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Oral Boards > Neuro > Flashcards

Neuro Flashcards

1
Q

SIADH vs. CSWS

A

SIADH

  • normovlemic
  • oliguria
  • Urine Na 50-100
  • tx = fluid restriction, Na

CSWS

  • hypovolemic
  • polyuria
  • Urine Na&raquo_space;100
  • tx = fluids, Na
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2
Q

Management of BP with intracranial mass

A

CPP MAP-ICP

BP elevated to maintain CP in the setting of inc ICP with the mass
Treat the ICP
- elevated head
- drain CSF
- mannitol or furosemide
- hyperventilate
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3
Q

Considerations for sitting position

A 
Contraindicated w/ intracardiac shunts
VAE
hypotention
Airway obstruction, poor access to airway
quadriplegia from neck flexion
Cerebral ischemia

Better exposure
Less tissues damage, retractions, bleeding, cranial nerve damage

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4
Q

Tx of VAE

A 
Call for help
100% O2
Surgeon flood field with saline
Bone wax on edges
Compress jugular veins
Aspirate air from CVC
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5
Q

BP management with aneurysm clipping

A

Deliberate hypotension reduced trans mural pressure and reduce risk of aneurysm rupture but given chronic HTN, CAD might place at unacceptable risk of cerebral and cardiac ischemia.

Discuss temporary clip with surgeon

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6
Q

Management with temporary aneurysm clip

A

MAP higher than normal to support collateral blood flow

Propofol to reduce CRMO2
Use EEG and SSEP
Brain relaxation with CSF drainage, mannitol to reduce traction needed

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7
Q

Effects of mild hypothermia for brain protection

A

Dec CRMO2

Delayed emergence
Slow metabolism
Inc infection
In O2 consumption 
Myocardial ischemia
Arrhythmias
Coagulation defects
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8
Q

ST changes during crani, what is going on? What would you do?

A

SAH?
Aneurysm likely bleeding —> apply clips, lower BP slightly to help with repair and give propofol for neuro protection understanding risk of end-organ ischemia

Massive hemorrhage — compress carotids, avoid hypotension and resuscitate

Or myocardial ischemia

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9
Q

How do you clear a c-spine?

A
  1. Absence of cervical pain or tenderness
  2. Absence of paraesthesia or neurological deficits
  3. Normal mental status
  4. No other distracting pain
  5. Age >4

If not pass above then lateral C1-T1, open mouth ondontoid and A/P

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10
Q

Urine SG <1.005, inc serum Na, large volume urine, Osm <200

A

DI
Replace urinary losses with D5 1/2 NS
If exceeds 350ml/hr —> DDAVP (replaces patients ADH)

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11
Q

Significant hypotension 4 days post pituitary tumor removal, what is the cause?

A

Adrenal insufficiency from panhypopiuitarism

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12
Q

What is the normal CPP and what is the ideal CPP with a TBI?

A

Normal 80-100mmHg

Unknown for TBI
>70 may inc risk of ARDS
50-60 –> ischemia
so ideal may be 60-70

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13
Q

Would you hyperventilate a patient with head trauma?

A

Mildly only to 25-30 if other means were not successful and the ICP was high enough to risk brainstem herniation

Dec blood flow following trauma –> at risk for ischemia

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14
Q

Would you use N2O in TBI?

A

No
If cerebral perfusion were compromised i would want 100% O2

If hyperemia were an issue, N2O can potentially inc CBF

If air were trapped in the cranium –> expand further inc ICP

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15
Q

Criteria for Fat embolism syndrome

A

1 major + 4 minor
Petechial rash, hypoxemia, CNS depression or pulmonary edema

Tachycardia, pyrexia, retinal fat emboli, fat microglobulinemia, unexplained anemia

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16
Q

Extubation plan following IC mass resection

A

If normal, awake and reassuring airway pre-op, reasonable to perform deep extubation to avoid coughing and allow neuro exam

If obtunded pre-op - risk for aspiration, CO2 retention I would delay extubation. Possible to have post-op edema or hematoma –> dec neuro status and prolonged intubation

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17
Q

Risk factors for peripheral nerve injury

A 
Male
LOS >14 days
Intra-op hypotension
Hx vascular disease, DM
Smoking
Very thin or very obese
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18
Q

When might you avoid using mannitol to lower ICP

A

Disrupted BBB (preeclampsia, trauma)
Intracranial hemorrhage
–> worsen cerebral edema

*Normal ICP <15mmHg

19
Q

Concerns with acute C-spine injury

A
  1. Resp function - esp if C3-5
  2. Hypotension - loss of sympathetic tone (T1-4)
  3. Aspiration - paralytic ileus
  4. Worsening SC injury - inadequate stabilization, hypotension, hypoxia, anemia
  5. Difficult airway - careful fiberoptic intubation
  6. Thermal regulation loss of vasoconstriction and temp sensation
  7. Autonomic dysfunction/hyperreflexia and arrthymia
20
Q

Use of steroids in SC injury

A

Controversial - maybe some benefit within 8 hours but weigh risks of side effects like sepsis, hyperglycemia, pneumonia

21
Q

Difference b/w spina bifida occulta and cystica?

A

Occulta = incomplete/abnormal formatio of midline structure w/o herniation of meninges

Cystica = failed fusion of neural arch, herniation of meninges +/- neural elements

Both have have underlying thethered cord or neuro deficits

22
Q

Abruption/trauma w/ difficult airway and dec FHR, what will you do?

