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11/26/2014
1
Neuro PROTECTion in Severe Traumatic Brain Injury
Presented by:
Mary Kay Bader RN, MSN
CCNS, CNRN, CCRN, SCRN, FAHA, FNCS
Neuro/Critical Care CNS
Mission Hospital
Disclosures
� Bader� Honorarium
� Bard, Neuroptics, & The Medicines Company
� AANN: Immediate Past President
� NCS Board of Directors
� Stock Options: Neuroptics
� Medical Advisory Board� Brain Trauma Foundation
� Neuroptics
PROTECT - ION
�� P P = Physiologic Changes from TBI
��RR = Resuscitation
��OO = Operative Intervention
��T T = Technology
�� EE = Entry to ICU
�� CC = Coordinated Care/Clinical Guidelines
��TT = Teamwork & Family Centered Care
Traumatic Brain Injury
Pathophysiology and Management
Classification
� Pathological Mechanisms� Direct � Indirect
� Mechanism of Injury� Blunt
� Falls� MVAs� Struck by object
� Penetrating -90% die
� Compression� Blast
Classification by Age Group - Mechanism
http://www.cdc.gov/mmwr/preview/mmwrhtml/figures/s6005a1f5.gif
11/26/2014
2
Classification of Head Injury:Presentation
Primary Head Injury
� Occurs at the time of injury� Compromised skull integrity
� tearing of vessels/sinuses� dural tears� brain contusions� cranial nerve injuries
� Compromised brain integrity� linear and rotational forces
� Prevention is paramount to alter primary injury
PPhysiology Changes in Brain Injury
� Primary Injury
� Skull integrity� Fractures
� Basilar
� Depressed’
� Linear
Primary Injury: Epidural Hematoma
PPhysiology Changes in Brain Injury
� Primary Injury
� Subdural hematoma
�Focal injuries
�Diffuse injuries
Cerebral Contusions
� Types:� Fracture
� Coup
� Countercoup
� Herniation
� Surface
� Gliding (focal hemorrhage in cortex/subjacent white matter found in DIA
� Frequently frontal or temporal regions
� Vasogenic edema and central necrosis
� Diagnosis: CT and Exam
11/26/2014
3
Diffuse Axonal Injury
� Extensive disruption of axons/white matter in both hemispheres
� Stress of gray-white interface
� Petechial hemorrhages
� Axonal shearing/swelling
� Diagnosis: CT and exam
Primary Head Injury
� Results of compromised brain integrity and cellular changes� cerebral edema
� hemorrhage/hematomas
� herniation
� brain death
Secondary Injury: Alteration in CBF
� Numerous studies have found low CBF in early hours after TBI
� Martin et al study on CBF in TBI� 1st 12 to 24 hours: Hypoperfusion/decrease in CBF
� 24 hours to Day 5: CBF exceeding CMRO2
� Days 5/6 to 14: Slow flow due to vasospasm
� CBF altered but it must be balanced with metabolism and oxygenation
PPhysiology Changes in Brain Injury
Secondary Injury
�Extracranial causes�Hypotension�Hypocapnia and Hypercapnia�Hypoxia�Anemia�Acidosis�Hyperglycemia�Hyperthermia
Cerebral Blood FlowAutoregulation
�Vasomotor control�Intact: Increase in CPP causes
vasoconstriction and decrease in ICP�Vasomotor reactivity failure: Increase
in CPP causes vasodilation and inc ICP
�Flow metabolism�↑ metabolism ↑ CBF
�Metabolic substances�PaO2�PaCO2�pH i.e., acidosis = vasodilatation
11/26/2014
4
PPhysiologic Changes:Intracranial Pressure
� Theories on Brain Compartment� 80% brain
� 10% blood
� 10% CSF
� If one increases the other two decrease
� Compensatory mechanisms
SDH
80%10%
10%
Brain moves over
CSF shunts to spine SAS
Venous blood to heart
Symptoms of Increased ICP: Adults
� Early� Altered level of consciousness, restless,
