In 2011, the Ministry of Health and

Long Term Care (MOHLTC)

requested Critical Care Services

Ontario (CCSO) to lead a planning

process to develop a

comprehensive neurosurgical

system to meet the needs of adult

and paediatric patients across

Ontario. As a part of this program,

the MOHLTC also committed new

nursing positions, including clinical

Neurosurgical Outreach Nurse and

Neurosurgical Nurse Educator

positions, to support the

management of specialized

paediatric and adult neurosurgical

patients.

The Neurosurgery Education and

Outreach Network (NEON) was

established in May 2013 to work in

collaboration with the Provincial

Neurosurgery Advisory Committee

to support the educational

component of recommendations

to better integrate access to

neurosurgical services in the

province. Originally comprised of

Nurse Educators and Program

Directors from each of the

province’s adult neurosurgical

centres, their work formed the

foundation for an educational

outreach program designed to

provide a wide breadth of

education to non-neurosurgical

centres on neurosurgical patient’s

care across the continuum. The

expanded network has grown to

include Clinical Nurse Specialists,

Advanced Practice Nurses and

Nurse Practitioners working in

both adult and paediatric

neurosurgery.

The OUTREACHER Newsletter will

be published three times per year

to provide regional hospitals with

Neurosurgery updates and

education.

IMPROVING ACCESS

IMPROVING QUALITY

AND RESPONSIVENESS

IMPROVING

NEUROSURGICAL

NURSING CARE ACROSS

ONTARIO

OUTREACHER July 2017 Issue 2, Volume 1

Inside this issue

Subdural Hematoma (SDH): pp. 2-3

Educational Opportunities in your LHIN: pp. 2-3

Cauda Equina: pp. 4-5

What’s New- Guidelines for Basic Paediatric Neurological Observation: pp. 5

Who to contact in your LHIN: pp. 6

NEON:

Working towards Provincial

improvements in neurosurgical

service delivery

2

Subdural Hematoma (SDH)

A subdural hematoma results from bleeding under the skull and on top of the brain between the dura mater and arachnoid layer.

Subdural hematomas may be caused by a fall, trauma, MVC,

assault or can be idiopathic. If a person has a bleeding

disorder or takes blood thinners they are more likely to

develop a subdural hematoma.

Three classifications of SDH

Acute

Time Interval: Up to 48-72 hours

CT Imaging: Clotted blood that is hyperdense and

crescent shaped

Causes: Major traumatic brain injury (TBI)

Subacute

Time Interval: 2 days to about 2 weeks

CT Imaging: Blood products and fluid that is isodense

Causes: Slowly expanding acute SDH

Chronic

Time Interval: Longer than 2 weeks to several months

CT Imaging: Fluid mass that is hyperdense

Causes: Minor trauma in the elderly, bleeding disorder

or anticoagulants

Symptoms

Headache, confusion, change in behavior, dizziness,

nausea and vomiting, lethargy or excessive drowsiness,

weakness, apathy, seizures, motor weakness

Signs – Increased intracranial pressure

Decreased level of consciousness

Changes in mental status, confusion, lethargy

Unequal and/or sluggish pupillary responses

Seizure activity

EDUCATIONAL OPPORTUNITIES IN YOUR

LHIN!

LHIN 2

May 16: Woodstock General Hospital – ER Skills Fair

LHIN 3&4

May 25: Welland General Hospital – Neuro Assessment ER

May 25, August 9 & 30: Niagara Health System – Neuro Assessment ER

May 26: Greater Niagara General Hospital – ER MD spine education

June 12: Greater Niagara General Hospital – Neuro

June 13: Niagara Health System – ER MD Emergency Guideline for consultation education

June 28: Mohawk College – Sim. Train the Trainer workshop (IPE)

August 30 & 31: West Lincoln Memorial Hospital – Neuro Review

LHIN 5&6

May 12: Headwaters Healthcare Centre – Cervical Collar Care and Management (Hands-on) (2:00- 2:45pm)

May 18 & 25: Oakville-Trafalgar Memorial Hospital – SIMS day ER with neurological assessment and scenarios (10:30-11:30am)

June 6: Brampton Civic Hospital – Neuro Assessment and Scenarios (11-12pm, 12-1pm, 1-2pm)

June 22: Etobicoke General Hospital – Cervical Collar Care and Management (Hands-on) (1-1:45pm, 2-2:45pm, 3-3:45pm)

August 9: Headwaters Healthcare Centre – Craniectomy Care (11:00am)

LHIN 10

May 10: Kingston General Hospital – Post-operative Neurological Assessment PACU (8:00am-9:00am)

May 21, 26, 29 & 31: Lennox & Addington County General Hospital- Neuro assessment and case study

LHIN 11

May 9: Winchester District Memorial Hospital – Skills Fair

3

Subdural Hematoma (SDH) – cont’d

Signs – Increased intracranial pressure

Headache

Hemiplegia

Abnormal motor responses

Vomiting (without nausea)

Brainstem pressure signs (vital signs and respiratory changes)

Investigations

CT scan

PT/PTT

Treatment

Depends on the classification:

Acute: Craniotomy

Subacute & Chronic: Usually managed with Burr

hole drainage

Craniotomy

Craniectomy

*Some SDH’s may only require monitoring and no surgical

interventions*

References

1. Canzian, S. (2012). Traumatic brain injury. In D. Tymianski, A. Sarro & T. Green (Eds.), Navigating neuroscience nursing: A Canadian perspective (1st ed.). Pembroke: Pappin Communications.

2. Greenberg, M. S. (2010). Handbook of neurosurgery (7th ed.). New York: Thieme Medical Publishers.

3. Hickey, J.V. (2014). The clinical practice of neurological and neurosurgical nursing (7th ed.). Philadelphia: Lippincott Williams & Wilkins.

