midterm Flashcards
subarachnoid hemorrhage: Five grades
- mild h/a with or w/out meningeal irritation
- severe h/a with or w/out pupillary change
- mild alteration in neurological exam
- depressed level of consciousness
- comatose with or w/out posturing
epidural hematoma: increase ICP: Cushing’s Triad
- (patient unresponsive w/imminent death):
1. systolic hypertension
2. bradycardia
3. irregular respiratory pattern
anterior cerebral artery stroke
- altered mental status
- impaired judgement
- contralateral weakness more in leg
- urinary incontinence
posterior cerebral artery stroke
- impaired thought/memory
- visual field deficits
vertebrobasilar artery occlusions
- vertigo
- syncope
- ataxia
- cranial nerve dysfunction- double vision, difficulty swallowing
middle cerebral artery stroke
-hemiparesis
subarachnoid hemorrhage
- arteries on brains surface bleed in subarachnoid space
- may cause mass shift
- caused by trauma, aneurysm, or arteriovenous malformation ruptures (arteries are directly connected to veins)
- signs: rapid onset of headache, unconsciousness, stroke symptoms
- elevate head, IV fluid
subdural hematoma
- may be acute, subacute, or chronic
- caused by tearing of bridging veins that communicate between the cerebral cortex and the venous sinuses -> blot clots
- coup-counter coup head injuries
- headache, unconsciousness, amnesia, hemiparesis
epidural hematoma
- trauma to the arteries in the epidural space
- high pressure mass effect
- trauma! -> usually skull fracture
- surgical decompression
- can sometimes be venous bleed -> depressed skull fracture
- dilated, fixed pupils
- Cushing’s triad- bradycardia, systolic hypertension, irregular respiratory patterns -> imminent death
- lucid interval- lose consciousness and then wake up
- do not start IV fluids unless BP is low, administer O2
frontal lobe
- speech
- motor cortex
- frontal association center
parietal lobe
- somatosensory cortex
- speech
- taste
- reading
temporal lobe
- hearing
- auditory association area
- smell
occipital lobe
-visual association area
intracranial hypertension (ICP)
- can compromise brain perfusion
- May be due to mass effect (hemorrhage or edema) or malfunction of ventriculoperitoneal shunt
- brain may herniate through foramen magnum (high mortality)
- unilateral pupil dilation
- loss of consciousness
- A ventriculoperitoneal (VP) shunt- relieves pressure on the brain caused by fluid accumulation.
meningitis
- Inflammation of meninges and infection of CSF
- infectious or non-infectious
- acute meningitis is usually bacterial infection (life threatening)
- bacteria colonizes in nasopharynx, spread to CSF
- Meningitis in infants usually caused by group B streptococcus or E. coli
- After 1 year old, Streptococcus pneumoniae and Neisseria meningitidis become more common
- lumbar puncture for CSF testing- diagnosis
- antibiotics for treatment
- signs and symptoms: nuchal rigidity, headache, photophobia, seizures, low LOC, death
- meningismus triad: headache, nuchal rigidity, photophobia
- kernigs sign- hip is flexed at 90 and legs cant straighten
- brudzinskis sign- flexing of the legs and hips when the neck is flexed
generalized seizures
- quickly involves both cerebral hemispheres
- loss of consciousness
- absence, atonic, tonic, clonic, and tonic-clonic
focal seizure
- involves only one cerebral hemisphere
- affects only one part of the body
- wakefulness is usually maintained
- may be changes in mentation, responsiveness, or behavior
absence: generalized seizure
- ceasing activity
- no response to stimulation
- lasts a few seconds
myoclonic generalized seizure
-isolated muscle jerking with no loss of consciousness
tonic generalized seizure
- increase in tone
- flexion or extension of the head, trunk, or extremeties
tonic-clonic generalized seizures
-vague warning (aura) followed by period of body rigidity (tonus)
-patient jerks rhythmically (clonus)
-can last minute
-frothing at mouth
-
atonic generalized seizures
-transient loss of muscle tone resulting in fall to the floor
guillain-barre syndrome
- A group of acute immune-mediated polyneuropathies
- Demyelinating disorders causing weakness, numbness, or paralysis throughout body
- Autoimmune response to recent infection
- Antibodies formed against peripheral nerves
- starts at legs and goes up -> goes to lung cavity
- can lead to pneumonia!
