Know your Glascow Coma Scale. I recommend reading about the scale. Memorize checking cranial nerves. When patients are intubated and unable to follow commands, the cranial nerves exams are corneal reflex (cranial nerve V), cough (cranial nerve X), and gag (cranial nerve IX and cranial nerve X). Use cotton wisp on cornea to check for corneal reflex. Know how to examine for doll's eyes aka vestibular-oculo relex (if no c spine injury turn head rapidly to one side, if this reflex is intact, eye will move to opposite side; if not, eyes remain midline. The MD can check for doll's eyes by instilling cold water in one ear at a time; if reflex intact, nystagmus is noted. Pupil checks are very important as one large pupil can indicate uncal herniation. Read up on ICP monitoring and ventriculostomy. With a ventriculostomy, the system is leveled to the external auditory meatus,i.e. ear canal. The MD chooses a level at which CSF wil drain if pressure is higher than the pressure of that level. There is 25 cc/hour of CSF made in the brain. You have to be careful when raising or lowering the head of the patient so you don't dump fluid. The skull encases the brain, the blood vessels in the brain and the CSF which is made mostly in the lateral ventricles, and the ventricles. Treatments to relieve high ICP (greater than 20 mm hg): remove part of the skull--craniotomy--allows brain to swell without getting squashed in the skull; allows for an evacuation of blood from epidural or subdural hematomas; CSF drainage via ventrix or lumbar drain; mannitol--uses osmosis to pull edema from the brain or 3% saline IV to shrink brain swelling. You need to use a filter on the IV with mannitol. Dexamethasone is used more often with tumors to reduce swelling--large amounts of it will cause leulocytosis. CO2 is a potent vasodilator. Its recommended to keep etCO2 at 35--lower can reduce cerebral perfusion and should be avoided--but can be a very temprary bridge if the patient is herniating--bag the patient to reduce etCO2 to reduce ICP. Treatment for subarachnoid hemorrhage is called triple h therapy (hypertension,hypervolemia and hemodilution). This prevents the vasospasm that occurs from irritation caused by blood. Vasospasm causes ischemia. The patient is also given nimodipine to reduce vasospasm. The patient will have routine bedside duplex studies to watch for vasospasm. The patient may be taken to the cath lab where the spasming vessel is dilated. Cushings triad is a harbinger to herniation: hypertension, widening pulse pressure, bradycardia, irregular breathing; also one or both pupils will become fixed and dilated (blown) and patient will lose cough, corneal and gag reflexes. Use strict asceptic technique with ICP, ventrix or lumbar drains. Fever and hyperglycemia worsen brain injury so goal is normothermia and blood sugar maintained within parameters set by the MD via an insulin drip. Fluid goals with multi trauma and head injury is to do the trauma fluid resuscitation as it is important to maintain optimal cerebral blood perfusion of 70 mm hg and perfuse major organs.. Cerebral Blood Perfusion is MAP mean arterial blood pressure) - ICP. Brain damage will occur with MAP 50 or lower, so ideal is between 60 and 70--if higher than 70 multitrauma patient is at high risk of ARDS. Lactate levels and/or base deficit/excess guide fluid resuscitation. Also early surgical intervention to stop hemorrhage is necessary. Cystalloids are used first, then blood products as necessary. Normal saline is started first when there is brain injury at saline content is higher with NS compared to LR. There are some great youTube viseos on neuro assessment. Sedation used in the ICU is often Precedex or propofol. Phenelephrine can be used to raise blood pressure with sedation induced hypotension. Dealing with family can be hard. I like open visiting during daytime hours. Family can be helpful too. Patients end up on tube feeding. Probiotics and fiber are helpful to prevent diarrhea. Also one of the things I always thought was difficult with neuro assessment is the fact that patients wax and wane, so you can expect a neuro exam to be worse when the patient is fatigued or during normal sleep time for that person. I sometimes had a hard time knowing if this change was a problem or a wax and wane issue. You already know a lot as a CVICU nurse, so this will just be a wonderful learning experience.