Ch18: Neurologic Emergencies Flashcards
Role of brainstem
the most basic functions of body such as breathing, bp, pupil constriction
Role of cerebellum
coordinate complex tasks e.g. playing piano, standing on one leg
Role of cerebrum
Front: emotions and thought
Middle: senses and movement
–> in most ppl, left and middle = speech
Back: sight
how many pairs of cranial nerves run DIRECTLY from the brain to the rest of the body
12
what is the large opening in the base of the skull called
foramen magnum
how many spinal nerves per each vertebrae
2, one on each side
what 3 changes is the brain most sensitive to?
oxygen, glucose and temperature
coma
state of unconsciousness where the patient cannot be roused
do the brain and spinal cord sense pain
no, they don’t have pain receptors
if the brain and spinal cord do not have pain receptors, what causes the feeling of headaches?
scalp
meninges (membrane around brain and SC)
blood vessels
muscles around head, neck & face
what causes tension headaches
caused by muscle contractions in the head & neck. caused by STRESS
quality of tension headache pain
dull, ache, squeezing
do tension headaches usually require medical attention?
no
what causes migraine headaches
change in size of blood vessels at the base of the brain
quality of migraine pain
pounding, throbbing, pulsating
are men or women more likely to get migraines
women by 3x
symptoms associated with migraines
nausea
vomiting
visual warning signs like partial vision loss
what causes sinus headaches
pressure build up in the sinus cavities
symptoms of sinus headaches
Pain, pressure and fullness in the cheeks, brow or forehead.
Worsening pain if you bend forward or lie down.
headache RED FLAGS
sudden onset
very severe pain - “worse than anything before”
explosive, thunderclap pain
altered mental status
neurologic deficits
changes in vision
one side paralysis or weakness
age over 50
depressed immune system
fever
stiffness
what is a hemorrhagic stroke?
ruptured blood vessel in the brain that causes an increase in intracranial pressure (ICP), hence a headache
early signs of ICP
altered mental status
seizures
vomiting
headache
causes of ICP
hemorrhagic stroke
tumor
swelling/inflammation from a recent head trauma
bacterial meningitis
bacterial infection of the meninges that results in headache, sensitivity to light, stiff neck and fever. CONTAGIOUS
what is a cerebrovascular accident (CVA)
stroke - interruption to blood flow in the brain that results in loss of function –> cause ischemia
ischemic stroke
caused by a blood clot that obstructs blood flow either a thrombus or embolus
thrombus
clot formed right at the site of obstruction
embolus
clot stuck in a vessel that originated from somewhere else
patients with what kind of conditions are more prone to ischemic strokes?
atrial fibrillation, they take blood thinners
and coronary artery disease
how does atherosclerosis cause ischemic strokes?
if the plaque in the carotid vessel wall ruptures, blood clotting processes are stimulated and blood clots form. the clots can obstruct the carotid vessel and prevent blood flow to the brain.
hemorrhagic stroke
bleeding in the brain because of ruptured vessel
transient ischemic strokes
mini strokes caused by partial obstruction of vessel that resolves on its own
general symptoms of stroke
face drooping
one side weakness
neglect - only lifting one arm
slurring (dysarthria)
lack of muscle coordination
loss of balance
aphasia - cannot express thoughts with the right words
severe headache
dizziness
confusion
combativeness
tongue deviation
coma
symptoms of stroke in left hemisphere
*left, mid hemisphere controls SPEECH
aphasia - can test by asking patient a question
weakness or paralysis on right side
symptoms of stroke in right hemisphere
slurred
left side weakness, paralysis
neglect - one arm, lack of pain, certain part of vision
cerebral hemorrhage
bleeding in the brain characterized with high bp (either caused by or compensated with it)
big indicator of cerebral hemorrhage
increasing blood pressure
followed by decreasing to normal level
and then sudden drops
conditions that mimic stroke
hypoglycemia
postictal state - for 5-30 mins after a stroke where there is altered mental status and labored respirations
subdural, epidural bleeding
bleed above dura of brain
epidural bleed
bleed below dura of brain, but outside brain
subdural bleed
what is the period of time between injury and deterioration in someone with epidural bleeding
lucid interval
seizure
an episode of electrical surge that causes convulsions characterized by uncoordinated muscle activity and/or altered LOC
generalized seizures
electrical surge from large area of the brain that causes generalized twitching and convulsions (generalized motor seizures).