- intubate and ventilate
- Lack of deep tendon reflexes is strong indicator of Guillain-Barre
- May have loss of vibratory sense, proprioception and touch
- degradation of myelin sheath
- progressive weakness of 2 or more limbs due to neuropathy
- areflexia
- disease course < 4 weeks
- exclusion of other causes (vasculitis, toxins, botulism, diphtheria, porphyria, localized spinal cord or cauda equina syndrome)
5 categories of stimuli
- insect bites and stings
- medications
- food
- plants
- chemicals
leukotrienes
- contractions in smooth muscles lining the bronchioles
- more powerful than histamine
5 classes of antibodies
- IgG: 80% of all antibodies -> resistance against viruses & bacteria
- IgE: attaches to basophil & mast cell surface -> triggers release of histamine, increases inflammation
- IgD: on the surface of B cells
- IgM: 1st antibody secreted by plasma cells after antigen is encountered -> anti-A & anti-B antibodies of blood typing
- IgA: in glandular secretions (saliva, sweat)
4 types of hypersensitivity reactions
- Type I (acute/immediate) hypersensitivity (IgE)- allergic reaction
- Type II (antibody-dependent cytotoxic) hypersensitivity (IgG, IgM)- cytotoxic reactions -> hemolytic rxn and goodpasture syndrome
- Type III (Ag-Ab immune complex) hypersensitivity- immune complex deposition -> hypersensitivity pneumonitis, systemic lupus erythematosus, polyarteritis nodosa, serum sickness
- Type IV (delayed) hypersensitivity (T cells, cell-mediated)- delayed -> poison ivy, chronic graft rejection, PPD test
histamine
- dilates blood vessels
- vasodilation
- hypotension
- hypovolemic shock
wheels vs urticaria
- wheels -> localized
- urticaria -> systemic
benadryl
- antihistamine
- diphenhydramine
- blocks the effects of the naturally occurring chemical histamine in the body
- helps with urticaria and itching associated with an allergic/anaphylactic reaction
- emergency dosage- 50mg IV
corticosteroids
- anti-inflammatory
- solu-medrol
- helps to reduce inflammation over the long term as opposed to other medications such as epinephrine that work immediately
- long term acting
- emergency dosage- 125 mg IV
epinephrine
- blood vessel constriction
- reverses vasodilation and hypotension
- increases cardiac contractility and relieves bronchospasms
- rapidly reverses the effects of anaphylaxis
- adult epipen delivers .3 mg of epinephrine
- the infant-child system delivers .15mg
upper airway
- nasopharynx
- oropharynx
- laryngopharynx
- epiglottis
- nasal cavity
- larynx
epiglottitis
- Seen on x-rays and fiber-optic laryngoscopy
- streptococcus
- administer oxygen
- Nebulizers, antibiotics, corticosteroids, epinephrine
- do not put anything in pt’s mouth -> intubate in field if absolutely necessary -> Endotracheal intubation is best achieved surgically w/ ENT nearby
obstructive vs restrictive
- both lower airway conditions
- obstructive- hard to exhale all the air in lungs
- restrictive- hard to inhale fully
emphysema
- mucus and puss in the alveoli
- not allowing good gas exchange
asthma
- tachycardia
- wheezing
- obstructive
- chronic inflammation and constriction of bronchi
- airway becomes overly sensitive to allergens, viruses, environmental irritants
- inflammation -> dyspnea, wheezing, coughing
- bronchoconstriction**
- Body responds to persistent bronchospasm with edema & mucous secretion, results in bronchial plugging and atelectasis
- initially hyperventilates -> results in decrease CO2 levels (respiratory alkalosis) -> narrowing -> increase in CO2
- accessory muscle recruitment
asthma treatment
- inhaled beta-2 agonists: albuterol, levalbuterol (Xopenex) used in early wheezing
- terbutaline or epinephrine: IV or injection added for more severe attacks
- IV corticosteroids reduce inflammation in bronchi, but may take hours to work (long acting)
- Beta 2 agonists: smooth muscle relaxation, bronchodilation
- inhaled beta-2 agonists:
- albuterol- 2.5-5 mg every 20 mins for 3 doses or continuously, followed by 2.5-10 mg every 1-4 hours as needed
- parenteral beta-2 agonists:
- terbutaline: 0.25 mg
- 1:1,000 epinephrine: 0.3 mg
COPD
- mainly maintaining oxygenation & ventilation
- nasal cannula
- if still hypoxic: nonrebreathing mask
- CPAP if indicated prior to intubation in alert patient
- severe cases: endotracheal intubation w/ RSI
