05.02 Intracranial Hemorrhage

When it comes to presentation, there some subtle differences between the two, and there are some glaring differences...so let's go through them

With our subdural bleed, our patient will most likely have a headache and this can be a simple annoying headache or one that is causing them a lot of pain. What we want to know, is how long they have been feeling this. The concept of acute vs chronic bleed comes into play with subdural (and you can read much more about that in our neuro lessons throughout NRSNG.com)

They will have a slow, progressive decrease in their level of consciousness. many complain of being overly tired.

Pupils… they will be fixed and dilated. First unilaterally, meaning only one side, but as the bleeding progresses it will be bilateral.

The respirations will be abnormal, and this could be hyper or hypoventilation

They can experience contralateral hemiparesis… one-sided weakness or paralysis

Most likely they will have an increase in their intracranial pressure and many times they will experience nausea and vomiting.

With our epidural bleed, the headache is going to be severe, some have reported feeling like a gunshot went off in their brain, or like they got stabbed in the head with an icepick.

They can be agitated and they might have a sudden loss of consciousness or a progressive one.

Lights out, lights on, lights out. This is a very telltale sign of an epidural bleed. Usually sustained from trauma, the patient will have an instant loss of consciousness, followed soon after by a period of awakened lucidity, which will then be followed by another loss of consciousness. If this is reported to you… it should send up a ton of red flags!

The pupils here will be unilaterally dilated.

They will also have that contralateral weakness

And as far as the vital signs go, we might see bradycardia, hypertension and abnormal respirations.

When we are assessing these patients, many of the assessments are the same.

We want to do our serial neuro exams, probably every 5 to 15 minutes...check your facilities policy. And what we are looking at is the GCS. Motor Response, Eye-opening, and verbal response. Remember...the scale goes from 3-15..not 0-15.

As with any of our patients, we want to monitor our Airway, breathing, and circulation

And if our patients have a GCS of 8 or less and a funky CT scan, we are probably going to monitor their intracranial pressure with an ICP monitor, most likely inserted right in the ED.

Now we have to manage these patients, right?

Well if the GCS is less than 8, it is usually assumed they are going to have trouble maintaining their own airway, so we are going to intubate and ventilate them.

We want to keep that oxygen level above 95Z% to make sure the brain is perfusing and we are getting the O2 where it needs to be. Be careful if we are bagging the patient with a BVM, or bag valve mask, that we do not hyperventilate them. Why would that be bad to give them more oxygen Nurse Mike? You just told us the brain needs oxygen. I’m glad you asked. While oxygen is of course vitally important to brain health,  hyperventilation can actually cause an increase in ICP, so clearly we want to be careful.

We are going to restore fluid volume as needed and the way we are going to monitor this is by inserting a urinary catheter and keeping an eye on output. we want 0.5 to 1 ml/kg an hour and we can adjust our fluid infusion rates accordingly.

If we have that patient with a GCS of less than 8 who s intubated and has that ICP monitor, we will want to reduce the ICP if needed. Whether we do that with medications like Mannitol or through physical interventions like positioning or decreasing stimulus will depend on the situation and the actual ICP level.