agitated, headache, nausea, and contralateral motor weakness
� cranial nerves III and VI
� Late� Coma, vomiting, contralateral hemiplegia,
and posturing
� Alteration in Vital Signs
� Impaired brainstem reflexes� Pupils, dysconjugate gaze
RResuscitation
Arrival: Emergency Department Trauma Bay
Assess A-B-C: Oxygenation and Ventilation
Airway: Secured with RSI
Breathing: Connect to Ventilator
Avoid hyperventilation
Use Capnography to monitor ET CO2
Assess Circulation: Pulse, ECG and BP
�Hypertonic Saline� Posturing� Fixed non-reactive pupil
�Fluid Resuscitation� IV fluids to maintain adequate MAP 80
mm Hg
�Arterial line/Foley/OG
RResuscitationSevere TBI Patient: GCS 3-8 CT+ Injury
Arrival: Emergency Department Trauma Bay
RResuscitationSevere Brain Injury Algorithm
� CT scan
� OR Priorities
� Vent:100% FIO2 and PaCO2 35-45
� Place PA catheter; PbtO2; ICP
� Optimize MAP > 90 mm Hg� Fluids
� Correct coagulopathies
� Propofol to reduce CMRO2/ICP
OOperative Intervention
� Operative Intervention as indicated� Removal of SDH/EDH
� Craniectomy
� Placement of monitors
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5
OOperative InterventionSevere TBI Patient: GCS 3-8 CT+ Injury
OOperative InterventionSevere TBI Patient: GCS 3-8 CT+ Injury
TTechnology
� Technology� Place ICP monitor
� Treat for ICP > 20 mm Hg
� Clinicians should use a combination of ICP, clinical and brain CT finding to guide treatment
� Consider placement of PbtO2 monitor and treat PbtO2 < 15 mm Hg
� Place Hemodynamic Monitors and Regulate CPP 50-70 mm Hg
TechnologyIntracranial Pressure
� Normal range � 0-15 mm Hg
� Abnormal ranges� moderate 20-40
� severe > 40
Technology Oxygenation
Delivery of oxygen to the brain dependent on Lungs
Hemoglobin and PlasmaPreload (CVP) /Cardiac Output/ Afterload
(SVR)CBF = CPP/CVR
Autoregulation
Vasomotor control
Flow Metabolism↑metabolism/flow ↓metabolism/flow
Chemical
PaCO2 / PaO2 / pH
TTechnologyOxygen Dynamics:
Brain Tissue Oxygen Monitoring
11/26/2014
6
TTechnologyBrain Tissue Oxygen(Pbt02)
� Normal: 20-40 mm Hg
� Risk of death increases� < 15 mm Hg for 30 minutes
� < 10 mm Hg for 10 minutes
� PbtO2 < 5 mm Hg � high mortality
� PbtO2 < 2mm Hg - neuronal death
TTechnologyBrain Tissue Oxygen(Pbt02)
� Decreasing PbtO2� Hypoxia
� Low Hemoglobin
� Decreasing PaCO2
� Increased ICP
� Decreased MAP/CPP
� Shivering
� Vasospasm
� Systemic Causes� Pulmonary
� Cardiac/Hemodynamic
� Increasing PbtO2� Increasing FIO2 when
PaO2 < 80 mm Hg
� Increasing Hemoglobin
� Increasing PaCO2
� Draining CSF
� Increasing CPP/MAP
� Control shivering
� Barbiturates
Outcomes: TBI
41 pts (1998-2000) vs 139 (2000-
2005)
CPP & PbtO2
EEntry into the ICU
11/26/2014
7
CCoordinated CCare BTF: Core TBI Management
� Place ICP and cerebral ischemia monitor
� Core interventions� Drain CSF
� CO2 35-45 mm Hg
� Sedation/Analgesia
� Normothermia T 37
� CPP 50-70 mm Hg
BTF 2007 Severe TBI Guidelines
� BP & Oxygenation
� Hyperosmolar Tx
� Prophylactic Hypothermia
� DVT Prophylaxis
� Indications for ICP Monitoring
� ICP Monitoring Technology
� ICP Thresholds
� CPP Thresholds
� Brain Oxygen Monitoring &Thresholds
� Anesthetics, Analgesics, & Sedatives
� Nutrition
� Anti-Seizure
� Hyperventilation
� Steroids
CCoordinated CCare/CClinical Guidelines
Intensive Care Unit
A & B: Oxygenation/Ventilation Optimization Target PaCO2: 35 mm Hg (Day 1) & 30-35 (Days2-5)