- once airway is secured -> beta-2 agonists early and often
- anticholinergic agents -> additional 20-40% bronchodilation
- systemic corticosteroids (injectable) in moderate or severe cases
- if acute respiratory failure: noninvasive positive pressure ventilation NPPV required or endotracheal intubation w/ invasive ventilation thru a ventilator
- 3 nebulized doses 20 minutes apart or consecutively in severe cases
respiratory syncytial virus (RSV)
- young children
- infection in lungs and airways
- premature babies and children with suppressed immune systems
- can lead to other more serious illnesses that affect heart and lungs
- can cause bronchiolitis and pneumonia
- highly contagious
- dehydration
- can cause severe upper respiratory infections and asthma symptoms in adults
- humidified supplemental oxygen for treatment
pleural effusion
- caused by fluid collecting between visceral and parietal pleura
- causes dyspnea
- may occur in response to any irritation, infection, CHF, or cancer
- should be considered as a contributing dx in any patients with lungs cancer and shortness of breath
- with each breath, tissues rub against each other causing inflammation and more fluid to accumulate in the space
- decreased breath sounds over region where fluid have moved lung away from chest wall
- patient usually feels better sitting upright
- if CPAP doesnt work -> fluid can be extracted by needle thoracentesis
- in rare cases tube thoracostomy
pulmonary embolism
- sudden blockage of lung artery with a blood clot
- DVT (deep vein thrombosis) is most common cause- blood clot travels to lungs from leg
- risk post surgery or trauma or with catheters
- chest pain, dyspnea, tachycardia, syncope, hemoptysis (coughing blood), new onset wheezing, new cardiac arrhythmia, thoracic pain
- may evolve quickly and lead to cardiac arrest
- treatment: anticoagulants, TPA
pulmonary final thoughts
- should be last option for asthmatic patients (difficult to ventilate, prone to pneumothorax)
- be proactive- intubate/ventilate before cardiac arrest occurs (conscious patients in respiratory arrest may need sedation/RSI)
- lack of gag reflex in stroke or intoxicated patients makes them prone to vomiting (consider intubation to protect airway)
- if med administered to diabetic or OD patient, use bag mask first and monitor for changes
two parts to secondary assessment
- obtaining vital signs
- head to toe survey
glasgow coma scale
- eye opening- spontaneous (4), to verbal command (3), to pain (2), no response (1)
- verbal response- oriented and converses (5), disoriented conversation (4), speaking but nonsensical (3), moans or makes unintelligible sounds (2), no response (1)
- motor response- follows commands (6), localized pain (5), withdraws to pain (4) decorticate flexion (3), decerebrate extension (2), no response (1)
- higher GCS (15)- no neurologic disability
- 13-14- mild dysfunction
- 9-12- moderate to severe dysfunction
- 8 or less- severe dysfunction (lowest possible is 3)
aortic aneurysm
- may be seen pulsating in the upper midline
- do not palpate an obvious pulsatile mass -> could burst
- dilates -> aneurysm
- wall of aorta burst or starts to expand
- bursts -> dissection (once it starts penetrating the wall
larynx
- extrinsic muscles connect larynx and elevate it during swallowing
- intrinsic muscles control vocal cords
- keeps food and drink out of airway
- marks where the upper airway ends and the lower airway begins
- epiglottis
- cartilage
- hypoid bone
- ligaments
kussmals respirations
- deep and fast gasping respirations
- lacking any apneic periods
- associated with metabolic/toxic disorders (diabetes mellitus)
biots respirations
- breathing normally and then dropping or raising
- irregular pattern
- may follow serious head injury
nonrebreather mask
- moderate respiratory distress patients
- 10-15 L/min
- delivers oxygen at 60-95%
- preferred way to give oxygen in prehospital setting
nasal cannulas
- 24-44% oxygen delivered
- 1-6 L/min
- used for chronic illnesses
- mild respiratory distress
- calms patients with minimal oxygen levels
bag mask device
- most common method used to ventilate patients in EMS and during initial respiratory failure in ER
- 10-15 L/min
- severe respiratory distress
- 75-100%
CPAP
- use with caution for people with low BP -> can cause pneumothorax
