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Neurointensivismo

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Neurointensivismo

  1. 1. MonitorizaçãoNeurológica em UTI
  2. 2. Alterações no Nível de Consciência Rebaixamento do nível de consciência é o parâmetro mais sensível de insuficiência encefálica. Escalas preditivas para avaliação do paciente consciente e inconsciente.
  3. 3. Alterações mais comuns Letargia ou sonolência: paciente acorda ao estímulo auditivo, está orientado no tempo, espaço e pessoa, responde lenta. Estado confusional agudo ou delirium: sintomas de início agudo, de caráter flutuante e com intervalos de lucidez. Obnubilação: paciente muito sonolento, ou seja, necessita ser estimulado intensamente, com associação de estímulo auditivo mais intenso e estímulo tátil.
  4. 4. Alterações mais comuns Estupor ou torpor: mais sonolento, não responsivo, necessitando de estimulação dolorosa para responder. Coma: Neste estado o paciente apresenta apenas respostas de reatividade
  5. 5. Escala de Coma de Glasgow Avaliação Pontuação1. Abertura ocular Espontânea 4 pontos Por Estimulo Verbal 3 pontos Por Estimulo A Dor 2 pontos Sem Resposta 1 ponto2. Resposta verbal Orientado 5 pontos Confuso (Mas ainda responde) 4 pontos Resposta Inapropriada 3 pontos Sons Incompreensíveis 2 pontos Sem Resposta 1 ponto3. Resposta motora Obedece Ordens 6 pontos Localiza Dor 5 pontos Reage a dor mas não localiza 4 pontos Flexão anormal – Decorticação 3 pontos Extensão anormal - Decerebração 2 pontos Sem Resposta 1 ponto
  6. 6. Escala de Coma de Glasgow
  7. 7. Escala de Coma de GlasgowEm que ano estamos? Solta!Almoço!Não Hugh! Ahrr! 2002 1972
  8. 8. Escala de Coma de Glasgow
  9. 9. Exame pupilar Avaliar diâmetro, simetria, assimetria e reflexo fotomotor;  Comparar uma pupila à outra;  Diâmetro normal: em média 3,5mm;  O diâmetro pode ser medido com uma régua ou por pupilômetro.
  10. 10. 1. Normais – Isocoria (= igualdade das pupilas)2. Dilatadas – Midriáse3. Contraídas – Miose4. Assimétricas – Anisocoria
  11. 11. Avaliação da força muscular Motricidade: capacidade de contração e relaxamento do músculo esquelético, controlada por fibras do sistema piramidal, extrapiramidal e cerebelar.
  12. 12. Sistema piramidal Responsável pela motricidade voluntária e integra os movimentos que exigem habilidade, movimentos delicados ou complicados.
  13. 13. Sistema extrapiramidal Responsável pela manutenção do tono muscular e pelo controle dos movimentos corporais, principalmente a deambulação. A lesão extrapiramidal não causa ausência de força motora, mas leva a um aumento no tono muscular, a alterações na postura e na marcha, à lentidão ou abolição dos movimentos involuntários.
  14. 14. Sistema cerebelar Responsável pela movimentação automática, involuntária e por correções e modulações dos movimentos voluntários. Proporciona um movimento mais preciso e coordenado; A lesão no sistema cerebelar conduz a alterações na coordenação, na marcha, no equilíbrio, como também reduz o tônus muscular.
  15. 15. Monitorização Neurológica em UTI Objetivos primários da Neuro-ICU: • 1- Manter fluxo sanguíneo cerebral fisiológico; • 2- Oxigenação cerebral adequada; • 3- Reduzir danos neurológicos secundários;
  16. 16. Doutrina de Monroe-Kelie Crânio MASSAENCEFALICA LÍQUOR SANGUE HEMATOMA Águaintra/extracelular Doutrina de Monroe-Kelie
  17. 17. Monitorização Neurológica em UTI PIC > 20mmHg = Hipertensão intracraniana moderada ≥ 40 > grave• Diversos autores encontraram melhores outcomes PIC<= 15mmHg• Uso de cateteres intraventriculares ou intraparenquimatosos Brock M.; University of Hannover.
  18. 18. Pressão de Perfusão Cerebral PPC = PAM – PICPPC normal: 70 mmHgPPC abaixo de 60-70: aumento de mortalidade e seqüelas neurológicas.
  19. 19. Monitorização Neurológica em UTI Pressão Perfusão CerebralPPC = PAM – PIC (Pv)Objetivos:1- Manter FCS adequado com PPC 60-70mmHg2- Reduzir probabilidade de isquemia cerebral
  20. 20. Fluxo Sangüíneo Cerebral Cérebro: 750 ml de sangue/min => 15% do DC e 20% do consumo de O2 cerebral. FSC normal: 50-60 ml/100g/min Se o FSC cai: diminui função neuronal e depois, há lesão cerebral irreversível. Se o FSC aumenta: edema cerebral e áreas de hemorragia.
  21. 21. Fluxo Sanguíneo Cerebral FLUXO SANGUINEO CEREBRAL
  22. 22. Tipo de Onda de PIC Normal  Aumentada
  23. 23. Monitorização Neurológica em UTI  Utilizar cateteres intraventriculares/ intraparenquimatos; Vantagens no intraventricular: • tratar hipertensão intracraniana atráves de retirada de LCR • Dosagens de lactato/piruvato – acompanhamento isquemia; • Dificuldades qdo edema cerebral com colabamento de ventriculos • Pico de taxa de infecção até o 5 dia após mantem um platô taxa 1,7%/d
  24. 24. Tratamento da HIC
  25. 25. Conduta Inicial UTI
  26. 26. Monitorização – PaCO2 Alterações no FSC
  27. 27. O2 PaO2<50 mmHg ↑ FSC por vasodilatação Pode haver hiperemia, edema, evoluir com aumento da PIC e diminuir PPC, causando isquemia e lesão neuronal secundária.
  28. 28. Monitorização BIS BIS
  29. 29. Monitorização Neurológica em UTI BIS
  30. 30. Hipotermia na UTI - Indução Diminuição do Metabolismo Neurológico; Diminuição Lesão Secundária;
  31. 31. Lesão NeurológicaTipos de Lesão Neurológica – Área Penumbra

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