• Clinical monitoring - GCS
16. SPECIFIC MONITORING
• Brain specific monitoring
• Pressure within the cranial cavity (ICP)
• Changes in brain oxygenation
• Metabolism (jugular venous oxygen saturation,
brain tissue monitoring)
• Cerebral hemodynamics (transcranial doppler)
• Electrical activity of the CNS
17. INTRACRANIAL PRESSURE
MONITORING
• ICP is defined as the pressure within the rigid
cranial vault relative to atmospheric pressure
• Normal ICP ranges between 5-15 mmHg
• Two components – a vasogenic (vascular)
component and a cerebrospinal fluid (CSF)
component
18. The relationship between ICP & the
volume of the skull contents
A – the compensation phase
•A large increase in volume, a little
increase in ICP
B – the pressure buffering system is
exhausted
•A small increase in volume, a large
increase in ICP
C – the steep part of the curve
•Increase ICP, reduce the CPP
profoundly
•Therefore increase MAP to maintain
CPP
19. ICP monitoring provide
• Continuous monitoring of pressure changes within the
intracranial cavity
• Acute rises in ICP occur when the compensatory mech
which control ICP (e.g, CSF production and outflow,
changes in cerebral blood flow and volume) are exhausted
• A small rise in intracranial volume results in a large rise in
ICP
• Pressure > 20mmHg are regarded as abnormal and usually
requires intervention to reduce ICP
20. Indications
• Severe head injury (GCS 3-8 • Tumour - obst hydrocephalus
following resuscitation)
• Vascular abn – AVM / aneurysm
• Abnormal CT scan – contusion, a/w obst hydrocephalus
edema, hematoma & compressed
basal cisterns • Postop on cerebral protection
• Severe head injury but has a
normal CT scan; however 2 or
more of the following findings are
present at admission:
• Age >40
• Uni or bilateral motor posturing
• Systolic hypotension ( ≤90 mmHg
21. Methods measuring ICP
• Common sites : intraventricular, intraparenchymal, subdural
and extradural
• Intraventricular drains allow direct measurement of ICP and
advantage of allowing CSF withdrawal when ICP rises
• Gold standard monitoring
• Cath inserted at lateral ventricle
• Zero reference pt at level of foramina of Monroe / ext
auditory meatus
• Insertion difficult or impossible brain swelling
• Risk of infection
• Continuous CSF drainage, measurement of ICP unreliable
22. • Intraparenchymal monitor
• Inserted through a support bolt or tunnelled
subcutaneous from burr hole either at bedside
or post craniotomy
• Common site frontal lobes
• Easy to insert
• Low risk of infection
23. • Subdural catheters are easily inserted but
measurement are unreliable and easily block
• Extradural probes are less reliable and less
specific due to uncertainty about the
relationship between ICP and pressure in the
extradural space
26. Advantages Disadvantages
Epidural catheter •Lower risk of infection •Decreased accuracy
•No transducer adjustment sensing through dura
with head movement •Unable to drain CSF
•Unable to recalibrate
or zero after placement
Subarachnoid •No penetration of brain •Unable to drain CSF
bolt /screw •Decreased risk of infection •Transducer
•Able to sample CSF repositioning with head
movement
•Direct pressure
measurement •Requires intact skull
•High pressure may
cause herniation of brain
tissue into bolt
27. Advantages Disadvantages
Ventriculostomy •CSF drainage and •Risk of intracerebral
catheter bleeding or edema along
sampling cannula track
• Direct •High risk for infection
measurement •Transducer
of pressure repositioning
with
head movement
Fiberoptic •Versatile, may be •Separate monitoring
catheter placed in ventricle or system required
subarachnoid space •Catheter relatively
• No adjustment of fragile
•Unable to recalibrate or
transducer with head rezero after placement
28. • Normal ICP 5-15 mmHg
• Active management when ICP 25-30 mmHg
• The normal ICP waveform contains 3 phases:
• P1 (percussion wave) from arterial pulsation
• P2 (rebound wave) reflects intracranial
compliance
• P3 (dicrotic wave) represent venous pulsation
29. normal ICP waveform - three peaks within
the cardiac cycle
first peak (P1) is called the percussion wave,
P2 is the tidal wave and
P3 is the dicrotic wave
30. • first peak (P1) is called the percussion wave,
• arterial pressure being transmitted from the choroid
plexus
• Arterial hypotension and hypertension affect the
amplitude of P1;
• severe hypotension causes a decrease in amplitude
whereas severe hypertension causes an increase in
amplitude
• P2 is the tidal wave and
• varies in amplitude with brain compliance and ends on
the dicrotic notch
• P3 is the dicrotic wave
• caused by closure of the aortic valve
31. ICP Wave Analysis
• Begins with understanding its shape and amplitude.
• The shape of the ICP waveform resembles the shape of the
arterial waveform.
• The amplitude, or height of the waveform, varies with changes in
physiologic state and is influenced by changes in intracranial
compliance and cerebral blood flow
• As the ICP increases due to an excess of components within the
cranial vault, the amplitude of P1, P2, and P3 all increase,
• but if the ICP continues to rise, P2 becomes more elevated than
P1 until eventually P1 may disappear within the waveform .
