Archive | May 2010

Charles Bonnet Syndrome

A condition that causes patients with visual loss to have complex visual hallucinations.

Etiology:

  1. damage to the eyes
  2. damage to the optic pathways
  3. high risk groups: those affected by macular degeneration resulting in central vision loss in conjunction withwith peripheral vision loss from glaucoma
  4. bilateral optic nerve damage due to methyl alcohol poisoning

Treatement and Management:

Symptom management

Blalock-Taussig Shunt

A surgical procedure where a connection is made between the aorta and  pulmonary artery to allow shunting of blood.

procedure developed in 1944.

Shunt sewn between one of the small arteries off the aorta and the pulmonary artery  to allow blood serving to channel blood to the lungs in patients with cardiac congenital defects where the pulmonary artery is blocked or nonexistent.

Hypoplastic left heart syndrome

A rare congenital heart defect in which the left side of the heart is severely underdeveloped. Portions of the left side of the heart, the mitral valve, left ventricle aortic valve, and aorta do not develop completely.

In patients with this condition, the left side of the heart is unable to sufficiently perfuse the body.

Brain Injury and Post-traumatic Seizures

 

  • patients with head injury are at an increased risk for post-traumatic seizures

 

Classified as:

  • immediate – occuring within 24h of injury
  • early – occuring within 1-7 days of injury
  • late – more than 7 days post injury

 

Seizure prophylaxis refers to the practice of administering antiseizure medications to patients following head injury to prevent the occurence of seizures

  • It is important to prevent post-traumatic seizures, especially in the immediate and early phase of recovery
  • Seizures may increase intracranial pressure and decrease oxygenation of brain tissues
  • Many antiseizure medications impair cognitive performance prolonging the duration of rehabilitation.
  • Therefore the benefits are weighed against the side effects of antiseizure medication administration
  • Research supports the benefits of immediate and early seizure prophylaxis, yet long term prophylaxis benefits are inconclusive

 

Assessments:

  • careful assessment for seizures must be undertaken

 

Risk factors increasing the likelihood of post traumatic seizures are:

  • brain contusions with subdural hematoma
  • skull fracture
  • loss of consciousness or amnesia of 1 day or more
  • traumatic brain injury patient over 65

 

Other complications of traumatic brain injury include:

Systemic infections

  1. pneumonia
  2. urinary tract infection
  3. septicemia

Neurosurgical infections

  1. wound infections
  2. osteomyelitis
  3. meningitis
  4. ventriculitis
  5. brain abscess
  6. heterotrophic ossification (painful bone overgrowth of weight bearing joints)

Day et al. 2009. Textbook of Medical Surgical Nursing. 1st Can. ed. Lippincott Williams and Wilkins.

Anoxic brain injury

when a brain does not receive adequate oxygen, usually resulting from a serious accident where heavy bleeding occurs.

When oxygen levels are significantly low for four minutes or longer, brain cells begin to die and after five minutes permanent anoxic brain injury can occur. Anoxic brain injury which is also called cerebral hypoxia or hypoxic-anoxic injury (HAI) is a serious, life-threatening injury; it can cause cognitive problems and disabilities.

Delirium Tremens and Alcohol Withdrawal Syndrome

 

Delirium Tremens

Alcohol Withdrawal Syndrome: an acute toxic state that occurs as a result of sudden alcohol cessation following prolonged alcohol intake.

Symptoms severity depends on the duration and alcohol quantity ingested.

Delirium Tremens may be precipitated by acute injury or infection such as pneumonia, pancreatitis or hepatitis.

Alcohol Withdrawal Symptoms:

  1. anxiety
  2. uncontrollable fear
  3. tremor
  4. irritability
  5. agitation
  6. insomnia
  7. incontinence
  8. hallucinations (visual, tactile, olfactory, auditory)
  9. Extremely talkative

Autonomic overactivity occurs resulting in:

  1. tachycardia
  2. pupil dilation
  3. profuse perspiration
  4. elevated vital signs
  5. condition is life threatening and carries a high mortality rate

 

