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Nursing Vigilance Calms Neuro Storm

Thursday May 15, 2003
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"It's unpredictable; and when you're the nurse taking care of the patient, you're in the midst of the storm. It's an uncontrolled situation."

His name was Damien, and he weathered a storm the likes of which few nurses witness. The victim of a serious motor vehicle accident in January, Damien endured the onslaught of neuro storming, an autonomic instability that can occur following traumatic brain injury.
As frightening as a tornado to the untrained eye, neurogenic storming is seen in 11% to 15% of patients with severe brain trauma, says Mark Klingbeil, MD, medical director of neuro rehabilitation services at Froedtert Hospital in Milwaukee.
"It's something we see not infrequently," says Klingbeil. "It's thought to be due either to an injury to the upper portions of the brain stem or the hypothalamus."
Neuro storming produces an excitatory response within the brain as the autonomic nervous system becomes hypersensitive. Rapid signs, such as hypertension, tachycardia or other dysrythmias, accelerated metabolism, hyperthermia, dilated pupils, cognitive impairment, tachypnea, poor eye tracking, tonic muscle activity, and abnormal sweating, surge in this adrenalinemia-like syndrome.
Klingbeil says neuro storming occurs when the autonomic nervous system loses control, causing a massive discharge of neuro transmitters, such as adrenaline, to be released from the central nervous system (CNS). The CNS becomes damaged or traumatized by an onslaught of rampaging neuro transmitters.
The syndrome can be fatal if its symptoms go untreated; malignant hypertension is one lethal example of unchecked neuro storming. If ignored, the condition can lead to herniation of the brain or even cerebral hemorrhage.
Becky Lauder, RN, CCRN, cared for Damien, 15, in Froedtert's surgical ICU when his storms began. At the time, he demonstrated decerebrated posturing, unresponsiveness, and a 104 F fever. His blood pressure flew to the 200s/100s; his heart rate jumped to 140 to 160. Damien required ventilatory management.
"His neuro storms would last 20 to 30 minutes at a time every one to two hours," Lauder says. "He required constant supervision on my part to ensure he didn't harm himself."
Witnessing such symptoms play out in patients explains why the syndrome is so aptly named, says Denise Lemke, a nurse practitioner with 25 years' experience in neuroscience nursing who works in interventional neuroradiology at Froedtert.
"Neuro storming is a spontaneous occurrence," she says. "It's unpredictable; and when you're the nurse taking care of the patient, you're in the midst of the storm. It's an uncontrolled situation."
Observant nurses will react to that situation, though it can be difficult to recognize.
"In these patients, EEGs show no epileptic activity," Lemke says. "There is hyperactivity of the brain, but CTs or MRIs will not show consistent abnormalities."
A symptomatic approach to treatment of patients experiencing neuro storms can be effective. Beta-adrenergic blocker drugs, such as Inderal, a CNS depressant, can be beneficial in reducing some signs and symptoms of neuro storming. Oxycodone or morphine sulfate, an opiate release drug, can help calm patients during the storm; and bromocriptine reduces diaphoresis and hyperthermia.
Finding the right medication to reduce patients' sympathetic neuro output, however, may take time - valuable time. Delays in suppressing the excitatory neuro response can lead to myocardial changes or further cerebral damage. High tachycardic episodes can cause hypoxic complications. A ketabolic state can develop, leading to acidosis.
But triggers should be watched, as well. Triggers - few for some patients, many for others - serve as catalysts that induce reactions in the body. They can come in the form of internal stimuli or external stimuli that amplify patients' discomfort. Triggers can include infection, nerve pain, cellular edema, psychological stress, and even environmental confusion, such as noise. Mere suctioning or soft restraints placed on patients can be enough stimuli to trigger a corporeal storm.
Lauder remained vigilant for triggers and signs of further trouble throughout Damien's stay in the SICU. She was relieved to see the teenager withstand the storm raging in his brain.
"It was amazing to see his progress during the course of seven days," she says. "It clearly reminded me of what a difference a day can make."
When Damien arrived on Froedtert's inpatient trauma unit, he still encountered sympathetic storms. On his fourth day in the unit, however, Damien "woke up." His eye tracking was focused with substantial cognitive return. As he still had a tracheotomy, he began to spell out words on a letter board, surprising both his parents and the medical staff.
Damien was next transferred to the neuro rehabilitation unit, where the teenager's spirit triumphed. His rehab nurse, Marcia Stickle, RN, remembers his remarkable improvement. Damien would challenge the staff, she recalls, with his own form of self-transfer. He would dive into bed, Stickle says.
Patients like Damien can recover from neuro storming when their nurses recognize trouble on the horizon. Vigilant nurses can break the cycle of irritability and agitation in patients in the throes of the syndrome. Sometimes that means quick determination of pharmacologic relief; sometimes it means a simple cool washcloth applied to a patient's forehead. Either way, with the right know-how, nurses can help calm even the toughest neuro tempest.