NeuroNerd

1. In an unsecured/unidentified aneurysm, it is standard to see AED given because those patients are at an increased risk for seizures due to the irritation from the blood in the subarachnoid space. Also, vasospasms are common in the acute period for that pt population, with the risk being the highest on days 7 through 14. Seizure activity has been associated with an increased risk of further disability and even pt mortality. Seizures are a known complication of this type of neurologic injury, and that is why you see patients on an AED. Once the aneurysm has been secured, the risk of mortality/further neurologic damage is rare, and they will discontinue prophylactic therapy. 2. In patients with cerebral edema, you will almost always see them on an AED. Hypertonic saline/mannitol is used at the neurosurgeon's discretion, and it is based on the patient's serum sodium level. The goal of hypertonic saline is to prevent herniation. If herniation appears to be imminent, the physician or AAP can push 23% saline that usually will take effect faster than the hypertonic or mannitol. If the patient's scan shows increased cerebral edema and the brain has no room to continue swelling, Neurosurgery will most likely have you bolus the patient with Mannitol, intubate them and take them to the OR for a crani. They may even do this first, depending on how imaging looks. 3. Hypertonic isn't a medication that would be started as a first-line treatment. The pt should have had imaging completed to assess for neurologic injury. Labs should be assessed, and if the imaging shows that hypertonic is appropriate, it would be started then based on the sodium result from labs collected before his scan. If the patient is posturing, they are most likely herniating or experiencing cerebral edema. The patient would need an emergent consult to neurosurgery and most likely end up with a crani.

I'm sure that you have figured out the answer to this, but just in case you haven' - here you go! If the pt can move all extremities, you wouldn't score him for not following commands; you would only score him for his receptive aphasia. I've had stubborn patients that refused to participate in their neuro assessment when I was in their room, but as soon as I would leave, they would move everything without any issues. I scored them for what I saw outside the room and documented in the chart that they refused to participate in their exam when I was in the room. You also have to consider seizure a possibility with 95%, if not all neuro pts. You always have to watch neuro patients because what they won't do while you're in the room, a lot of the time they'll do when they think you're not watching. You'll think they cannot move or they have had a neuro change and, next thing you know, they're jumping the side rails standing butt naked ready to go home. Assessing neuro patients is an ongoing process. Not only do you see what they are truly able to do, but you are also able to catch neuro changes quicker and intervene immediately. I always position myself directly outside my most critical/acute patient to see them throughout my shift.