Management

  • Goal: to give adequate sedation and support to facilitate patient rest and recovery while preventing injury and peripheral vascular collapse
  • Physical exam is performed to identify preexisting or contributing illness or injury
  • Drug history is obtained to elicit information and facilitate supplementation of sedative requirements
  • Baseline blood pressure obtained as subsequent treatment may depend on blood pressure changes
  • Typically patient is sedated as directed with sufficient dosages of benzodiazapines to establish and maintain sedation
  • Sedation acts to reduce agitation, prevent exhaustion, prevent seizures and promote adequate rest.
  • Sedation guideline: Patient should be calm, able to respond and able to maintain own airway safely

 

Pharmacologic Management:

  1. Chlordiazepoxide
  2. Lorazepam
  3. Clondine

Management of severe symptoms

  1. Haloperidol
  2. Droperidol
  3. Phenytonin (Dilantin) used to prevent repeated withdrawal seizures

 

Dosage adjustment is based on patient’s symptoms of agitation, anxiety level and blood pressure response.

Optimum Environment:

  1. calm nonstressful environment
  2. patient under close supervision
  3. closet or bathroom doors are closed to eliminate shadows
  4. Room lighting remains to minimize potential for illusions of hallucinations
  5. Homicidal or suicidal thoughts may result from hallucinations
  6. Frequent checks and reassurance offered to calm patient
  7. Patient is frequently reoriented to maintain contact with reality

 

The use of restraints:

  • used as prescribed if necessary
  • used when patient is violent or aggressive
  • used when other alternatives have been unsuccessful
  • use of least restrictive device that will effectively prevent patient from injuring self or others
  • caution taken to ensure restraints are applied properly and not impairing circulation or impeding respirations
  • restraints checked and reassessed hourly or as per facility protocol

 

Ongoing Physical observation of the following:

  • skin integrity
  • circulatory status
  • respiratory status
  • patient response documented

 

Fluid losses:

  • result from gastrointestinal losses such as vomiting, profuse perspiration and respiration (hyperventilation)
  • Patient assessed for dehydration as a result of alcohol effect on decreasing antidiuretic hormone
  • oral or IV fluid restoration and electrolyte balancing used as needed
  • Temperature, pulse, respiration and blood pressure are recorded as frequently as q30min for severe delirium tremens in anticipation of peripheral circulatory collapse or hyperthermia

 

Frequent Complications

  • pneumonia
  • trauma
  • hepatic failure
  • hypoglycemia
  • cardiovascular problems
  • Hypoglycemia may accompany withdrawal due to alcohol depleting hepatic glycogen stores
  • Gluconeogenesis may be impaired due to malnourishment
  • Juice and Osmotically balanced drinks may be used to hydrate, replenish sugars and restore electrolyte balance
  • Vitamin supplements are administered to counteract vitamin deficiency
  • Patients referred to alcohol treatment center following delirium tremens resolution for rehabilitation and follow-up.

Day et al. Textbook of Medical Surgical Nursing. 1st Can. ed.Delirium Tremens. p. 2182 and 2186.  Lippincott Williams and Wilkins.

Russell-Silver syndrome

an inherited condition characterized by short stature, skeletal asymmetry, café au lait spots, and a small triangular face.

Etiology:

imprinted gene mutation on chromosome 7 is suggested to be responsible for the Russell-Silver Syndrome phenotype. This gene mutation has been found in 10% of cases (Goto et al, 2000).

Manifestations:

  • Arms and legs of different lengths
  • Cafe-au-lait skin spots
  • Curving of the pinky toward the ring finger
  • Delayed bone age
  • Failure to thrive
  • Gastroesophageal reflux disease
  • Kidney problems, such as:
    • Horseshoe kidney
    • Hydronephrosis
    • Posterior urethral valves
    • Renal tubular acidosis
  • Low birth weight
  • Normal width of head
  • Poor growth
  • Short arms
  • Small stature
  • Short, stubby fingers and toes
  • esophageaomegaly
  • Wide forehead with a small triangle-shaped face and small, narrow chin

 Treatment and Management:

Maintaining caloric intake sufficient to meet growth requirements.

Pharmacologic intervention with Growth hormone.

Physiotherapy to facilitate increased range of motion and mobility.

Goto et al. 2000. Imprinting of Human GRB10 and Its Mutations in Two Patients with Russell-Silver Syndrome. The American Journal of Human Genetics. 67 (2): 476-482.