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CEN > Neurologic Emergencies > Flashcards

Neurologic Emergencies Flashcards

1. Describe assessments specific to the care of a neurologic patient in an emergency department. 2. State presenting symptoms of common neurologic conditions treated in an emergency department. 3. Describe management of patients with spinal cord injuries. 4. Differentiate complete and incomplete spinal cord injuries.

1
Q

define neuron

A

building block of nervous system

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2
Q

types of neurotransmitters

A

excitatory

inhibitory

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3
Q

excitatory neurotransmitters

A

norepi

acetylcholine

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4
Q

inhibitory neurotransmitters

A

serotonin
dopamine
GABA

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5
Q

what protects the brain?

A 
hair
scalp
skull
meninges
CSF
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6
Q

mengines overview

A

think PAD:

  • pia mater
  • arachnoid mater
  • dura mater
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7
Q

components of the cerebrum

A

frontal
temporal
parietal
occipital

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8
Q

frontal lobe

A

speech on L side (90%)

  • Broca area
  • Wernicke area

judgement, affect, coordinates voluntary motor movements, social behavior

AKA “Mother”

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9
Q

Broca area

A

production of speech

aka “broken words”

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10
Q

Wernicke area

A

comprehension of speech

aka “What?”

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11
Q

temporal lobe

A

memory
hearing
emotions
dominant-hemisphere speech

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12
Q

parietal lobe

A

sensory interpretation

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13
Q

occipital lobe

A

vision

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14
Q

components of brainstem

A

midbrain
pons
medulla

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15
Q

importance of brainstem

A

houses all vital centers:

  • cardiac
  • respiratory
  • vasomotor
  • reticular activating system (RAS)
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16
Q

cerebral blood flow

A

cerebral vessels autoregulate to maintain adequate blood flow based

MAP - ICP = CPP

maintain CPP > 60 mmHg to ensure auroregulation and adequate perfusion

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17
Q

intracranial pressure

A

Monro-Kellie doctrine

fixed cranial vault

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18
Q

Monro-Kellie doctrine

A

to maintain constant intracranial volume, an increase in one element must be accompanied by corresponding decrease in another element (blood, CSF, brain)

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19
Q

fixed cranial vault

A

brain tissue: 80%
CSF: 10%
blood: 10%

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20
Q

myelin sheath

A

surrounds axon

allows nervous or chemical transmission quickly down neuron

damage such as MS

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21
Q

pia mater

A

very thin layer that adheres to brain

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22
Q

arachnoid mater

A

very thin vascular layer like spider-web

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23
Q

where is CSF?

A

between pia and arachnoid mater

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24
Q

dura mater

A

tough, fibrous membrane

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25
Q

cerebellum

A

posture
coordination
muscle memory

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26
Q

reticular activating system (RAS)

A

determines level of alertness and attention

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27
Q

how does motor and sensory information travel?

A

crosses at level of brainstem

aka L side injury affects R side

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28
Q

primary determinant of cerebral blood flow autoregulation

A

CO2

  • high levels causes vasodilation
  • lower levels cause vasoconstriction
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29
Q

normal MAP and normal ICP

A

MAP: 100
ICP: 10

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30
Q

AVPU

A

alert
responds to voie
responds to pain
unresponsive

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31
Q

Glasgow Coma Scale

A

best eye opening
best verbal response
best motor response

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32
Q

eye opening in GCS

A

4 spontaneous
3 verbal
2 pain
1 none

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33
Q

verbal response in GCS

A 
5 oriented
4 confused
3 inappropriate words
2 incomprehensible sounds
1 none/intubated
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34
Q

motor response in GCS

A 
6 obeys
5 localizes pain
4 withdraws to pain
3 flexes to pain
2 extends to pain
1 none
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35
Q

FOUR score overview

A

to assess neuro status
includes resp pattern
useful for ventilated patients

out of 16

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36
Q

components of FOUR score

A

eye movement
motor response
brainstem reflex
respiratory quality

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37
Q

purpose of NIH stroke scale

A

to determine if tPA is an option and to predict outcomes

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38
Q

components of NIH stroke scale

A 
LOC
best gaze
visual fields
facial palsy
motor
ataxia
sensory
language/dysarthria
extinction/inattention
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39
Q

