Neuro Flashcards
Role of APRN in HA and face pain
accurately dx rule out secondary causes recognize red flags provide acute management assist with HA prevention
HA
most common pain problem seen in family practice
Primary HA
Benign
Recurrent
NOT associated with underlying patho
The HA is the disease
Types of primary HA
Migraine with or without aura
Tention type HA
Cluster HA
Secondary HA
sudden
progressive
associated with pathology
may require immediate action
Patho of Secondary HA
Aneurysms Subarachnoid hemorrhage Thunder clap HA Meningitis Stroke Carotodynia Temporal Arteritis HTN Sinus TMJ Trigeminal Neuralgia
Worrisone Red Flags of HA “SNOOP”
S: systemic symptoms or diease N: neurological signs/symptoms O: onset sudden O: onset before 5 or after 50 P: patterns change from prior HA
Characteristics of migraine
unilateral moderate/severe intensity lasts 4-72 hours throbbing quality associated symptoms females
Characteristics of tension-type HA
bilateral mild/mod intensity lasts 30 min to 7 days pressure/tightening quality no associated symptoms females
Characteristics of cluster HA
strictly unilateral severe intensity last 15-90 minutes severe quality associated symptoms males
To Dx migraine with an aura
must have 2 attacks with the following criteria:
fully reversible visual, sensory, speech deficits
homonymous visual symptoms
aura developing over 5 mintues
each symptom lasts 5-60 minutes
not attributed to another disorder
To Dx migraine without aura
must have 5 attacks with the following: HA lasting 4-72 hours unilateral, pulsating, mod pain, aggravation by physical activity N/V Photophobia
Tension type HA Criteria
At least 10 episodes occuring < 1 day/month with: HA lasting 30min-7days Bilateral pressing/tightening quality not aggravated by physical activity No N/V only one of photophobia or phonophobia
Cluster HA Criteria
Deep pain around eyes or temporal NO throbbing Nightly occurrence 6-12 wks at a time can have facial sweating, eyelid edema, conjunctival injection, ptosis
Chronic daily HA in children
HA persists >2 h and occurs > 15 days/month
Increased intracranial pressure in children
chronic or intermittent increasing frequency progressive severity occipital neuro signs (papilledema)
Facial pain
most adults female unilateral or bilateral paroxysmal remissions or constant may be triggered by slight touch, wind, speaking
Reasons for facial pain
trigeminal neuralgia postherpetic neuralgia TMJ dental pain sinusitis glaucoma angina pectoris
Tx for Migraine
NSAIDS Triptans, Ergotamine, Dihydroergotamine rescue medication prophylaxis with amitriptyline, propranolol, timolol avoid hormone fluctuations foods alcohol environmental changes stress, lack of sleep
Tx Tension type HA
NSAIDS
don’t provide anything addicting
Tx Cluster HA acute attack
100% O2
SL ergotamine
itranasal lidocaine can be helpful
Tx Cluster HA preventive tx
verapamil 80mg QID (cardiac monitor) Lithium 300-900 mg Prednisone taper Ergotamine 2mg 2 hours before bedtime Divalproex
Refer HA and facial pain
uncertainty
tx failsure
unremitting HA
medication overuse or chronic daily HA
Episodic loss of consciousness
Seizure: temporary neuro signs from abnormal paroxysmal, hypersynchronous electrical activity in cerebral cortex
Syncope: due to a reduced supply of blood to cerebral hemispheres (vasovagal)
Symptoms present in both syncope and seizures
LOC or loss of awareness
with or without myoclonus opisthotonus
myoclonus
incontinence may occur
Events during a spell
tonic-clonic LOC with tonic stiffening then clonic jerking
hypoperfusion produces flaccid unresponsiveness, stiffening or jerking
LOC from hypoperfusion rarely lasts more than 15 second
Posture when LOC occurs
orthostatic hypotension and faints occur in the upright or sitting position
only occur in lying position suggest seizure or cardiac arrhythmia unless phelbotomy
Physical exertion with syncope
usually due to cardiac outflow obstruction
Postictal state
brief confusion, disorientation or agitation
Seizures
transient disturbance of cerebral fx caused by an abnormal neronal discharge
epilepsy is recurrent seizures
aura associated with seizures
postictal confusion
urinary incontinence and jerking doesn’t dx
Seizures etiology
CNS dysfx genetic metabolic systemic disease drug induced
Common causes of new onset seizures
fever head trauma stroke meningitis hypoglycemia hyponatremia uremia drug toxicity eclampsia
Tonic phase of seizure
generalized stiffening of body and limbs 10-30 seconds flexion then extension epileptic cry cyanosis
Clonic phase of seizure
limb jerking
saliva frothing
jerks of limbs, body and head
Postictal phase of seizure
confusion (can last 10-30 minutes)
limp limbs
HA
Absence Seizures
last 5-10 seconds
keep posture
may not answer or seem out of it
Diff Dx of seizures
TIA Rage Panic attack syncope cardiac dysrhythmias pseudoseizures
Eval of seizure
EEG MRI Serum creatine kinase 3 hrs after event. elevation = tonic clonic FBS electrolytes renal fx liver fx
Management of New onset seizure
avoid driving
monitor serum drug levels: treat clinical response rather than blood levels
special considerations before and during pregnancy
Risk of seizure reoccurance
75% after second seizure!