• This signifies a decrease in intracranial compliance and may warrant
intervention
34. ICP: b-waves II
b-
B-waves are frequent elevations (up to 50mmHg)
lasting several seconds
- Suggestive of poor intracranial compliance
35. A waves or plateau waves comprise a steep increase ICP
from normal value & persisting 5-20mins. Always
pathological and occur in reduce IC compliance. Long
lasting waves (several mins) indicative of diffuse cerebral
ischemia, and often precede herniation.
36. JUGULAR BULB OXIMETRY
• Blood from the venous sinuses of brain drains into
IJV
• Monitoring oxygen saturation in JV blood gives an
estimation the balance of global oxygen delivery
and cerebral metabolism
• Tech involves inserting a retrograde cath into IJV
and advancing cephalad
• Correct cath placement is level of mastoid process
and confirm by lateral neck x-ray
37. • Normal range SjvO2 60-75%, less than 50%
associated with worsen outcome in head injury
• Limitation - regional or small area of ischaemia
may not detected
38.
39. Physiology of jugular venous
oxygenation
• Clinical measurementof SjvO2, reflect the
balance of oxygen supply and consumption of
the brain
• SjvO2 reflects an average value from the
whole brain and cannot detect focal changes
in CBF
• Sjv02 < 55% indicates brain hypoxia
40. • Reduced SjvO2 values • Elevated SjvO2
• Vasoconstriction induced • Hyperaemic phase of TBI
by low PaCO2 • Hypercapnia induced
• Hypoxemia vasodilatation
• Anemia • Brain death (brain cells
• Insufficiency low CPP cease to extract O2)
• Inapp high CPP
41. BRAIN TISSUE OXYMETRY
• Brain tissue oxygenation can be monitored
with an oxygen sensitive microelectrode place
in brain parenchymal
• Accurate to area 15mm2 around the probe
• Aim to detect evolving brain injury before
global sign brain injury become apparent
• Critical PbrO2 ~ 1.3-7 kPa
42. MICRODIALYSIS
• Continuous monitoring of changes in brain
chemistry
• Inserted at risk tissues – next to hematoma /
brain injury
• Monitoring markers of brain ischaemia and cell
damage e.g; lactate, pyruvate, glycerol,
glutamate and glucose
• Lactate-pyruvate ratio >25 – indicate focal
ischaemia
• Glycerol elevated in TBI, seizure and secondary
brain damage
43. TRANSCRANIAL DOPPLER
ULTRASONOGRAPHY
• Non invasive monitoring – measures flow
velocities in basal cerebral arteries
• Normal MCA velocity : 60-70 cm/s
• Normal ICA velocity : 40-50 cm/s
• MCA:ICA = 1.76
• High velocity states – cerebral vasospasm or
hyperaemia
44. ELECTROPHYSIOLOGY
ELECTROENCEPHALOGRAM (EEG)
• EEG represents spontaneous electrical activity of
cerebral cortex
• Summation of excitatory and inhibitory post
synaptic potential of cortical neurons
• Not reflect activity in subcortical , cranial nerves
and spinal cord
• Important tools in investigations and
management of epilepsy and detect ischaemic
cerebral event
45. • EEG wave
• Recorded from the scalp / surface of the brain
• Summation of extracellular current fluctuations :
excitatory and inhibitory synaptic potentials
(EPSP & IPSP)
• Surface negative waves : summation of EPSP’s
• Surface positive waves : summation of IPSP’s
• EEG recorded from the scalp is attenuated and
filtered by tissues between the brain and
recording
46. Anaesthetic effects on EEG
Awake
high frequency, low amplitude
Light anesthesia
increase amplitude
slow frequency
Deep Anesthesia
Burst suppression
Isoelectric EEG
47. Goal for EEG monitoring
• To assess :
• Cerebral ischemia
• Cerebral protection
• Epilepsy surgery
49. Bispectral index scores
• Electroencephalogram (EEG) monitor display
analog score 1 to 100
• Represent patient level of awareness
• 100 – fully awake
• 65-85 – recommended for sedation
• 40-65 – general anesthesia
• 1- complete lack of brain activity
• However in comparison with MAC, BIS poorly
predicts a movement or non-movement response,
esp in the presence of opiates
• Inaccurate with ketamine
50.
51. SOMATOSENSORY EVOKED
POTENTIALS (SSEPs)
• SEP is a time locked event related, pathway
specific electroencephalographic activity
generated in response to a specific stimulus such
as electrical stimuli.
• The SSEPs recorded in response to stimulation of
the median nerve, ulnar nerve and posterior tibial
nerve monitor the integrity of the respective
pathways from the periphery to the cortex.
• Routine monitor for surgical procedure on the
spinal column with potential risk to the spinal cord
52. • As with EEG, ischemia/hypoxia leads to
depression of conduction with resultant
decrease in amplitude and increase latency of
the specific peaks
• For SSEPs, 50% reduction in amplitude from
baseline in response to a specific surgical
maneuver is generally accepted to be a
significant change warranting alteration of
surgical strategy to avert potential damage
53. • As with EEG, anesthetic agents influence cortical
evoked potentials.