blood glucose in neuro assessment

A

hypoglycemia can mimic sx of neuro emergency

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40
Q

pupil assessment

A

test both direct and consensual response

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41
Q

causes of pinpoint pupils

A

opioids
organophosphates
uveitis

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42
Q

causes of unilateral pupil dilation

A

pressure on cranial nerve III

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43
Q

causes of bilateral, fixed pupils

A

impending tentorial herniation

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44
Q

causes of nystagmus

A

drugs
MS
tumor

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45
Q

causes of ovioid pupils

A

glaucoma

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46
Q

decorticate posturing

A

abnormal flexion

lesion in cerebrum

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47
Q

decerebrate posturing

A

abnormal extension

lesion in brainstem

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48
Q

otorrhea/rhinorrhea in neuro assessment

A

clear drainage from ear or nose may indicate CSF lea

check for glucose

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49
Q

Babinski reflex

A

+ result is dorsiflexion of great toe w/ fanning of remaining toes in response to stroking lateral aspect of foot

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50
Q

Brudzinski sign

A

sx of meningitis

flexion of hips and knees in response to flexion of neck

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51
Q

Kernig sign

A

sx meningitis

inability to extend knee in response to hip flexion

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52
Q

doll’s eyes

A

+ test in comatose patient will have eyes move in opposite direction when head is rotated to one side, indicating intact brainstem

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53
Q

CN I

A

olfactory

smell

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54
Q

CN II

A

optic

vision

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55
Q

CN III

A

oculomotor

pupil size, extraocular movement

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56
Q

CN IV

A

trochlear

extraocular movement

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57
Q

CN V

A

trigeminal

facial sensation, jaw movement

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58
Q

CN VI

A

abducens

extraocular movement

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59
Q

CN VII

A

facial

facial movement

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60
Q

CN VIII

A

vestibulochoclear/acoustic

hearing

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61
Q

CN IX

A

glossopharyngeal

swallowing

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62
Q

CN X

A

vagus

gag

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63
Q

CN XI

A

accessory (spinal)

shoulder shrug

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64
Q

CN XII

A

hypoglossal

tongue movement

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65
Q

mnemonic for names of cranial nerves

A 
Only - Olfactory
Once - Optic
One - Oculomotor
Takes - Trochlear
The - Trigeminal
Anatomy - Abducens
Final - Facial
Very - Vestibulochoclear/acoustic
Good - Glossopharyngeal
Vacations - Vagus
Are - Accessory (spinal)
Had - Hypoglossal
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66
Q

mnemonic for functions of cranial nerves

A

some say marry money, but my brother says bad business marrying money

S - sensory
M - motor
B - both

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67
Q

function of CN II, III, IV, VI

A

sight, pupils, eye movements

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68
Q

function of CN IX, X, XII

A

gag, speech, swallow

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69
Q

function of V, VII

A

raise eyebrows, facial sensation

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70
Q

function of XI

A

shoulder shrug

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71
Q

HA sx indicating serious underlying cause

A 
sudden onset
peak intensity in min
no hx of similar HAs
concurrent infection w/w/o fever
altered LOC
> 50 yo
HA with exertion
stiff neck
paiplledema
toxic appearing
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72
Q

two types of HAs

A

primary

secondary

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73
Q

define primary HA

A

no identifiable organic cause

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74
Q

types of primary HAs

A

migraine

cluster

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75
Q

migraine HAs

A 
w/w/o aura
trigger
unilateral
photo, phonophobia
N/V
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76
Q

cluster HAs

A 
episodic
excruciating
unilateral
burning, severe, sharp pain (periorbital, temporal)
<1 hr, 1-8x/day
unilateral tearing, nasal congestion
flushing
more in men
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77
Q

causes of secondary HAs

A

tumor
aneurysm
meningitis

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78
Q

assessing HAs

A

CBC, ESR
CT/MRI
lumbar puncture

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79
Q

HA interventions

A 
analgesics (NSAIDs, opioids)
antiemetics
antihistamines
vasoconstrictors
anticonvulsants
education
80
Q

define stroke

A

rapid or gradual neurologic deterioration that affects a known vascular territory, resulting in focal deficits

81
Q

types of stroke

A

ischemic (80%)

hemorrhagic (10%)

82
Q

causes of ischemic strokes

A

atherosclerosis

emboli

83
Q

types of hemorrhagic strokes

A

intracerebral

subarachnoid

84
Q

define transient ischemic attack

A

brief episode of neurologic dysfxn d/t focal cerebral ischemia not associated with infarction