Circulation: Maintain CPP 50-60 mm Hg as initial target
Autoregulation Testing: Intact – may need CPP to 70 mm Hg
Mannitol/Hypertonic Saline
ICP Management:
Draining CSF and Providing Sedation/Analgesia
Normothermia
CCoordinated CCare CClinical Guidelines
� Tertiary Interventions� Mild Hypothermia
� Decompressive Hemicraniectomy
� Barbiturate Coma� Not used much in US
TTeamworkPutting It All Together
Real World Real Patients
TTeamworkFamily Focused Care
� The healthcare team can impact patients outcome by actively engaging families in care: Family Focused Care
� Providing FFC requires assessment, planning, intervention, and evaluations for each unique family� Assurance, Proximity to Patient,
Information, Comfort and Support
11/26/2014
8
Teamwork: MD Protocols
Teamwork: MD Protocols
TTeamworkPrimary Interventions: Airway
� Assessment of Oxygenation/Ventilation� Patency of airway� Intervene: Rapid Sequence Intubation
� Oxygenation� Ventilation
� 1st 24 hours: PaCO2 35-45 mm Hg� If…Increased ICP PaCO2 30-35 mm Hg
� Influence of Airway/Ventilation
Issues Day 1� Pulmonary worsens
with PaO2 131 to 54� PbtO2 24 drops to 11
mm Hg
� ICP ↑35 mm Hg
– Low PbtO2 correlating with low PaO2
– Leads to Inc ICP
PbtO2 8 mm Hg
TTeamworkPrimary Interventions:
Circulation� Optimize CPP: Find the
right place
� Goal 50-70 mm Hg � Fluids: SVV < 13%
� Vasopressor support once euvolemic
Interventions: Circulation
�Neck midline
�Head of Bed�Flat if hypovolemic –
temporary measure
�30 degrees if euvolemic
11/26/2014
9
TTeamworkPrimary
Intervention: Intracranial
PressureCSF Drainage
� Normal range
� 0-15 mm Hg
� Abnormal ranges
� > 20 mm Hg
� Compliance waveform analysis
TTeamworkPrimary Intervention: Optimal
Sedation /Analgesia
� Analgesia� Fentanyl
� Sedation� Propofol
� Benzodiazepines
� Dexmedetomidine
TTeamworkPrimary
Intervention
Normothermia
&
Shivering
Step-Wise Managementof Shivering
TTeamworkSecondary/Tertiary
Interventions
� Secondary Interventions� HTS
� Mannitol
� Tertiary Interventions� Pentobarb coma
� Decompressive hemicraniectomy
� Mild Hypothermia
Interventions: Systemic
� Bundles� Infection prevention
� Ventilator� Foley� Central Line
� GI: �OG for gastric decompression�Stress ulcer prophylaxis�Nutrition: caloric goal by day3
11/26/2014
10
Interventions: Mobility
� Musculoskeletal� Early Mobility Program
START HERE
MOVEN SCREEN � Perform initial mobility
screen within 8 hrs of ICU
admission AND reassess
every 12 hours
� Report at MDR daily (RN,
RT, PT)
� Refer to the following
criteria in determining
mobility level:
M: Myocardial stability
• 50 < HR* < 120
• 90 < SBP* < 200
• 55 < MAP* < 120
*or normal range for pt
• No active ischemia x 24 hrs
• No new IV antidysrhythmic
agents x 24 hrs
O: Oxygenation
• FiO2 ≤ 60%
• PEEP < 12
• SPO2 ≥ 92% (88% with
activity)
• 10 < RR < 35
V: Vasopressor(s) minimal
• No increase in vasopressor
infusion in last 2 hrs
E: Engages to voice
• Pt opens eyes to verbal
stimulation
N: Neurologic stability
• ICP <20mmHg
• Absence of active seizures x
24hrs
CONTRAINDICATIONS:
• Unstable fx
• Active bleeding
• Active fluid resuscitation
• Open chest/abdomen
Includes complex, intubated, hemodynamically unstable and
stable intubated patients; may include non-intubated.
Includes intubated, non-intubated and hemodynamically
stable/stabilizing, no contraindications.