- increases intrathoracic pressure -> aspiration
cranial nerves
- olfactory- smell
- ocular- sight
- oculomotor- movement of eyes, size, shape and symmetry of pupils
- trochlear- downward eye movement
- trigeminal- cheek, jaw, chewing
- abducens- lateral eye movement
- facial- facial muscles, taste, saliva
- auditory/vestibular- hearing and balance
- glossopharyngeal- tongue and pharynx sensation, taste, swallowing
- vagus- throat and trachea, taste, voice, heart rate
- accessory- shoulder movement, ability to turn head
- hypoglossal- speech and tongue
decorticate posturing
- arm at chest and angled in
- fists are clenched
- dysfunction of the cerebral cortex
- 3 on the glasgow scale
decerebrate posturing
- significant brain injury
- rigidity
- arms and legs are extended
- toes point downward
- head and neck are arched
- 2 on the glasgow
common types of vertebral injury
- C-1/C-2: delicate vertebrae
- C-7: transition from flexible cervical spine to thorax
- T-12/L-1: different flexibility between thoracic and lumbar regions
pedicles
Thick, bony structures that connect the vertebral body to the
spinous and transverse processes
Vertebral Ligaments: Anterior Longitudinal
- Anterior surface of vertebral bodies
- Provides major stability of the spinal column
- Resists hyperextension
vertebral ligaments: Posterior Longitudinal
- Posterior surface of vertebral bodies in spinal canal
* Prevents hyperflexion
sacral spine
- 5 fused vertebrae
– Form posterior plate of pelvis
– Help protect urinary and reproductive organs
– Attach pelvis and lower extremities to axial
skeleton
growth of spinal cord
- Fetus- Entire cord fills entire spinal foramen
- Adult- Base of brain to L-1 or L-2 level
- adult Peripheral nerve roots pulled into spinal foramen at the distal end (cauda equina)
dermatomes
- Topographical region of the body surface innervated by one nerve root
- umbilical- T-10
- nipple line- T-4
myotomes
-Muscle and tissue of the body innervated by spinal nerve roots
parasympathetic / sympathetic
- parasympathetic- sacral and cranial peripheral nerve roots
- sympathetic- lumbar and thoracic peripheral nerve roots -> vasoconstriction
axial stress / loading
-Compression* common between T-12 and L-2
• Distraction
• Combination
-Distraction/rotation or compression/flexion
-pressure to the length of the spine
-you land feet first (or head) -> squish the spine
complete transient cord injury
-Cervical Spine damage:
-Quadriplegia
-Incontinence
-Respiratory paralysis
–> Below T-1:
» Incontinence
» Paraplegia
incomplete transection cord injury: anterior cord syndrome
- Anterior vascular disruption
- Loss of motor function and sensation of pain, light touch, and temperature below injury site
- Retain motor, positional, and vibration sensation
incomplete transection cord injury: central cord syndrome
- Hyperextension of cervical spine
- Motor weakness affecting upper extremities
- Bladder dysfunction
incomplete transection cord injury: brown-sequard’s syndrome
- Penetrating injury that affects one side of the cord
- Ipsilateral (same side) sensory and motor loss
- Contralateral pain and temperature sensation loss
spinal shock
-Temporary insult to the cord
-Affects body below the level of injury
-Affected area:
• Flaccid
• Without feeling
• Loss of movement (flaccid paralysis)
• Frequent loss of bowel and bladder control
• Priapism
• Hypotension secondary to vasodilation
neurogenic shock
-Occurs when injury to the spinal cord disrupts the brain’s ability to control the body
-Loss of sympathetic tone:
-Dilation of arteries and veins -> Expands vascular space and results in relative hypotension
-Reduced cardiac preload
-Reduction of the strength of contraction -> Frank-Starling reflex
-ANS loses sympathetic control over adrenal medulla
-Unable to control release of epinephrine and norepinephrine -> Loss of positive inotropic and chronotropic effects
• Bradycardia
• Hypotension
• Cool, moist, and pale skin above the injury
• Warm, dry, and flushed skin below the injury
• Male: priapism
Autonomic Hyperreflexia Syndrome
-Associated with the body’s resolution of the effects of
spinal shock
-Commonly associated with injuries at or above T-6
-Presentation
• Sudden hypertension
• Bradycardia
• Pounding headache
• Blurred vision
• Sweating and flushing of skin above the point of injury