85
Q

concerns with TIAs

A

not benign

10-15% have stroke w/in 3 mo
of those, 50% w/in 48 hrs

86
Q

sx TIA

A 
sudden onset
unilateral weakness/paralysis
abnormal sensation
altered speech
facial weakness
AMS
visual changes
dizziness
87
Q

conditions mistaken for stroke

A 
hypoglycemia
migraines
sepsis
Bell's palsy
peripheral neuropathy
benign positional vertigo
conversion disorder
seizures
88
Q

Bell’s Palsy overview

A

occurs after infection
unable to close eye
weak blink
facial droop

89
Q

assessing stroke

A 
ABC
glucose
labs
last known normal
CT, CTa
90
Q

stroke time goals

A

last known normal, sx onset

door to physician: 10 min
door to CT: 45 min
door to needle: 60 min
door to floor: 3 hrs

91
Q

criteria for tPA

A 
institutional criteria
negative head CT
NIH 4-20 or 4 with visual/speech sx
door to needle 60 min
sx onset <3-4.5 hrs ago
92
Q

intervene for ischemic stroke

A

BP < 185/110

  • labetalol
  • nicardipine

tPA

93
Q

administering tPA

A 
0.9 mg/kg (max 90mg) bolus
10% over 1 min, remainder over 1 hr
BP < 185/110
VS, neuro q 15 min for 1 hr
monitor for bleeding, angioedema
94
Q

sx intracerebral hemorrhage

A

focal deficits

rapid deterioration

95
Q

intervene intracerebral hemorrhage

A

ABCs
BP
limit bleeding

96
Q

BP in intracerebral hemorrhage

A

can lower systolic to 140 aggressively

97
Q

limiting bleeding in intracerebral hemorrhage

A

vit. K
fresh frozen plasma
frequent reA

98
Q

define subarachnoid hemorrhage

A

bleeding into subarachnoid space

usually d/t aneurysm or AV malformation

99
Q

sx subarachnoid hemorrhage

A 
"worse HA of life"
altered LOC
N/V
focal deficits
photophobia
nuchal rigidity
100
Q

intervene subarachnoid hemorrhage

A

ABCs
BP
surgery
SBP @ 160

101
Q

define seizure

A

sudden, excessive, abnormal electrical discharge

102
Q

sx seizure

A

involuntary movement
altered sensation/behavior
possible altered LOC

103
Q

causes of seizures

A 
pH, electrolytes
alcohol withdrawal, drugs
hypoglycemia, hypoxia
fever, meningitis
trauma, tumor
stress, stroke
vascular insufficiency
104
Q

classifications of seizures

A 
partial
general
simple
complex
convulsive
nonconvulsive
105
Q

define status epilepticus

A

series of seizures or one continuous seizure lasting greater than 5 minutes that is unresponsive to traditional treatments

106
Q

concerning sequelae of status epilepticus

A

hypoxia
acidosis
hypoglycemia

107
Q

intervene for status epilepticus

A

ABCs

cause

108
Q

meds for active seizures

A

lorazepam

phenytoin

109
Q

meds to prevent seizures

A

phenytoin
fosphenytoin
thiamine
antipyretics

110
Q

define meningitis

A

acute inflammation of meninges

111
Q

bacterial causes of meningitis

A

meningococcus
strep. pneumoniae
group B beta hemolytic streptococci

112
Q

viral causes of meningitis

A

enteroviruses

113
Q

sx meningitis

A

AMS
fever, nuchal rigidity
nonblanching petechial rash

114
Q

rash in meningitis

A

usually on torso and legs
assume bacterial, isolate
septic work up
abx ASAP

115
Q

intervene meningitis

A

droplet

abx ASAP

116
Q

peds specific sx for meningitis

A 
poor feeding
irritable, high-pitched cry
lethargy
bulging fontanels
seizures
117
Q

purpose of ventricular shunt

A

divert CSF from lateral ventricle to low-pressure area such as peritoneum, atriumm

118
Q

complications of ventricular shunt

A

infection
obstruction
mechanical failure

119
Q

infection of ventricular shunt

A

sepsis
meningitis
ventriculitis

120
Q

obstruction of ventricular shunt

A

plugging by choroid plexus
blood clot
debris

121
Q

mechanical failure of ventricular shunt

A

detachment
malposition
growth of pediatric patient

122
Q

define Guillain-Barre

A

acute peripheral neuropathy causing ascending weakness

autoimmune disease causing damage to myelin sheath

123
Q

sx Guillain-Barre

A

extremity tingling
loss of deep tendon reflexes
ascending symmetric paralysis

124
Q

Guillain-Barre interventions

A

25% require ventilation

supportive care

125
Q

define multiple sclerosis

A

autoimmune disease that attacks CNS and demyelinates axon

126
Q

sx multiple sclerosis

A

changes in sensation
complete/partial vision loss, double vision
weakness
unsteady gait, balance