LEVEL I LEVEL II LEVEL III LEVEL IV LEVEL V
RASS -5 TO -3 RASS -3 AND UP RASS -1 AND UP RASS 0 AND UP RASS 0 AND UP
Goal: Passive ROM;
Initiate nutrition within
24 hrs
Goal: Upright sitting;
Increased strength;
Move arms against
gravity
Goal: Increased trunk
strength; Move legs against
gravity and readiness to
weight bear; Ability to
perform some ADL’s with
assist
Goal: Stand with assist;
March in place and
transfer to chair
Goal: Increase
ambulation distance
Activity:
• HOB ≥ 30o
• Passive ROM 3x/day
by RN, PCT or family
• Turn Q 2hr
• Cycle ergometry (as
determined by PT)
Consults:
• Dietician Consult
• PT Consult for cycle
ergometry and family education board
recommendations
• ST Consult for coma
stim and family
education board recommendations
Begin Family Education
Board
Activity:
• Full chair position 3x/day x 30 min
• Passive ROM
3x/day by RN, PCT
or family
• Turn Q 2hr
• Cycle ergometry (as determined by PT)
Consults:
• PT Consult if not
already following
• OT Consult PRN
(i.e., neuro, splinting
needs)
• SP Consult if pt has trach
Activity:
• Self or assisted turning Q 2hr
• Sitting EOB with RN, PT,
OT x 15 min
• Full chair position
3x/day x 45-60 min
• Begin transfer to chair via Sabina lift
• Passive ROM/begin to
encourage AAROM
3x/day by RN, PCT or
family
• Cycle ergometry (as
determined by PT)
Consults:
• OT Consult
• SP Consult if extubated
and not already
following
ARU Consult (if consistently
participating with therapy and
able to follow commands)
Activity:
• Active transfer OOB to chair with RN, PT, OT
3x/day x 30 min (meal time)
• Sitting on EOB/stand
at bedside with RN,
PT, OT
• Self or assisted
turning Q 2hr
• Full chair position
3x/day x 60 min
• Encourage
AAROM/AROM
3x/day with RN, PCT,
PT, OT or family
• Cycle ergometry (as
determined by PT)
Consults:
• ARU Consult
Activity:
• OOB to chair 3x/day with RN,
PCT, PT, OT x 60 min
• Ambulate
progressively
longer distances 2-
3x/day with RN, PCT, PT, OT
• Cycle ergometry
(as determined by
PT)
*For each position/activity change, allow 5-10 min for equilibration before determining the patient is intolerant.
**If the patient is intolerant of current activity level, reassess and place in appropriate mobility level.
MDR: Multidisciplinary Rounds EOB: Edge of Bed
PROM: Passive Range of Motion AAROM: Active-Assisted Range of Motion
AROM: Active Range of Motion ADL’s: Activities of Daily Living
Tolerates Level I activities, progress
to Level II.
Tolerates Level II
activities, progress
to Level III
Tolerates Level III
activities, progress
to Level IV.
Tolerates Level IV
activities, progress to Level V.
Guidelines for Early Mobility
• Levels
– Levels I-II-III• Complex, intubated, hemodynamically unstable and stable
intubated patients
• May include non-intubated
– Levels III-IV-V• Intubated, non-intubated and hemodynamically
stable/stabilizing, no contraindications.
• For each position/activity change, allow 5-10 min for equilibration before determining the patient is intolerant.
• If the patient is intolerant of current activity level, reassess and place in appropriate mobility level.
stable intubated patients; may include non
LEVEL I
RASS -5 TO -3
Goal: Passive ROM;
Initiate nutrition within
24 hrs
Activity:
• HOB ≥ 30o
• Passive ROM 3x/day
by RN, PCT or family
• Turn Q 2hr
• Cycle ergometry (as
determined by PT)
Consults:
• Dietician Consult
• PT Consult for cycle
ergometry and family
education board
recommendations
• ST Consult for coma
stim and family
education board
recommendations
Begin Family Education
Board
*For each position/activity change, allow 5
Tolerates Level I
activities, progress
to Level II.
