Neuro: Part 2

Question 1

Head Injuries

Answer 1

Concussion-alt.in mental status following trauma. NOT associated with structural abnormalities or identifiable on X-ray. Symptoms 1 month-1 yr.

Contusions-result of laceration of the microvasculature. Dx by CT. Symptoms depend on size.

Diffuse axonal injury (also called a “shearing injury”)
Most severe

Question 2

Head Injuries Cont.d

Answer 2

Skull fractures
Linear, depressed, compound, basilar

Basilar
**Check for Battle’s sign: Mastoid process bruising, periorbital swelling, racoon eyes
Check for glucose from nasal / ear drainage
**Never EVER place a nasogastric tube in a patient with a basilar skull fracture!!

Question 3

Signs of Trauma or Infection for Head Injuries

Answer 3

Battle’s sign-bruising over mastoid bone
Raccoon’s eye-periorbital edema and bruising
Rhinorrhea-CSF from nose.
Otorrhea-CSF from ear

Question 4

Epidural Hematoma

Answer 4

Results from bleeding between the Dura and the inner surface of the skull
Require immediate surgical intervention – emergency!
Associated with a linear fracture crossing a major artery in the Dura, causing a tear
Arterial hemorrhage – hematoma develops rapidly and under high pressure

Signs and symptoms:
Unconsciousness with brief lucid intervals, followed by decreased LOC
Other manifestations include headache, nausea and vomiting

Treatment:
Rapid surgical intervention

Question 5

Subdural Hematoma

Answer 5

Occurs from bleeding between the Dura matter and the arachnoid layer of the meninges
Results from injury to the brain substance and its parenchymal vessels
Venous in origin – hematoma develops slowly

Acute S&S: manifests signs within 48 hours of injury
Treatment: craniotomy, evacuation and decompression

Subacute S&S: manifests within 2 to 14 days of the injury
Treatment: evacuation and decompression

Chronic S&S: develops over weeks to months. Peak incidence is around age 50-60 due to brain atrophy
Treatment: evacuation and decompression

Question 6

Spinal Cord Injuries

Answer 6

Primary Injury: the initial mechanical disruption of axons as a result of stretch or laceration

Secondary Injury: refers to the ongoing, progressive damage that occurs after the initial injury

Goal is to minimize secondary injury and prevent complications

Question 7

Types of Spinal Cord Injury

Answer 7

Flexion Injury:
Forward dislocation with ruptured posterior ligaments

Hyperextension Injury:
Ruptured anterior ligament and compressed posterior ligaments

Compression fracture:
Fractured vertebrae caused by compression of spinal cord (diving accidents)

Flexion-Rotation Injury:
Displacement of the vertebrae which often results in tearing of ligamenous structures that normally stabilize the spine. This is the most unstable of all injuries and most often implicated in severe neurological deficits

Question 8

Spinal Cord injuries by area

Answer 8

1. Upper cervical (C1–C2) injuries Most dangerous. Impaired intercostal muscles, respiratory failure, lifelong ventilation
2. Lower cervical (C3–C8) injuries
3. Thoracic (T1–T12) injuries
4. Lumbar (L1–L5) injuries
5. Sacral (S1–S5) injuries.

Question 9

Tetraplegia/Paraplegia

Answer 9

Complete lesions involving spinal cord regions C1 to T1 result in tetraplegia.
Complete lesions involving spinal cord regions T2 to L1 result in paraplegia

Question 10

CENTRAL CORD SYNDROME

Answer 10

Damage to the spinal cord in this syndrome is centrally located. Hyperextension of the cervical spine often is the mechanism of injury, and the damage is greatest to the cervical tracts supplying the arms. Clinically, the patient may present with paralyzed arms but with no deficit in the legs or bladder

Question 11

BROWN-SÉQUARD SYNDROME

Answer 11

The damage in this syndrome is located on one side of the spinal cord (an incomplete spinal cord injury)

*****Characterized by loss of motor function, position, vibratory sense and vasomotor control on the SAME side as the lesion (IPSILATERAL), and loss of pain and temperature sensation below the level of the lesion on the OPPOSITE side (CONTRALATERAL)

Question 12

ANTERIOR CORD SYNDROME

Answer 12

Patient usually has complete motor paralysis below the level of injury and loss of pain, temperature, and touch sensation.

(preserved: light touch, proprioception, position sense)

Question 13

POSTERIOR CORD SYNDROME

Answer 13

Posterior cord syndrome is usually the result of a hyperextension injury at the cervical level and is rare.

***Position sense, light touch, and vibratory sense are lost below the level of the injury.

Question 14

Spinal Injuries -cervical

Answer 14

C2-C3 usually fatal
C4 is major innervations to diaphragm 
C4 = paralysis of 4 extremities
C5 may have movement of shoulders
C3-C5 is greatest risk for impaired spontaneous ventilation (phrenic nerve)

Question 15

Spinal Injuries -Thoracic

Answer 15

Loss of chest, trunk, bowel, bladder and legs may occur

***Lesions/injuries above T7 are associated with autonomic dysreflexia (hypertension, medical emergency, seizure/stroke possible. Noxious stimulus, pain on skin level, obstructed catheter could be stimulus)

Question 16

Spinal Cord Injury - S & S

Answer 16

***DO NOT MOVE THEM IF UNSURE
Pain, tenderness, deformity
Numbness, paresthesias
Alterations in sensation
Urinary/Bowel- retention/incontinence
Difficulty breathing
Shock

Question 17

SCI: complications

Answer 17

Spinal shock- loss of motor, sensory, reflexic and autonomic activity below the level of injury caused by the sudden cessation of impulses from the higher centers. Can last days, weeks, or month

Neurogenic shock- loss of vasomotor tone due to injury and loss of sympathetic innervation and results in **hypotension, **bradycardia, and warm dry extremities. Associated with cervical or high thoracic injuries.