127
Q

intervene multiple sclerosis

A

steroids
immunosuppressants
antineoplastics

128
Q

define myasthenia gravis

A

autoimmune disease of neuromuscular junction causing decreased receptor sites for acetylcholine binding

129
Q

sx myasthenia gravis

A

slowed innervation - muscle fatigue
weak eye muscles - ptosis
weak pharyngeal muscles - dysphagia
weak resp muscles - resp paralysis

130
Q

define Parkinson’s disease

A

chronic degenerative disease affecting dopamine pathway

less dopamine produced

loss of modulating effect of dopamine on voluntary motor pathways

131
Q

sx Parkinson’s disease

A 
tremor at rest
rigidity
resistance to passive movement
cogwheel extremity movement
facial "mask"
132
Q

intervene Parkinson’s

A

carbidopa/levodopa

sx management

133
Q

define ALS

A

genetic mutation causing progressive loss of voluntary muscle control

134
Q

sx ALS

A 
limb weakness
gait/grip strength loss
dysarthria
dysphagia
dyspnea
resp insufficiency

does not affect personality, intelligence, eye function

135
Q

define Alzheimer’s/dementia

A

loss of global cognitive ability for 6 mo or more

136
Q

sx Alzheimer’s/dementia

A

changes or loss in:

  • memory
  • attention
  • language
  • problem solving
137
Q

differential diagnoses with Alzheimer’s/dementia

A

delirium
encephalopathy
depression

138
Q

causes of primary traumatic brain injury

A 
direct neuronal/glial disruption
compression
stretching
shearing
brain lacerations
139
Q

causes of secondary traumatic brain injury

A 
cellular changes
hypoxia
hypercarbia
cerebral edema
hypotension
140
Q

mild TBI overview

A

GCS 13-15
LOC < 30 min
no deficits
no changes on imaging

141
Q

moderate TBI overview

A

GCS 9-12
+ LOC
focal deficits
pathology on imaging

142
Q

severe TBI overview

A

GCS < 8
significant LOC
abnormal posturing, pupils
pathology on imaging

143
Q

early sx of increased ICP

A 
altered LOC
HA
N/V
amnesia of injury
restlessness, drowsiness
changes in speech
loss of judgement
144
Q

late signs of increased ICP

A

unresponsive to verbal/pain
abnormal motor posturing
dilated/nonreactive pupils
Cushing triad

145
Q

cingulate hernia

A

midline shift

146
Q

central hernia

A

uniform increase in ICP
pushes on ventricles
both hemispheres through tentorium

147
Q

uncal hernia

A

pressure on CN III
ipsilateral/same side pupil dilation
contralateral muscle paresis

148
Q

cerebellotonsillar hernia

A

cerebellum pushes toward tentorium

149
Q

upward hernia

A

increased pressure in posterior fossa

tissues moves upward

150
Q

transcalvarial

A

pushes through skull fracture site

151
Q

hernia interventions

A 
airway
prevent:
-hypoxia
-hypotension
-hyperventilation
-hyperglycemia
-hypo, hyperthermia

surgical decompression

152
Q

definitive increased ICP treatment

A 
sedation, paralysis
elevate HOB
mannitol
ICP monitoring
CSF drainage
153
Q

define diffuse axonal injury

A

significant deterioration of neurologic fxn with no focal lesions

characterized by microscopic damage to axons

154
Q

sx diffuse axonal injury

A

immediate LOC

abnormal posturing

155
Q

sx basilar skull fractures

A

HA

altered LOC

156
Q

sx anterior fossa basilar skull fractures

A

periorbital ecchymosis (raccoon eyes)

rhinorrhea

157
Q

sx middle fossa basilar skull fractures

A

mastoid ecchymosis (Battle’s sign)