sometimes it only shows as a brief lapse of consciousness (generalized absence seizures).
other symptoms associated w/ generalized seizures:
hyperventilation
tachycardia
sweating
drooling/salivation
incontinence
postictal state
5 - 30 minutes after a generalized seizure when person might have:
altered LOC
hemiparesis (weakness on one side: stroke-like symptoms)
labored breathing to level hypercapnia
focalized seizure
electrical surge coming from a particular area of the brain
types of focal seizures
aware and impaired-awareness
both can either be motor or absence
what happens during a focal-onset aware seizure
no changes in LOC
possible changes in senses
twitching of muscles that spread to extremities but not as much as generalized seizures
paralysis
cause of focal-onset impaired-awareness seizure
abnormal discharges from temporary lobe
what happens during a focal-onset impaired-awareness seizure
lapse of consciousness
isolated twitches e.g. lip smacking, eye blinking
unpleasant smells, visual hallucinations, fear, repetitive physical movements
patients don’t remember the episode
aura
signs that a seizure is coming. e.g. vision impairment or hallucinations
status epilepticus
when a seizure recurs every few minutes OR lasts more than 30 minutes
what to do with status epilepticus
ALS!! need airway mgmt and medication to stop seizures
common causes of seizures
1) epileptic
2) structural
- tumor
- scar tissue
- infection
- head trauma
- stroke
3) metabolic
- hypoglycemia
- hypoxia
- abnormal chemical values
- poisoning
- overdose
- withdrawal
4) febrile - fever in children
seizure medications
levetiracetam (Keppra)
phenytoin (Dilantin)
phenobarbital
carbamazepine (Tegretol)
valproate (Depakote)
topiramate (topamax)
clonazepam (klonopin)
causes of altered mental status
AEIOU TIPS
Alcohol
Epilepsy, Endocrine, Electrolytes
Insulin
Overdose or other drugs
Uremia
Trauma, temperature
Infection
Poisoning, psychogenic causes
Shock, stroke, seizure, syncope, subarachnoid hemorrhage
delirium
change in mental status characterized by disorganized thoughts, hallucinations, disorientation, memory loss and changes in personality
which is worse: seizures in a patient with a Hx of seizures or no Hx
no Hx because it indicates a potentially dangerous change in the brain e.g. tumor or intracranial bleeding
stroke assessment
BE-FAST
Balance
Eyes
Facial droop
Arm lift
Slurring/speech
Time
most commonly used pre-hospital stroke screening
Cincinnati Prehospital Stroke Scale
Los Angeles Prehospital Stroke Screen
Cincinnati Prehospital Stroke Scale
FAS
Facial droop
Arm lift
Slurring/speech
Los Angeles Prehospital Stroke Screen
- Age > 45
- History of seizures/epilepsy
- Symptoms <24h
- Patient is not bedridden or wheelchair-bound at baseline
- Blood gluc between 60-400 mg/dL
- Asymmetry in: face (smile/grimace), arms and grip
what stroke scale is used in the hospital
NIH Stroke Scale (11 steps)
0 stroke symptoms
1-4 minor stroke
5-15 moderate stroke
16-20 moderate to severe stroke
20-42 severe stroke
3-Item Stroke Severity Scale
LAG
LOC
0 = normal
1 = mild dysfunction
2 = severe dysfunction e.g. unconscious
Arm drift (hemiparesis)
0 = none
1 = drift
2 = no movement on one side
Gaze
0 = normal gaze
1 = mild dysfunction
2 = severe dysfunction - cannot follow moving objects (fixed gaze)
Key information to document for a patient with suspected stroke
1) time of onset; sign + symptoms
2) GCS score
3) Stroke scale (NIH, LA, Cincinnati, LAG, BE-FAST)
4) Changes during reassessment
within how many hours do fibrinolytic drugs work to reverse the clot of a stroke?
3 hours
are febrile seizures in children usually benign or life-threatening?
benign
