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Cerebral Perfusion Pressure Case Study (60 min)

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Mrs. Ramirez is a 61 year old female who presents to the Emergency Department (ED) complaining of a headache and fatigue. Her temperature is 102.6°F and nuchal rigidity is noted when trying to flex Mrs. Ramirez’s neck. The charge nurse suspects she has meningitis and immediately places her in a closed room under droplet precautions.

Critical Thinking Check
Bloom's Taxonomy: Application

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The provider performs a lumbar puncture which shows elevated white blood cell count and a decreased glucose level. Mrs. Ramirez’s temperature has increased to 103.5°F. She is oriented x 3, but drowsy. The provider starts her on IV antibiotics as ordered and initiates q1h neuro checks. 

Critical Thinking Check
Bloom's Taxonomy: Comprehension

What should be included in your routine q1h neuro exam?

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Critical Thinking Check
Bloom's Taxonomy: Application

What additional adjunct assessments could be included in your neuro exam?

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Mrs. Ramirez is admitted to the ICU. She receives 1g Acetaminophen PO for her fever. One hour after admission to the ICU, you go to reassess Mrs. Ramirez’s neuro status. You find that she is somnolent, oriented x 1, and her pupils are unequal (right larger than left) but reactive to light.

 

Critical Thinking Check
Bloom's Taxonomy: Application

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Critical Thinking Check
Bloom's Taxonomy: Analysis

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The CT scan shows a large amount of edema on the right side of Mrs. Ramirez’s brain, as well as some hydrocephalus. The ICU Provider determines Mrs. Ramirez will need an External Ventricular Drain (EVD).  The EVD is inserted successfully and shows an ICP of 17 mmHg. The patient’s vital signs are as follows:

BP 122/52 MAP 75

HR 78 RR 32

SpO2 96% Room Air Temp 102.9°F

Critical Thinking Check
Bloom's Taxonomy: Application

Calculate the patient’s Cerebral Perfusion Pressure (CPP). Is it sufficient? What is the goal? What is the risk if the CPP falls too low?

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Critical Thinking Check
Bloom's Taxonomy: Analysis

What interventions could be requested from the provider to keep the patient safe??

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The EVD is open to drain at 10 cmH2O (7-8 mmHg). It is draining a moderate amount of serosanguineous fluid. Mrs. Ramirez is confused and begins to get agitated. She is placed in bilateral soft wrist restraints for safety and to prevent her from pulling out the EVD. She continues to pull at the restraints and is thrashing in bed. She is drooling excessively and doesn’t seem to be able to swallow effectively as she keeps coughing. Her ICP is reading 14 mmHg. Her BP is 92/44, MAP 60.

Critical Thinking Check
Bloom's Taxonomy: Application

Calculate the patient’s CPP. Is it sufficient? Explain.

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Critical Thinking Check
Bloom's Taxonomy: Analysis

What interventions could be requested from the provider to keep the patient safe?

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  • Mrs. Ramirez is intubated and sedated in order to minimize her ICP and keep her safe. She continues to receive IV antibiotics and corticosteroids.  Four days later she is able to be weaned safely from sedation and can be extubated. She is calm and oriented x 3. Her ICP is reading between 5-8 mmHg. Her repeat CT scan shows the edema has decreased, so the provider removes the EVD.
  • Critical Thinking Check
    Bloom's Taxonomy: Analysis

    What assessment findings would indicate increasing ICP after removal of the EVD?

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