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Description : Herniation

Tags : brain herniation

Published on : Mar 18, 2020 | Views : 1786 | Downloads : 8

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BRAIN HERNIATION Ralph Marlon M. Guballa
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DEMOGRAPHICS Patient: RV Age: 12 years old Sex: Male Ward/Bed No.: 9/8 Date of Admission: 01-20-2020 Date of Death: 01-24-2020 Weight: 40kg Case No.: 4735550 Residenst-In-Charge: Dr. Barbadillo/Dr. Martinez
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HISTORY OF PRESENT ILLNESS CC: Seizures 1 week prior to consult Noted onset of cough with yellowish sputum, no other symptoms No medicine taken, no consult done 2 days prior to consult Patient had undocumented fever, took Paracetamol with minimal relief 1 day prior to consult Patient noted foreign body (insect) went inside left ear (+)nape pain (+)recurrence of fever (+)increased sleeping time Took Mefenamic Acid with minimal relief, no consult done 9 hours prior to consult Noted onset of “blank stares” (+)weakness (+)change in behavior 4 hours prior to consult Patient could not stand (+)generalized weakness (+)stiffening of hands Patient brought to local hospital, advised transfer hence PGH consult
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PAST MEDICAL HISTORY (-)allergies (-)PTB (-)hospitalization (-)surgery (-)maintenance medications
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LIFESTYLE Non-smoker, non-alcoholic Denies illicit drug use Supposedly in Grade 7 but stopped attending class because of bullying
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REVIEW OF SYSTEMS 1-20-2020 (-)headache (-)urinary and bowel changes (+)vomiting (+)status epilepticus (+)drowsy (+)not arousable (+)responds to pain 1-21-2020 (-)seizure (+)bleeding right ear (+)febrile episodes 1-22-2020 (-)seizure no response to pain – all extremities 1-23-2020 no spontaneous eye opening no spontaneous movement no reaction to light
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VITAL SIGNS
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HEMATOLOGY
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ARTERIAL BLOOD GAS ↓ ↓ N METABOLIC ACIDOSIS ↓ ↓ ↓
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BLOOD CHEMISTRY
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URINALYSIS
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Gram Stain Ear discharge (1-21-2020) = Gram (+) cocci in clusters Endotracheal aspirate = Gram (-) bacilli Cranial CT Scan Impression (1-21-2020): Diffuse cerebrocerebellar edema Tonsillar herniation Tymapnomastoiditis
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PWI: Acute Suppurative Otitis Media (ASOM) An infection of the middle ear Pus and infected fluid accumulate in the middle ear space and discharged The foreign body/insect that went inside the left ear caused the ASOM during its mechanism of blood feeding of the ear drum. Middle Ear
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PRESENT WORKING IMPRESSION Brain Herniation Acute CNS Infection Bacterial Meningitis Viral Encephalitis
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Acute CNS Infection Bacterial Meningitis Meningitis is the inflammation of the leptomeninges and the most common central nervous system (CNS) bacterial infection. Spread of infection from the ear causes intracranial complications like mastoiditis and meningitis. Bacteria invade the CNS following: direct inoculation of the brain parenchyma or by spread from a focus of infection outside the CNS or hematogenous spread, the most common route
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Meningitis in the setting of acute suppurative otitis media may be secondary to the direct spread of infection through the skull then penetrates the dura. Eventually ending up in CSF.
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Pathogen Endothelial Cells of Blood Brain Barrier Through: Binding to surface receptors Areas of damage
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Acute CNS Infection Bacterial Meningitis The development of brain edema further compromises cerebral circulation, and this effect can result in increased intracranial pressure (ICP) and brain herniation. Seizures are a common complication of bacterial meningitis.
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Acute CNS Infection Inflammation of meninges, the covering of the brain Inflammation of the brain itself Two main ways virus can get into the CNS: 1)Hematogenous Spread 2)Retrograde Axonal Transport
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-coming from the blood Virus highly selective semipermeable border that separates the circulating blood from the brain Virus either has to: Directly infect and pass through the endothelium Or they need to pass between endothelial cells Either by disrupting or loosening the tight junctions between endothelial cells Or by sneaking a ride on cells such as immune cells that might be passing between endothelial cells
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Virus Axon Neurons Neurons have transport mechanism that carry molecules along the axon in both direction. Virus hitch a ride on these transport mechanism to travel into the CNS.
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Acute CNS Infection Viral Encephalitis Cardinal signs and symptoms of viral encephalitis include: Headache Fever Alterations of consciousness (ranging from lethargy to coma) Confusion Personality changes Motor weakness Seizures Increased intracranial pressure can occur and progress to coma.
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BRAIN HERNIATION Occurs when brain tissue, blood, and cerebrospinal fluid (CSF) shifts from their normal position inside the skull. Classified based on the structure through which tissue is herniated: Tonsillar herniation: Usually, the cause is an expanding infratentorial mass (eg, cerebellar hemorrhage), forcing the cerebellar tonsils, through the foramen magnum. Clinical Manifestation: Impaired consciousness Neck rigidity Vomiting Irregular respirations Bradycardia
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DRUG THERAPY PLANBrain Herniation probably from Acute CNS Infection probably from Bacterial Meningitis or Viral Encephalitis &Acute Suppurative Otitis Media
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DRUG THERAPY PLANStatus Epilepticus from Acute CNS Infection
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DRUG THERAPY PLANNeurogenic Shock
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DRUG THERAPY PLANMiscellaneous Drugs
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PROBLEM AND INTERVENTION Phenobarbital may increase the hepatotoxic potential of Paracetamol and decrease its therapeutic effects. Monitor: If temperature does not go down to <37.80C upon administering Paracetamol. Jaundice ↑AST, ALT, Bilirubin Valproic Acid may displace Diazepam from plasma protein binding sites and inhibit its metabolism. Valproic Acid may increase the plasma levels of Phenobarbital. CNS- or respiratory-depressant effects may also be additively increased. CNS- or respiratory-depressant effects may be additively increased in patients taking Diazepam and Phenobarbital. Close observation of excessive sedation. Close observation of: Excessive sedation and Lethargy Close observation of: Excessive sedation Lethargy Shortness of breath
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PHARMACIST’S CARE PLAN
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PHARMACIST’S CARE PLAN
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PHARMACIST’S CARE PLAN