Neuro: Part 2 Flashcards
Head Injuries
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
Head Injuries Cont.d
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!!
Signs of Trauma or Infection for Head Injuries
Battle’s sign-bruising over mastoid bone
Raccoon’s eye-periorbital edema and bruising
Rhinorrhea-CSF from nose.
Otorrhea-CSF from ear
Epidural Hematoma
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
Subdural Hematoma
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
Spinal Cord Injuries
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
Types of Spinal Cord Injury
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
Spinal Cord injuries by area
- Upper cervical (C1–C2) injuries Most dangerous. Impaired intercostal muscles, respiratory failure, lifelong ventilation
- Lower cervical (C3–C8) injuries
- Thoracic (T1–T12) injuries
- Lumbar (L1–L5) injuries
- Sacral (S1–S5) injuries.
Tetraplegia/Paraplegia
Complete lesions involving spinal cord regions C1 to T1 result in tetraplegia.
Complete lesions involving spinal cord regions T2 to L1 result in paraplegia
CENTRAL CORD SYNDROME
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
BROWN-SÉQUARD SYNDROME
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)
ANTERIOR CORD SYNDROME
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)
POSTERIOR CORD SYNDROME
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.
Spinal Injuries -cervical
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)
Spinal Injuries -Thoracic
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)
Spinal Cord Injury - S & S
***DO NOT MOVE THEM IF UNSURE Pain, tenderness, deformity Numbness, paresthesias Alterations in sensation Urinary/Bowel- retention/incontinence Difficulty breathing Shock
SCI: complications
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
Neurogenic/Spinal Shock
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
Neurogenic/Spinal Shock cont.d
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
Autonomic Dysreflexia
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
Care of the Spinal Cord Injury Patient
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!
Spinal Cord Injury Complications
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
Medical Interventions for SCI
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.
SCI: Nursing Care
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
Trauma Initial Assessment and Management
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.
In-Hospital Management
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
Musculoskeletal Injuries
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
Musculoskeletal Injuries cont.d
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).
Complications of Musculoskeletal Injuries
Compartment syndrome: decreased sensation is the earliest sign. Pallor and pulselessness are late signs
Deep venous thrombosis
Pulmonary embolus
Fat embolism syndrome