Autonomic dysreflexia- syndrome that affects T7 and above. Negative stimulus (full bladder or bowel). Characteristic include: severe HTN with flushed upper body and pale lower body. Danger of seizure or stroke

Question 18

Neurogenic/Spinal Shock

Answer 18

Neurogenic: causes cellular ischemia
Seen with severe cervical and upper thoracic injuries
Loss of sympathetic input. Treat with a vasoconstrictor to force blood out of venous storage

Spinal Shock:
Decreased sympathetic innervation
Impossible to assess full damage until deep tendon reflexes return

Question 19

Neurogenic/Spinal Shock cont.d

Answer 19

Autonomic dysreflexia- syndrome that affects patients with injuries at T7 and above. Provoked by a negative stimulus (full bladder or bowel, heat, cold). Massive uncompensated cardiovascular reaction mediated by the sympathetic nervous system.

Characteristic severe HTN with flushed upper body and pale lower body. Danger of seizure or stroke. Patient will have severe headache.

If this happens— sit the patient up, remove the noxious stimulus-may need to be catheterized in order to drain the bladder, or given enemas to decompress the rectum.
If untreated-can lead to stroke, MI, status epilepticus and/or death

Question 20

Autonomic Dysreflexia

Answer 20

Hypertension--systolic may reach 300
Bradycardia 30-40
Flushed face and neck
Severe pounding headache
Nasal stuffiness
Dilated pupils, blurred vision
Sweating and nausea (pilomotor reflex)
Restlessness

Question 21

Care of the Spinal Cord Injury Patient

Answer 21

A – airway with cervical spine control

B – breathing, with particular attention to the cervical area and intercostal muscles

C – circulation, including checking pulses, stopping external bleeding, and obtaining IV access

D – disability: a quick neuro exam for responsiveness , pupil checks, and motor and sensory deficits. DO NOT MOVE!

Question 22

Spinal Cord Injury Complications

Answer 22

Prevent injury R/T shock
Monitor for S&S of condition
Monitor for hypotension and bradycardia
Monitor reflex activity
Assess bowel sounds
Monitor bowel/bladder retention (autonomic dysreflexia)
Provide supportive care as prescribed
Possible Naso-Gastric tube to prevent aspiration

Question 23

Medical Interventions for SCI

Answer 23

Non- operative stabilization – tongs, traction, Philadelphia collar, Halo vest

Surgical Therapy – reduce cord compression (laminectomy), fusion, insertion of rods

Medications
- Methylprednisolone (solumedrol)- in first 8 hours can reduce edema at site of injury and cord ischemia.

• Vasopressors (dopamine, Epi)- helps keep SBP>90 so that perfusion of the cord is improved.

Question 24

SCI: Nursing Care

Answer 24

Prevent skin breakdown

Temperature regulation (SCI have decreased ability to sweat or shiver below level of injury which affects self temp regulation

Musculoskelatal – alignment, rotor-rest bed, elevating extremeties

Psychosocial/sexual issues

Question 25

Trauma Initial Assessment and Management

Answer 25

Maintain the airway, ensure adequate ventilation, control external bleeding and prevent shock, maintain spine immobilization, and transport to the closest appropriate facility.

Transporting the patient to a level I facility allows definitive care to be initiated earlier in the process, thereby reducing patient mortality.

Question 26

In-Hospital Management

Answer 26

Primary survey
Airway, breathing, ventilation, and life-threatening injuries identified

Secondary survey
Detailed head-to-toe survey, plan for appropriate diagnostic tests

Tertiary survey
On admission to the ICU, another head-to-toe examination, assess response to interventions, labs and x-rays reviewed

Question 27

Musculoskeletal Injuries

Answer 27

Usually not considered life threatening unless there is a traumatic amputation or pelvic fracture

Assessment is done in the secondary survey after hemodynamic stabilization.

Major causes MVCs, falls, assaults, and industrial, farming, and home accidents

Important to understand the circumstances surrounding and the mechanism

Question 28

Musculoskeletal Injuries cont.d

Answer 28

Cervical spine, chest, and pelvis films are obtained first, CT, MRI.

Limb swelling, ecchymosis, or deformity is noted, that extremity should be immobilized.

Test the extremities for capillary refill (< 2 seconds is normal), pulses, crepitus, muscle spasm, movement, sensation, and pain.

Monitor for vascular or neurological compromise.
Infection is common with open injuries (open fractures treated with antibiotics).

Question 29

Complications of Musculoskeletal Injuries

Answer 29

Compartment syndrome: decreased sensation is the earliest sign. Pallor and pulselessness are late signs

Deep venous thrombosis
Pulmonary embolus
Fat embolism syndrome