Febrile Seizures in Children
age 3 months to 5 years non-CNS infection > 90% are generalized lasts < 5 minutes acute respiratory illnesses are most commonly associated
Febrile seizure work up
WBC > 20,000 could indicated baterial
blood and urine cultures
if younger than 18 months do lumbar puncture
EEG
Tx for febrile seizure
hydration
diazepam with fevers in future
no long term consequences
Alcohol withdrawl seizures
48 hrs of withdrawl
hopital for 24 hours
benzos are effective ans safe
Syncope
LOC with loss of postural tone
global hypoperfusion of the brain and brain stem
Most common causes of syncope
vasovagal can reoccur with within 30 minutes of restanding situational orthostatic hypotension decreased cardiac output arrhythmias neurologic disease
Stroke facts
3rd leading cause of death
work force impact
economic impact
Stroke risks
age: doubles each decade after 55
gender: male, but more women die from stroke
genetics: african american, family hx
chronic diseases: HTN, Lipids
diet
obesity
smoking
drug use
Stroke etiology
intrinsic to the vessel: plaque, inflammation, arterial dissection, malformations, thrombus
inadequate blood flow
rupture of vessel
Stroke types
Ischemic
Hemorrhagic
Hemorrhagic Stroke types
subarachnoid
cerebral hemorrhage
Subarachnoid hemorrhage
aneurysm in carotid ruptures and leaks into subarachnoid space
on surface of brain leaking
bleeds into space between brain and skull
Cerebral hemorrhage
defective artery in brain bursts
HTN, trauma, malformation
Subarachnoid clinical features
worst HA ever
rapidly LOC
signs of meningeal irritation
nuchal regidity
Cerebral hemorrhage clinical features
LOC sudden N/V focal signs and symptoms neuro deficit HA sometimes present
TIA
transient neruo dysfunction with focal, spinal or retinal ischemia without acute infarction
tissue based
small emboli
offer opportunity to initiate tx prior to perm diasability
Delirium
acute, fluctuating disturbance of consciousness with change in cognition
poor clinical outcomes if persists
may be first indication that there is an underlying medical condition
Delirium Dx
inability to maintain attention disorganized thinking develops in short amount of time fluctuating LOC caused by medical condition, substance intoxication or medication S/E reversible!
Delirium presentation
onset acute/abrupt progression reversible decreased perception of environment orientation fluctuates recent and immediate memory impaired
Dementia Presentation
chronic onset progression irreversible clear awareness increased impairment over time recent and remote memory impaired
Depression presentation
Variable onset
progression reversible
clear awareness
patchy memory
Delirium risk factors
sensory impairment old age pre-existing cognitive impairment substance abuse social isolation trauma pain
2 parts of delirium assessment
1. recognize delirium history of care givers, MMSE <24 2. uncover the underlying illness medication review labs imaging
Delirium Differentials
D: dehydration, dementia, depression E: electrolytes, elimination L: lungs liver, low profusion I: Infections R: restraints I: injury U: unfamiliar environment M: medications
Closed Head injury
injury to the skull, brain or both
interfere with normal activities
Primary causes closed head injuries
direct insult direct trauma concussion contusion epidural hematoma subdural hematoma
Secondary causes of closed head injuries
intracranial insults to the brain (ischemia, edema)
systemic insults to the brain (hypoxia, anemia, hyperglycemia
Concussion symptoms
HA feeling in a fog emotional lability LOC amnesia irritability slowed reaction times sleep disturbance
Second impact syndrome of concussion
can lead to herniation and coma
someone with concussion goes back in to play prior to concussion resolving and gets reinjured
Contusion
bruising of part of the brain with no puncture of the pial covering
follow with CT after 24 hours to ensure no growth
Coup injury
with contusion
direct impact
Contrecoup injury
with contusion
rotational
Intracranial hemorrhage
accumulation of blood within cranium
acute or latent
includes epidural and subdural
Refer closed head injuries
head trauma with altered LOC paresthesia, paralysis raccoon or battle sign hemotympanum rhinorrhea otorrhea
