Adrenal and Neurological Disorders: Key Indicators
Adrenal Disorders: Key Indicators
| Disease | Na+ | BP | Blood Volume | K+ | Glucose |
|---|---|---|---|---|---|
| Addison’s Disease | ↓ | ↓ | ↓ | ↑ | ↓ |
| Cushing’s Syndrome | ↑ | ↑ | ↑ | ↓ | ↑ |
Neurological and Hepatic Conditions
Cushing’s Triad: Hypertension (wide pulse pressure), bradycardia, irregular respirations.
Glasgow Coma Scale (GCS): Minor 13-15 | Moderate 9-12 | Severe 3-8 (8 = coma). Best score = 15 | Worst score = 3 | Eye (4 points) | Verbal (5 points) | Motor (6 points).
Normal Cerebral Perfusion Pressure (CPP) = 60-100 mmHg | <50 mmHg: ischemia to neurons | CPP = MAP – ICP | Normal ICP: 5-15 mmHg; >20 mmHg: medical emergency.
Neomycin (PO or rectal) for hepatic failure: helps decrease bacteria & ammonia levels (Lactulose also used).
Ascites: Sodium and fluid restriction.
Tolvaptan: Vasopressin antagonist that manages hyponatremia.
Hepatic Encephalopathy (Hep. Encep.): Mental status changes & asterixis (neurological checks every 2 hours).
Cirrhosis Diet: Low protein, high calorie (small, frequent meals), moderate to low fat, low sodium (for ascites & edema). Supplement with B complex vitamins, vitamins A, C, and K, folic acid, and thiamine.
Endoscopy: Procedure of choice for examining Upper Gastrointestinal (UGI) bleeds. Barium studies evaluate the site and tumors. Angiography is used when endoscopy cannot be performed. For active bleeding, check vital signs every 15-30 minutes.
Delirium Tremens: Agitation, uncontrolled shaking, sweating, and hallucinations (hemorrhage related to chronic alcohol (ETOH) abuse).
Somatostatin (Octreotide): Reduces portal pressure.
Transjugular Intrahepatic Portosystemic Shunt (TIPS): A non-surgical procedure for recurrent bleeding (using fluoroscopy). A stent is placed between the hepatic and portal veins to reduce pressure. Connect balloon to manometer (20-45 mmHg), secure to avoid dislodging, tape to face or helmet. Avoid necrosis, deflate every 8 hours for 15 minutes. A common complication is pulmonary aspiration. If it migrates, it may occlude the airway; deflate with respiratory distress.
Neuromuscular Disorders
Guillain-Barré Syndrome (GB): Autoimmune disorder causing muscle weakness, sensory loss, and areflexia (respiratory status is very important). It starts in the lower extremities and ascends. Decreased/absent tendon reflexes are an *early sign*. Decreased inspiratory force and tidal volume occur when it reaches the thorax, indicating respiratory compromise.
Lumbar Puncture to diagnose GB: Elevated Cerebrospinal Fluid (CSF) proteins with normal cell counts. Plasmapheresis (plasma exchange) removes antibodies causing the syndrome. Obtain weight before/after, monitor vital signs, and watch for dizziness and hypotension. Monitor the site for bruising and infection. Complications include *hypovolemia*, infection, and electrolyte imbalance. Intravenous Immunoglobulin (IVIG) is given for 5 days based on body weight to help suppress the attack on the immune system. Assess motor function every 2-4 hours. Prevent Deep Vein Thrombosis (DVT), Pulmonary Embolism (PE), and skin breakdown. Neurotin (gabapentin) is used for neuropathic pain, along with morphine.
Amyotrophic Lateral Sclerosis (ALS): Affects upper and motor neurons in the brain and anterior gray horns of the spinal cord. It causes progressive muscle weakness, wasting, atrophy, spasticity, and reflexia. Symptoms include twitching, cramping, dysarthria (slurred speech), dysphagia (difficulty swallowing), and fasciculations (twitching) of the face. Baclofen is used as an antispasmodic, and Riluzole (a glutamine antagonist) helps slow the progression/deterioration of motor neurons from hepatotoxic agents. Monitor progression and the need for respiratory support.
Multiple Sclerosis (MS): Autoimmune disorder affecting myelin sheaths. An inflammatory response causes diffuse, patchy areas of plaque in the white matter. The myelin sheath is damaged, and its thickness is reduced (demyelinated). Impulses are not transmitted as effectively, and over time, they may be completely blocked. The patient’s history is most important to obtain (vision, mobility, and sensory changes). Ask about the progression of symptoms and aggravating factors (avoid extreme temperature changes, stress, and fatigue). A CT scan may be used. Treatments include Interferon beta (Avonex, Betaseron, Rebif), Natalizumab, and Glatiramer. An eye patch is used for diplopia (rotate the patch from eye to eye to keep eye muscles stronger).
Myasthenia Gravis (MG): Autoantibody attack on acetylcholine receptors in muscles, preventing contraction. Characterized by “weak muscles & respiratory muscles.” Onset may be slow (fatigue) or rapid. Limitations or inability to perform Activities of Daily Living (ADLs) include a history of ptosis (droopy eye), diplopia (double vision), dysphagia, respiratory difficulties, choking, and voice weakness.
Tensilon Test: Marked improvement in muscle strength for 4-5 minutes indicates myasthenic crisis (Neostigmine is used). Cholinergic Crisis: Muscle strength *does not improve* after Tensilon, and weakness may increase. Tensilon danger: Ventricular fibrillation, cardiac arrest (have atropine available as an antidote).
MG Crisis Management: Have an Ambu bag, oxygen, and an endotracheal tube ready. Provide small amounts of food with pyridostigmine. Eat meals 45 minutes to 1 hour after taking the drug to avoid aspiration. Monitor for myasthenic and cholinergic crises. Cholinergic Crisis: Administer atropine 1 mg IV and repeat as needed.