Cerebrovascular Dysfunction Flashcards
physical exam findings
- mental status - orientation (situation, person, place, time)
- Glasgow coma scale (verbal, motor, eye, LOC)
- cranial nerves (movement and pupils)
- posturing (flexion/extension)
- reflexes
- intracranial pressure
signs of increased ICP (9)
- headache
- decreased LOC
- seizure
- vomiting w/ out nausea
- papilledema
- periorbital bruising
- cranial nerve VI palsies (looking side to side)
- cushing’s triad
- peds = increasing agitation
Glasgow coma scale
- eye opening
- verbal response
- motor response
Glasgow coma scale scores
- 15-13 = mild head injury
- 12-9 = moderate head injury
- 8-0 = severe head injury (coma)
assessment of infant responsiveness
- alert - responsive to parents, babbles, smiles
- verbal - responsive to verbal stimuli
- pain - responsive to painful stimuli only
- unresponsive - to painful stimuli
diagnostic test for head injury
- neuroimaging - MRI, CT
- X-Ray
- EEG = electro encephalogram - abnormal electrical impulses
- biopsy
- lumbar puncture
MRI for peds
need to be sedated which is bad for a head injury
EEG for kids
- sleep deprived EEG
- kid has not slept so that they sleep through EEG
lumbar puncture
- worried about how much increased ICP they have
- if highly increased then LP can cause brain to shift down and put pressure on brain stem affecting autonomic functioning
tentorial herniation
- when LP causes brain to shift down and put pressure on brain stem
LP for kids
roll on their side
concussion
- the brain shakes in skull stretching fibres holding brain in place
- stretch releases neurochemicals = symptoms
concussion symptoms
- fog
- headache
- photosensitivity
- nausea
- confusion (short or long)
- amnesia 5 mins before event
- weird pupil response
concussion treatment
- physio
- gradually brought back to activities that increase HR
- avoid weight training because of straining which increases ICP
meningitis
inflammation of the meninges
- less often now cause of vaccines
types of meningitis
- bacterial = worse than viral, caused by bacteria
- viral = caused by a virus
meningitis symptoms (8)
- stiff neck
- headache
- Kernig’s sign
- Brudzinski’s sign
- rash (red/purple pinpoint)
- photosensitivity
- high temp
- lethargy/irritable
Kernig’s sign
- to diagnose meningitis
- pain when knee bent
Brudzinski’s sign
- to diagnose meningitis
- knees bend when head if lifted
3 main seizure types
1) partial seizures
2) generalized seizures
3) unclassified epileptic seizures
epilepsy
- more than one seizure
- a chronic disorder
- no triggers
partial seizures
- local onset
- involve small location in brain
- one hemisphere
- no loss of consciousness
- short lived
generalized seizures
- initial discharge from both hemispheres
- no focal onset
- lose consciousness
unclassified epileptic seizures
- don’t fit into any other category
- generally associated with other syndromes
febrile seizures
- seizure associated with a febrile illness (upper resp or GI)
- absence of CNS infection
- no acute electrolyte imbalance
- higher risk w seizure disorder
- peds population
- happens at initial spike in temperature once per illness
- some kids are just more prone than others
- treat infection in ER and educate
status epilepticus management
- medical emergency
- ABC’s, vitals
- O2 - not taking big breaths (100%)
- IV access and IV or rectal antiepileptics
status epilepticus
- full blown seizure lasting at least 10 mins
steps for seizure management (7)
- safety (move objects) & help
- time
- place on side
- O2 sat & monitor
- call doc for stat med orders
- if 10+ mins get BP (manual) and BG
- admin anti epileptics
antiepileptics
- lorazepam (Ativan) is drug of choice = shorter 1/2 life and less risk of resp depression
- can give IV or rectally, kept in fridge, cant draw up in advance
- dilantin (Phenytoin) - filtered when IV
- not diazepam
management of seizures
- drug therapy
- ketogenic diet
- vagus nerve stimulation
- surgical
ketogenic diet
- high fat no sugar
- lowers seizure threshold
vagus nerve stimulation
- implanted
seizure surgery
- cut corpus callosum
Cushing’s triad
- requires intubation
- widened pulse pressure (systolic rises but not diastolic)
- bradycardia
- irregular respirations
interventions to lower ICP
- airway management
- hyperventilation
- activity management
- positioning (45 degree angle)
- bowel management (no straining)
airway management to lower ICP
- hyperoxygenation
- open airways
activity management to lower ICP
- cluster interventions so not bugging all the time
- quiet calm environment to decrease brain stimuli
stroke
- ischemia or hemorrhage results in death of brain cells
- severity based on location and extent of brain involved
2 types of stroke
- ischemic - blocking flow
- hemorrhagic - bleeding
ischemic stroke
- 87% of all strokes
- thrombotic or embolic
- TIA usually precursor
transient ischemic attack
- TIA
- resolves, lasts ~1hr
- may be residual effects
- increases risk of stroke
thrombotic stroke
- thrombosis from injury to blood vessel wall and formation of clot or narrowing of blood vessel
- most common cause of stroke
embolic stroke
- embolus lodges and occludes a cerebral artery
- infarction and edema of area supplied by artery
- rapid severe clinical symptoms
- sudden onset as immediate blockage
- may or may not be r/t activity
- usually conscious with headache
carotid endarterectomy
- surgery for stroke
- shunt placed to re-route BF around blockage
brain stent
- placed in clogged artery to open in
edovascular treatment in cerebral ischemic stroke
- removal of clot with wire and balloon
hemorrhagic stroke
- 15% of all strokes
- bleeding into brain tissue or subarachnoid space
- from ruptured vessel
- HTN is most important cause
- occurs during period of activity
why does hemorrhage occur during activity
- increased BP
- can sometimes also happen first thing in AM as BP is higher in AM
intracerebral hemorrhage
- sudden onset of symptoms with progression over minutes to hours
- neuro deficits
- headache
- N & V
- decreased LOC
- HTN
subarachnoid hemorrhage
- commonly cause by ruptures of a cerebral aneurysm
- majority of aneurysms are in circle of Willis
- “worst headache of life”
GDC coil
- coiling an aneurysm
- slow blood through it decreasing BF and rupture potential
clipping and wrapping of aneurysm
- clip aneurysm so blood doesn’t flow into it causing rupture
signs of stroke
- face = drooping
- arms = cant raise both
- speech = slurred/jumbled
- time = brain tissue
treatment of bacterial meningitis
- anitpyretics
- antibiotics
treatment of viral meningitis
- symptom management
- self-limiting disease
CSF bacterial meningitis
- increased pressure
- increased protein (5+)
- low glucose
- thick, cloudy
CSF viral meningitis
- increased pressure
- increased protein (0.5-5)
- normal or low glucose
- clear or cloudy