Level I• RASS -5 to -3
Level II• RASS -3 and UP
stable intubated patients; may include non-intubated
LEVEL II
RASS -3 AND UP
Goal: Upright sitting;
Increased strength;
Move arms against
gravity
Activity:
• Full chair position
3x/day x 30 min
• Passive ROM
3x/day by RN, PCT
or family
• Turn Q 2hr
• Cycle ergometry (as
determined by PT)
Consults:
• PT Consult if not
already following
• OT Consult PRN
(i.e., neuro, splinting
needs)
• SP Consult if pt has
trach
Tolerates Level II
activities, progress
to Level III
Level III
• RASS -1 and UP
intubated. stable/stabilizing, no contraindications
LEVEL III
RASS -1 AND UP
Goal: Increased trunk
strength; Move legs against
gravity and readiness to
weight bear; Ability to
perform some ADL’s with
assist
Activity:
• Self or assisted turning
Q 2hr
• Sitting EOB with RN, PT,
OT x 15 min
• Full chair position
3x/day x 45-60 min
• Begin transfer to chair
via Sabina lift
• Passive ROM/begin to
encourage AAROM
3x/day by RN, PCT or
family
• Cycle ergometry (as
determined by PT)
Consults:
• OT Consult
• SP Consult if extubated
and not already
following
ARU Consult (if consistently
participating with therapy and
able to follow commands)
10 min for equilibration before determining the patient is intolerant.
Tolerates Level III
activities, progress
to Level IV.
11/26/2014
11
Levels IV and V• RASS 0 and UP
stable/stabilizing, no contraindications.
LEVEL IV LEVEL V
RASS 0 AND UP RASS 0 AND UP
Goal: Stand with assist;
March in place and
transfer to chair
Goal: Increase
ambulation distance
Activity:
• Active transfer OOB to
chair with RN, PT, OT
3x/day x 30 min (meal
time)
• Sitting on EOB/stand
at bedside with RN,
PT, OT
• Self or assisted
turning Q 2hr
• Full chair position
3x/day x 60 min
• Encourage
AAROM/AROM
3x/day with RN, PCT,
PT, OT or family
• Cycle ergometry (as
determined by PT)
Consults:
• ARU Consult
Activity:
• OOB to chair
3x/day with RN,
PCT, PT, OT x 60
min
• Ambulate
progressively
longer distances 2-
3x/day with RN,
PCT, PT, OT
• Cycle ergometry
(as determined by
PT)
Tolerates Level IV
activities, progress to Level V.
Nursing Strategies for Neuro
PROTECT - ION�� P P = Physiologic Changes from TBI
�� RR = Resuscitation
�� OO = Operative Intervention
�� T T = Technology
�� EE = Entry to ICU
�� CC = Coordinated Care/Clinical Guidelines
�� TT = Teamwork & Family Centered Care
�� I I – Individualize Care!
��O O – Outcomes must be measured and analyzed!
��NN – Nuances: What have you learned as a team?
Individualize Care� Each patient is unique!
� Responses to injury vary
Outcome Measurement in TBI
Case Study
Case Overview
� 30 year old male involved in altercation falls backwards/strikes head
� Arrival in ED as a Trauma� GCS 3 with fixed non-reactive pupils at
5 mm bilateral
� Intubated with 7.5 ET/Foley/OG
� IV � Mannitol 100 grams IV
11/26/2014
12
CT
4/6/19834/6/1983
Page: 13 of 217Page: 13 of 217
Acq No: 2Acq No: 2KVp: 120KVp: 120mA: 223mA: 223Tilt: -8Tilt: -8RD: 217RD: 217
BRAIN WO STBRAIN WO ST
11/15/2013 6:52:37 PM 11/15/2013 6:52:37 PM
C T20131115-0111C T20131115-0111
LOC : 1717.30LOC : 1717.30
C ompressed 11:1Compressed 11:1
Jakishev, Amirzhan AJakishev, Amirzhan A
AR01001691AR01001691
4/6/19834/6/1983
Page: 14 of 217Page: 14 of 217
Acq No: 2Acq No: 2KVp: 120KVp: 120mA: 218mA: 218Tilt: -8Tilt: -8RD: 217RD: 217