A
  1. Optimize mothers condition and prepare for emergency C/S
  2. Apply O2, auscultate for PTX
  3. Eval EKG
  4. LUD
  5. Call for surgeon to obtain surgical airway have area prepped
  6. Difficult airway equipment
  7. Secure airway awake
  8. Avoid ketamine (inc ICP, inc uterine tone, dec placental perfusion)
  9. Get labs (ABG, H&H, coags, lytes)
23
Q

What are the monitoring options for CEA?

A

Awake - gold standard, requires cooperation, limited access to airway

TCD - non-invasive, can continue post-op, operator dependent, placed very near surgical site

Stump Pressure - >60 ideally

EEG - non-invasive, only reflects cortical structures, requires skilled interpretation

SSEPs - useful with abnormal EEG baseline, requires skilled interpretation

24
Q

Would you give mannitol to a patient with AMS with new Cushing response?

A

It could potentially reduce ICP BUT it may worsen cerebral edema if BBB is not intact (trauma, Pre-E)

IC bleeding –> expansion of hematoma = avoid until intracranial pathology was clearly defined.

25
Q

When would cardiac revascularization be indicated prior to CEA?

A

Risk benefit with vascular surgeon and cardiologist. When CABG or PCI may improve neurological and cardiac outcome in patient with severe cardiac disease., especially if they would benefit even is CEA were not planned.

26
Q

Which anesthetic technique for CEA is best?

A

No evidence that either GA or regional is better

27
Q

How would you monitor neurologic function during CEA?

A

If the surgeon utilized carotid shunting, i would use some form of monitoring to aid in determining whether patient required a shunt.

EEG
SSEPs
TCDs
Stump pressure
Cerebral oximetry

None of the current techniques are completely reliable and without limitation.

Best = awake patient –> consciousness, speech, C/L handgrip

28
Q

As you raise the patients BP following slowing on EEG, you notice new onset ST depression. What would you do? Would you give NTG?

A

I would optimize myocardial O2 supply and demand

  • 100% O2
  • correct anemia
  • treat tachycardia
  • then if necessary carefully red SVR to treat ST depression while providing adequate cerebral perfusion

NTG may be a good choice for vasodilation, short duration and beneficial effects of coronary circulation

29
Q

How would you intubate MVA patient with c-spine injury, SC compression, DM, HTN, etOH abuse?

A

Goals are to secure the airway avoiding further C-spine injury and aspiration

  • aspiration ppx
  • topicalize airway
  • In-line stabilization
  • Awake FOI
  • Neuro assessment
30
Q

What is PION?

A

Syndrome of post-op vision loss ranging from dec acuity to complete blindness - dec O2 delivery to part of optic nerve

First 24-48 hrs
Painless
Afferent pupillary defect, visual field defects, lack of light perception, optic disc normal

31
Q

Who is at risk for developing PION?

A 
Prolonged procedures (>6.5hrs)
Substantial blood loss
32
Q

How can you reduce the risk of vision loss?

A

Avoid/limit anemia, hypotension, hypovolemia hypoxia, external ocular pressure, prone head down, prolonged surgery, massive fluid rescusication, consider staging procedure

33
Q

What are your concerns with MS?

A 
Avoid spinal 
Epidural or block ok
Sux = relative contraindication
Avoid hyperthermia 
Autonomic dysfunction, exaggerated effect with sympathomimetics
Sensitive to ND-NMBDs
Relapse risk inc post-op and post-partum
34
Q

Concerns with Myasthenia

A

Resistant to sux
Sensitive to ND-NMBDs

Severity, ocular to resp failure

Tx = pyridostigmine

Cholinergic crisis - weakness, salivation, bradycardia

Tensilon test - edrophonium inc strength = MG
- worsen = cholinergic crisis = give atropine

35
Q

Risk factors for post-op ventilators support following thymectomy

A

> 6 years duration
Vital capacity <2.9L or <40ml/kg
Pyridostigmine dose >750mg
Co-existing resp disease

36
Q

Concerns with Guillan-Barre

A

Spinal exacerbate symptoms
Epidural ok

Dysautonomia —> hypotension
Resp failure

No Sux

Tx = IVIG (even in pregnancy)

37
Q

What are the advantages of furosemide over mannitol in reducing ICP

A

Does not inc CBF or ICP
Can be used in CHF and renal patients
Can be used when BBB has been compromised (trauma, pre-e, SAH)

38
Q

What are normal values for cerebral blood flow?

A

50ml/100g/min

39
Q

What are the determinants of cerebral blood flow?

A
  1. PaCO2 - 1ml/100mg per 1mmhg change
  2. PAO2 - dec to 50mmhg needed for sig increase in CBF
  3. Neurogenic control
  4. Temp
40
Q

Midway through TURP, patient become confused and tachycardic. Stat Na returns at 120. Will you administer hypertonic saline?

A

No

Correction must be gradual to avoid central pontine myolinolysis

Start by restricting fluids, furosemide, monitoring EKG
Further deterioration –> consider 3%

Speed = 4-6 –> 6-12mmol/L/day first 24 hours

41
Q

What are you concerns with the acromegalic patient?

A

DI
- glottic stenosis

CAD
HTN
OSA
Insulin resistance

42
Q

Why is air embolism risk greater with cranial operations than other surgical sites?

A

There is greater gravitational gradient –> more air entry

43
Q

How would you differentiate osmotic diuresis from over hydration?

A

Osmotic

  • Osm >300
  • SG >1.010

Overhydration

  • Osm low
  • SG <1.010 (like DI)

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