EDUCATIONAL OPPORTUNITIES IN YOUR

LHIN! (Cont’d)

Neurosurgery Outreach education days

May 10: Cornwall Community Hospital – Skills Fair LHIN 14

May 16: Red Lake Margaret Cochenour Memorial Hospital (10:00-4:00pm)

May 17: Meno Ya Win Health Centre (9:00-3:00pm)

May 18: Dryden Regional Health Centre (11:00 – 4:00pm)

May 23: Atikokan General Hospital (10:00-3:00pm)

May 24: La Verndrye Hospital (10:00-3:00pm)

May 26: Lake of the Woods District Hospital (9:00-2:00pm)

June 14: Nipigon District Memorial Hospital (10:00 – 3:00pm)

June 15: Geraldton District Hospital (10:00-3:00pm)

June 20: Manitouwadge General Hospital (1:00 – 5:00pm)

June 21 & 22: North of Superior Health Care Group (10:00 – 2:00pm)

Contact your Neurosurgery Outreach nurse – Kim Belluz regarding neurosurgery education, Monday to Friday 8-4 at belluzk@tbh.net or 807-684-6004

4

Cauda Equina Syndrome (CES)

Cauda Equina Syndrome is compression of the lumbar and

sacral nerve roots. “Depending on the affected nerve roots,

changes in motor, sensory, and/or bowel and bladder

function may occur. If left untreated, paraplegia and/or

bowel and bladder incontinence may occur” (Strayer et al.,

2010).

Early recognition of the signs/symptoms and emergent

surgical intervention can improve the outcome for patients

experiencing CES.

Causes

Large disc herniation L4-L5, L5-S1 level – most common cause

Trauma – e.g. fractures

Tumour

Spinal Stenosis

Hemorrhage

Epidural abscess

Symptoms

Sphincter disturbance: Urinary retention, urinary and/or fecal

incontinence, diminished anal sphincter tone

Saddle Anesthesia: decreased sensation to anus, lower

genitals, perineum, over buttocks, posterior-superior thighs

Significant motor weakness

Low back pain and/or sciatica: usually bilateral may be

unilateral or absent (prognosis may be worse when absent or

bilateral)

Possible bilateral absence of Achilles reflex

Sexual dysfunction

Diagnosis Physical exam: determines nerve root involvement and level

of impairment

Motor

Sensory

Reflex function

Post void residual: assess bladder function PVR with catheterization or bladder ultrasound

Digital rectal exam-assess for saddle anaethesia

Diagnostic imaging – MRI

Treatment

Surgical decompression of nerves within 24-48 hours.

References

1. Strayer, A., Prendergast, V., & Henwood, A. (2010) Spine disorders. In M.K. Bader & L.R. Littlejohns (Eds.), AANN Core curriculum for neuroscience nursing (5th ed., pp. 456). USA: American Association of Neuroscience Nursing.

2. Greenberg, M. S. (2010). Handbook of neurosurgery (7th ed., pp. 446). New York: Thieme Medical Publishers.

3. Ahier, J., & Sarro, A. (2012). Paediatric and adult spine. In D. Tymianski, A. Sarro & T. Green (Eds.), Navigating neuroscience nursing: A Canadian perspective (1st ed., pp. 142). Pembroke: Pappin Communications.

4. Hickey, J.V. (2014). The clinical practice of neurological and neurosurgical nursing (7th ed.). Philadelphia: Lippincott Williams & Wilkins.

RED FLAG!

“Loss of bowel and bladder control or function is considered a surgical emergency”

(Tymianski et al., 2012)

5

What’s New!

Guidelines for Basic Paediatric Neurological

Observation

The Guidelines for Basic Paediatric Neurological Observation provide direction for local development of bedside neurological observation protocols, in order to enhance existing skills and to ensure consistency of paediatric neurological assessment within and across different organizations. It is intended to enhance and build on current knowledge and skills. For the individual patient, this provides a baseline from which changes in the patient's neurological status may be identified, reported, and managed in a timely manner. These Guidelines were developed by the Neurosurgery Education and Outreach Network (NEON) in collaboration with Provincial Neurosurgery Ontario. Click here to view the OTN Presentation: Webinar-Guidelines for Basic Paediatric Neurological Observation

Now offered through the OTN Hub!

Please visit:

www.criticalcareontario.ca

For the latest neurosurgical guidelines and educational

webinars

LHIN Organization Neuro-Nurse Educator Clinical Outreach Specialist

LHIN 1 Windsor Regional Hospital Sean Hopkins Sean Hopkins

LHIN 2 London Health Sciences Centre Jean Morrow Kimberly Salway

LHIN 3/4 Hamilton Health Sciences Brenda Bousfield

Klaudia Gogishvili Sera Nicosia

Tina Petrelli (Paeds)

LHIN 5/6 Trillium Health Partners Beverly Espedido Beverly Espedido

LHIN 7/8/9W/12 University Health Network Charmaine Arulvarathan Dawn Tymianski

LHIN 7/8/9W/12 St. Michael’s Hospital Wendy Legacy Wen-Ya (Lory) Lee

LHIN 7/8/9W/12 Sunnybrook Health Sciences Centre Lars Kure Catherine Morash

LHIN 7 The Hospital for Sick Children Elisabeth White Elisabeth White

LHIN 9E/10 Kingston General Hospital Marnie Cranston Nicole Chenier-Hogan

LHIN 11 The Ottawa Hospital Raizha Gramcko Dianna Hughes

LHIN 13 Health Sciences North Sudbury Lisa Weiler Lindsay Roach

LHIN 14 Thunder Bay Regional Health Sciences

Centre Chad Johnson Kim Belluz

Who to Contact in your LHIN-Click on the name to connect via email 6

www.criticalcareontario.ca