MIssion AS64 MIssion AS64
CT Brain Head wo ContrastCT Brain Head wo Contrast
BRAIN WO STBRAIN WO ST
11/15/2013 6:52:37 PM 11/15/2013 6:52:37 PM
CT20131115-0111CT20131115-0111
LOC: 1722.30LOC: 1722.30
Compressed 11:1Compressed 11:1
AAAR01001691AR01001691
4/6/19834/6/1983
Acq No: 2Acq No: 2KVp: 120KVp: 120mA: 206mA: 206
RD: 217RD: 217
C T Brain Head wo C ontrastC T Brain Head wo Contrast
BRAIN WO STBRAIN WO ST
11/15/2013 6:52:38 PM 11/15/2013 6:52:38 PM
C T20131115-0111CT20131115-0111
LOC : 1737.30LOC: 1737.30
Acq No: 2Acq No: 2
BRAIN WO STBRAIN WO ST
11/15/2013 6:52:40 PM 11/15/2013 6:52:40 PM
CT20131115-0111CT20131115-0111
LOC: 1752.30LOC : 1752.30
159.63mm159.63mm
18.76mm18.76mm
CT20131115-0111CT20131115-0111
LOC: 1777.30LOC: 1777.30
Operating Room
� Preop Diagnosis� Left Subdural Hematoma
� Sagittal suture diastasis
� Procedure� Evacuation of L SDH
� Left craniectomy
� Placement of ICP/PbtO2
� EBL: 1 liter
Jakishev, Amirzhan A
AR01001691AR01001691 MIssion AS64
CT Brain Head wo ContrastCT Brain Head wo Contrast
BRAIN WO ST H45sBRAIN WO ST H45s
11/17/2013 5:00:45 AM 11/17/2013 5:00:45 AM
CT20131117-0001CT20131117-0001
LOC: -783.30LOC: -783.30
A
Page: 20 of 211Page: 20 of 211
Acq No: 3Acq No: 3KVp: 120KVp: 120mA: 257mA: 257Tilt: -14RD: 233RD: 233
11/17/2013 5:00:46 AM 11/17/2013 5:00:46 AM
CT20131117-0001CT20131117-0001
LOC: -768.30LOC: -768.30
IM: 19 SE: 3IM: 19 SE: 3Compressed 11:1Compressed 11:1
PP
C T20131117-0001CT20131117-0001
LOC : -753.30LOC: -753.30
LOC: -738.30LOC: -738.30
Page: 30 of 211 Compressed 11:1
To SICU
� Arrived 2230 Transported on 100% from OR� MAP 93 – ICP 10 = CPP 82
� PbtO2 50 PaCO2 42 PaO2 379
� FIO2 titrated down to 50% within 1 hour
SICU Day 1-2
� ICP 10 to low 20s � MAP 75 ICP 10-22
PbtO2 20-25 mm Hg
� Tx Hypertonic Saline
� Pupillary reaction improving� CS -1.0-0.8 mm/sec
in R
� CS 0.5-0.2 mm /sec in L
MAP
ICP
CPP
PbtO2
R CV
L CV
Improvement if goes in this direction
Day 3: Assessment for MOVEN
� Pt intubated/ventilated
� Sedated RASS -4� Versed & Fentanyl
� ICP requiring drainage
� Assessed for MOVEN� Phase I
� Ready for ergometry evaluation
Safety Screening (Patient must meet all criteria)
MOVEN SCREENRefer to the following criteria in determining mobility level:
M: Myocardial stability50 < HR* < 12090 < SBP* < 20055 < MAP* < 120 *or normal range for ptNo active ischemia x 24 hrsNo new IV antidysrhythmic agents x 24 hrs
O: OxygenationFiO2 ≤ 60%PEEP < 12SPO2 ≥ 92% (88% with activity)10 < RR < 35
V: Vasopressor(s) minimalNo increase in vasopressor infusion in last 2 hrs
E: Engages to voice ----------- ORPt opens eyes to verbal stimulation
N: Neurologic stability ICP <20mmHgAbsence of active seizures x 24hrsCONTRAINDICATIONS:Unstable fxActive bleedingActive fluid resuscitationOpen chest/abdomen
11/26/2014
13
Focused Mobility with Team Day 4
Before Ergometry
After 20 minutes into Ergometry
ICP
ICP
PbtO2
PbtO2
ICU Course – Days 3-7
ICP controlled with periodic spikes above 20
PbtO2 range 20-35 mm Hg
Day 5 MobilityBefore Ergometry
After 20 minutes into Ergometry
ICP
ICP
PbtO2
PbtO2
Notes PT Day 6
Days 6-8
� Weaning sedation
� ICP controlled / VS stable
� Continues with ergometry
Nurse Note Day 7
Nurse Note Day 8
PT Note Day 10
11/26/2014
14