otorhea

158
Q

define epidural hematoma

A

collection of blood between skull and dura

secondary to temporal impact with laceration of middle meningeal artery

159
Q

sx epidural hematoma

A

brief LOC
lucid interval
then 2nd LOC

contralateral hemiparesis
ipsilateral pupillary dilation

160
Q

define subdural hematoma

A

collection of blood between dura and subarachnoid layer

161
Q

MOI in subdural hematoma

A

acceleration/deceleration

tear of bridging veins

162
Q

risk factors for subdural hematoma

A

older
chronic alcohol use
anticoags

163
Q

types of subdural hematomas

A

acute - 48 hrs
subacute - 2-14 days
chronic - > 2 weeks

164
Q

sx acute subdural hematoma

A

HA

focal deficits

165
Q

sx subacute subdural hematoma

A

confusion

ataxia

166
Q

assessing spinal trauma

A 
motor function
-tone
-strength
sensory function
dermatomes
167
Q

assessing tone in spinal trauma

A 
flaccid
spastic
rigid
hypertonia
hypotonia
168
Q

assessing strength in spinal trauma

A 
0 no movement
1 trace movement
2 muscle movement not against gravity
3 muscle movement not against resistance
4 weak muscle movement against resistance
5 normal
169
Q

assessing sensory function in spinal trauma

A

sharp/dull
light touch
absent

170
Q

dermatomes

A 
8 cervical
12 thoracic
5 lumbar
5 sacral
1 coccygeal
171
Q

vertebrae and anatomical landmarks

A 
C3 - diaphragm
C6 - deltoid
T4 - nipple line
T10 - umbilicus
T12 - symphysis pubis
L4 - toe
L5 - perianal area
172
Q

define spinal cord injury (general)

A

bruising or tearing of cord from trauma, fracture/dislocation of vertebrae, MVC, falls, sports, violence

173
Q

types of spinal cord injuries

A 
hyperflexion
hyperextension
axial load/compression
rotation
penetration
174
Q

SCIWORA

A

spinal cord injury without radiographic abnormality

more in children d/t more flexible bones

175
Q

define incomplete spinal injury

A

some degree of motor fxn or sensation below level of injury

176
Q

cause of central cord syndrome

A

hyperextension

falls in older adult

177
Q

sx central cord syndrome

A

upper extremities more affected than lower extremities

sensory deficit varies

178
Q

causes of anterior cord syndrome

A

hyperflexion

179
Q

sx anterior cord syndrome

A

paralysis below level of injury
loss of pain and temp sensation
intact touch and proprioception

180
Q

corticospinal tract

A

descending motor pathways from cortex to periphery

cross at brainstem - contralateral injury

181
Q

dorsal column

A

position sense

cross at brainstem but with ipsilateral injury

182
Q

spinthothalmic tract

A

from periphery to cortex
cross at/near level of injury

contralateral injury

183
Q

Brown-Sequard syndrome

A

hemisection of cord (knife, gun)

184
Q

sx Brown-Sequard syndrome

A

ipsilateral paralysis
ipsilateral los of light touch, proprioception
contralateral loss of pain, temp

185
Q

define complete spinal cord injury

A

loss of all motor/sensory fxn and reflexes below level of injury

bilateral external rotation of legs at hips

loss of voluntary bowel/bladder fxn

priapism

186
Q

spinal shock overview

A

injury at any level

loss of motion/sensation below level of injury

187
Q

sx spinal shock overeview

A

flaccid paralysis
loss of reflexes
bowel/bladder dysfxn

188
Q

neurogenic shock overview

A

injury at T6 or above

loss of sympathetic innervation and vasomotor tone

189
Q

sx neurogenic shock

A

hypotension
bradycardia
warm, flushed skin

190
Q

intervene for complete spinal cord injury

A 
ABCs
spinal motion restriction
normothermia
emotional support
highdose steroids?
191
Q

define autonomic dysreflexia

A

after spinal shock resolved,
strong sensory input from below level of injury causes massive sympathetic discharge

T6 or above

192
Q

causes of autonomic dysreflexia

A

over-distended bladder
bowel distention/impaction
skin breakdown/pressure
intra-abdominal pathology

193
Q

sx autonomic dysreflexia

A 
HA
HTN
nasal congestion
flushed head and neck
pupil constriction
sweating
194
Q

intervene autonomic dysreflexia

A

treat cause and HTN

195
Q

define cauda equina syndrome

A

“horsetail” bundle of nerves at base of spinal cord is compressed, trauma, or damaged

196
Q

sx cauda equina syndrome

A 
weakness, paralysis
sensory impairment
pain
saddle anesthesia
bowel/bladder sx
197
Q

assessing cauda equina syndrome

A

emergent CT/MRI

CEN (12 decks)

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