Brain Code: A Standardized Response to a Neurological Emergency

POSTER

Brain Code: A Standardized Response to a Neurological Emergency Erin Szemak, BSN, RN, DNP Student BACKGROUND  Prolonged intracranial hypertension (IH) is a neurological emergency  Intracranial hypertension (IH) is a “brain code”, which without proper intervention can compromised cerebral blood flow and lead to cerebral herniation, coma and death  Common acute care conditions can lead to IH, including stroke, traumatic brain injury, brain tumor, and encephalopathies  Standardized clinical practice guidelines in the acute care setting have resulted in improved efficiency, better outcomes, and decreased expenditures  No standardized guideline exists for IH at a local tertiary hospital PURPOSE  Create a standardized guideline to facilitate rapid identification and treatment of IH at a local tertiary hospital OBJECTIVES 1. Create a brain code guideline for chosen facility 2. Present brain code guideline to neurocritical care providers at chosen facility 3. Provide education on IH to nursing staff outside of neurocritical care 4. Disseminate brain code guideline by participating in clinical poster presentation at local medical conference GUIDELINE TREATMENT    HYPERVENTILATION Using bag-valve mask or ventilator EtCO2 monitoring with a goal of 30-35 Temporary measure that should not exceed six hours HYPEROSMOLAR THERAPY Given simultaneously:  If only PIV access: • 3% NaCl 500mL bolus (preferably in a large vessel PIV) • 20-25% Mannitol bolus 0.5-1 g/kg • Start 1.8% NaCl @ 100mL/hr until CVC in place • If placing a central line during a brain code, place femoral line. DO NOT place SC or IJ  If CVC access: • 23.4% NaCl 3% NaCl 500mL bolus • 20-25% Mannitol bolus 0.5-1 g/kg • Start 3% NaCl @ 50mL/hr    IMMEDIATELY CALL NEURO PROVIDER WITH RESULTS If ICH, see ICH protocol If SAH, see SAH protocol If normal, call ASERT and follow ischemic stroke protocol NONCONTRAST CT SCAN BLOOD PRESSURE MANAGEMENT  Avoid hypotension by maintaining MAP >60 SEDATION CONSIDERATIONS  For patients requiring sedation, DO NOT sedate prior to the completion of a formal neuro exam  IF ETT in place administer Propofol. Otherwise, use Fentanyl, Ketamine, or Precedex TEMPERATURE  If hyperthermic, initiate cooling measures to normalize temperature, with a goal of 36.5-37.5C • Tylenol • Mechnical cooling  Avoid shivering METHODS  Brain code guideline was created by incorporating Emergency Neurological Life Support recommendations, evidence-based practices, and current practices at chosen facility  Guideline was presented to neurocritical care providers at chosen facility  Educational presentation on IH and brain code guideline were given to a group of nurses at chosen facility  Brain code guideline was disseminated during a clinical poster presentation at a local medical conference RESULTS  Feedback received from neurocritical care providers allowed for further revisions  Following education on IH, there was a 45% positive change between pre-/post-test results  All nurses who reviewed the brain code guideline found it to be feasible, useable, and felt it could improve their ability to respond to this neurological emergency FUTURE IMPLICATIONS  Piloting the guideline within the neurocritical care unit to validate effectiveness  Guideline dissemination to rural care centers to improve the treatment of IH prior to patient transfer to tertiary center  Further educate staff on IH to improve recognition and prompt intervention Project Chair: Heidi Favero, DNP, ACNP-BC Content Expert: Shawn Smith, M.D.