Progress from Level I to II
stable intubated patients; may include non-intubated
LEVEL II
RASS -3 AND UP
Goal: Upright sitting;
Increased strength;
Move arms against
gravity
Activity:
• Full chair position
3x/day x 30 min
• Passive ROM
3x/day by RN, PCT
or family
• Turn Q 2hr
• Cycle ergometry (as determined by PT)
Consults:
• PT Consult if not
already following
• OT Consult PRN
(i.e., neuro, splinting
needs)
• SP Consult if pt has
trach
Tolerates Level II
activities, progress
to Level III
PT Note Day 11
Days 10-14� Weaning sedation
� ICP controlled / VS stable� Day 10 ICP & PbtO2
D/C
� Weaned from Vent� 1st extubation Day 8
fail due to secretions
� 2nd extubation Day 13
� Continues with ergometery
Nurse Note Day 10
Nurse Note Day 14
Days 14 Level III
intubated. stable/stabilizing, no contraindications
LEVEL III
RASS -1 AND UP
Goal: Increased trunk
strength; Move legs against
gravity and readiness to
weight bear; Ability to
perform some ADL’s with
assist
Activity:
• Self or assisted turning
Q 2hr
• Sitting EOB with RN, PT,
OT x 15 min
• Full chair position
3x/day x 45-60 min
• Begin transfer to chair
via Sabina lift
• Passive ROM/begin to
encourage AAROM
3x/day by RN, PCT or
family
• Cycle ergometry (as
determined by PT)
Consults:
• OT Consult
• SP Consult if extubated
and not already
following
ARU Consult (if consistently
participating with therapy and
able to follow commands)
10 min for equilibration before determining the patient is intolerant.
Tolerates Level III
activities, progress
to Level IV.
Days 14-25
� Progress with strengthening but has ++ secretions
� GCS improves from 3-5-1T on Day 14 to 4-6-1T by Day 25
� Increasing interaction with family and nurses
� PT/OT/ST working with patient 2x per day each service
PT Note Day 23
11/26/2014
15
Progressing Level IV-V
stable/stabilizing, no contraindications.
LEVEL IV LEVEL V
RASS 0 AND UP RASS 0 AND UP
Goal: Stand with assist;
March in place and
transfer to chair
Goal: Increase
ambulation distance
Activity:
• Active transfer OOB to
chair with RN, PT, OT
3x/day x 30 min (meal
time)
• Sitting on EOB/stand
at bedside with RN,
PT, OT
• Self or assisted
turning Q 2hr
• Full chair position
3x/day x 60 min
• Encourage
AAROM/AROM
3x/day with RN, PCT,
PT, OT or family
• Cycle ergometry (as
determined by PT)
Consults:
• ARU Consult
Activity:
• OOB to chair
3x/day with RN,
PCT, PT, OT x 60
min
• Ambulate
progressively
longer distances 2-
3x/day with RN,
PCT, PT, OT
• Cycle ergometry
(as determined by
PT)
Tolerates Level IV
activities, progress to Level V.
1 month � Pt has no insurance
� Case Manager working on arrangements for ARU for 4 weeks (Began working on case early in hospital stay)
Nurse Note Day 30
Nurse Note Day 34
Nurse Note Day 40
Outcomes
� Transferred to PCSU on Day 43
� Admitted to ARU on Day 53� By Day 61: independent in bed mobility, improved
transfer, able to walk 150 ft with supervision/contact guard assist; ADLs supervised; cognition overall moderate assist
� Cranioplasty completed on Day 61� Complicated by EDH develop Post op day 1- return
to OR for evacuation
� Transferred to ARU Day 68 to complete ARU
� Discharge home on Day 76� Ambulating 175 feet; ADLs supervised; Cognition – minimal
assist for attention to task; Problem solving min assist level
Conclusion