• Unlike EEG, SSEPs resist the influence of intravenous
agents.
• Although the amplitude maybe slightly reduced and
the latency increased, cortical SSEPs can be recorded
• In contrast, inhalational cause a dose related decrease
in amplitude and increase in latency
• Opioids have negligible effects on SSEP.
54. MOTOR EVOKED POTENTIALS
(MEP)
• Because SSEP monitors only the integrity of the
sensory pathway, it is theoretically possible to miss an
injury specifically affecting the motor pathway but
sparing the sensory tracts.
• Thus, MEP recording was introduced to complement
SSEP recording.
• An electromyographic potential recorded over
muscles in the hand or foot in response to
depolarization of the motor cortex.
• Depolarizaton can be achieved using transcranial
magnetic or electrical stimulation.
56. INTRODUCTION
• Cerebral protection – interventions aimed to
reduce neuronal injury that instituted before
possible ischaemic / hypoxic event
• Cerebral resuscitation – interventions that
occur after such event
57. Indication for cerebral
protection
• Majority associated with high ICP:
• Cerebral oedema
• Post myocardial infarction
• Post cranial surgery
• Seizures
• Head injury
• Cerebral hypoxia
• Post cardio respiratory arrest
• Brain infection
• Space occupying lesion
58. Aims:
• Prevent further cerebral damage
• Reverse cerebral damage
• Improve cerebral functions and neurological
outcome
• Maintain of cerebral perfusion
• Maintain of systemic hemodynamics
• Maintain adequate oxygenation and ventilation
59. Methods
• Various methods to reduce intracranial
pressure
• Physiological manipulation
• Pharmacological
• Physical manipulation
60. Physiological manipulation
1) Mechanical ventilation
• To maintain PaCO2 normocapnia between 35-40
mmHg
• ICP reduced by 30% per 10mmHg reduction in CO2
• Avoid hypoxia – cytotoxic cerebral oedema
• For how long? 24-48H only
• After 48H, acute changes in hyperventilation return
to normal value owing to normalize CSF pH and
compensatory to CSF volume
• Can be repeated if needed : interval of 12-24 H in
between cerebral resuscitation
61. 2) Hypothermia
• Each 1°C reduction can reduce CMRO2 by 7%
• Aim for mild (33-34°C) to moderate (26-31°C)
hypothermia
• Avoid shivering- increase CMRO2 & CBF, may
require muscle relaxant
62. 3) Hypertension
• Aim
To limit ischemia by increasing regional CBF
To overcome regional vasospasm
Done usually with drugs - vasopressors
• During ischemia
Autoregulation is impaired
CBF is pressure dependent
• Maintain CPP 70-80 mmHg
63. Pharmacological
• Sedation and neuromuscular blockade
• IV anaesthetic agent decreased cerebral
metabolism and reduce CBF
• Propofol more potent than benzodiazepine
• Opioid min effect on cerebral metabolism and
CBF
• Routine use NMB should be avoided
• Prevent raise ICP during straining and
coughing
• Impossible to recognized the seizure
• Long term polyneuropathy and myopathy
64. • Anticonvulsant
• Severe TBI – 20% seizures
• Highest in depressed skull fractures, IC
hematoma and contusion
• Efficient in reducing of early post traumatic
seizure
• First line therapy – phenytoin ( a week duration)
65. Fluid management and
glycaemic control
• Aim fluid management provide adequate
hydration
• Hypotonic fluid (dextrose) may exacerbate
brain edema
• High plasma levels of glucose associated with
poor outcome from TBI
66. Osmotherapy
• Mannitol
• Increase plasma osmolality – withdrawal of brain
across bbb
• Reduction ICP after 20-30mins
• Need to monitor plasma osmolality, not > 320
mosmol/ml
• Hypertonic saline (5or 7.5%)
• Reduces brain water by establish osmotic gradient
across bbb
• Hypernatremia, <155 mmol/L
• Cause tissue necrosis and thrombophlebitis
67. Barbiturate coma
• Barbiturates decreases ICP – reduce CMRO2
and CBF
• Can lower ICP refractory to other measures
• Dose titrated to burst suppression on EEG
68. Physical manipulation
1) Patient position
Important for both prevention and treatment of
elevated ICP
Aim :
Allow proper cerebral venous drainage (venous return)
Maintain the head and neck elevated 30°
Maintain neutral position
Avoid obstruction to jugular vein i.e; ETT anchoring,
cervical collar
Avoid increase in intrathoracic & intraabdominal
pressure
69. Avoid ;
Excessive stimulation e.g suctioning, only do it
when necessary
Sudden movement to head
Rough handling of patient
Painful stimulation
Hyperthermia >38°C
70. Surgical intervention
1) Ventriculostomy / CSF drainage
Eg; EVD, VP shunt
1) Decompressive surgery
Decompressive craniectomy part of skull is
removed
Decompressive lobectomy brain parenchymal is
resected either from non dominant temporal or
frontal lobe