Neurological Flashcards
Cranial Nerves 1-12
I - Olfactory (Smell)
II - Optic (Sight)
III - Oculomotor (Pupil function)
IV - Trochlear (Eye Movement)
V - Trigeminal (Chewing, blinking)
VI -Abducens (Eye Movement)
VII - Facial (Expression, taste)
VIII - Vestibulocochlear (Hearing, balance)
IX - Glossopharyngeal (Swallow, gag)
X - Vagus (Pharyngeal/Laryngeal)
XI - Spinal Accessory
XII - Hypoglossal (Tongue movement)
*All cranial nerves arise from the brain stem except for cranial nerves I and II
Circle of Willis
- The circulatory system of arteries which supply blood to the brain
-The basilar artery and middle cerebral arteries are not part of the Circle of Willis
Mental Status
- A change in level of consciousness is ALWAYS the first sign of a neurological problem (Other than during an epidural hematoma; pupil changes may occur first)
Mental Status Changes
Memory: Short term usually changes before long term
Personality: Sometimes the first sign of a problem prior to change in LOC
Reticular Activating System (RAS)
- UPPER responsible for awareness
-If damaged the patient becomes unaware but still sleeps properly - LOWER responsible for sleep cycle
-If damaged the patient goes in to a coma
Eye Changes
- Sympathetic dilates the pupils
-Parasympathetic constricts the pupils
-Changes occur on the SAME SIDE as the injury
-“Dolls eye” is good (Eyes move opposite side as head turn)
-“Ice Water” eyes move toward side of ice water injection (in to ear)
Vital Sign Changes
- LATE sign of neurological injury
Cushing’s Triad:
1. Slow respiration rate
2. Slow Heart Rate
3. Widening pulse pressure (Increase systolic)
GCS:
Score 8 or lower typically indicates poor outcome
Eyesight Changes
-Opposite side of problem
-Neglect to the same side
- Approach from unaffected side to prevent confusion until vision improves… then approach from affected side
Neuro Assessment Summary
- Eyes deviate towards pathology
- Pupil changes SAME SIDE
- Visual Changes OPPOSITE SIDE
- Motor Changes OPPOSITE SIDE
- Babinski OPPOSITE SIDE
Brain Herniation (Focus on Uncal and Transtentorial (Central) Herniation)
UNCAL
-Displacement of the temporal lobe
-NO initial changes to LOC
-Loss of parasympathetic nervous system on affected side
-**Most often caused by epidural hematoma
-Babinski opposite side
CENTRAL (Transtentorial)
-Bilateral swelling of brain with downward displacement
-Pupils start small and then rapidly dilate
-Babinski bilaterally
Encephalopathy
- A diffuse disease that alters bran function or structure
-May result in swelling and ICP
-Avoid conditions that raise ICP more
Stroke
-A medical emergency that occurs when blood flow to the brain is blocked or a blood vessel in the brain bursts
Stroke Treatment
-Rule out hypoglycemia
-Assess ABC’s
-Only treat BP acutely if SBP > 220
-CT scan within 25 minutes of arrival/onset
-rTPA use indications
- CT Negative
- onset less than 4.5 hours ago
- No contraindications
-rTPA Contraindications
- MI in last 3 months
- Stroke or head trauma last 3 months
- Major surgery last 14 days
- Active bleeding last 21 days
Post rTPA Infusion Care
WORST OUTCOME IS INTRACEREBRAL HEMORRHAGE
-Do not give antiplatelets or anticoagulants within 24 hours
-Maintain BG of 80-150
Elevate head to 45 degrees or more
Keep NPO
Subarachnoid Hemorrhage
-Middle cerebral artery aneurysm is most common
-LOC doesnt change until a 3+ on Hunt/Hess scale
Signs:
1. Explosive headache
2. Decreased LOC
3. Nuchal rigidity (stiff neck)
-Surgery for Grade I, II, III within 48 hours
Complications of Subarachnoid Hemorrhage
-Hydrocephalus due to chorionic villi in the subarachnoid space reabsorbing CSF
-Re-bleed and Vasospasm
Vasospasm
-Narrowing of vein that restricts blood flow
-Typically occurs 5-7 post bleed (not post-op)
Treatment:
- Transluminal balloon angioplasty
- AVOID hypotension
- Monitor and treat hyponatremia
Brain Tumors
-A growth of cells inside or near the brain causing disruption
-The only neurological issue that includes steroid therapy To prevent increased ICP
Intracranial Pressure (ICP)
- The first sign of ICP is change in level of consciousness
- Normal 0-10
- Moderate 11-20
- Increased is > 20
- Monitoring includes transducer placement at the external auditory meatus
- MEASURE AT “C” wave
How to Lower ICP
-Decrease volume: Furosemide, mannitol, 3% saline
-Patient Positioning: Sit upright
-Prevent Dilation (acidosis)
-Prevent Constriction (alkalosis)
-Propofol works well
-Use ISOtonic fluids
Keep pH normal ~low~ 7.35
Traumatic Brain Injury
-A blunt or penetrating insult to the brain from an external force
-CT is diagnostic tool used
Epidural Hematoma
Think UNCAL herniation
Younger population
-Typically the middle meningeal artery bleeds 2/2 temporal bone trauma
-Symptoms occur RAPIDLY
- Headache, vomiting, contralateral hemiparesis and hemiplegia
- Decreased LOC
Treatment
- Emergent surgery to evacuate the hematoma (burr hole)
Subdural Hematoma
Older population
-Spontaneously bleeding between the dura and arachnoid matter
-Signs and symptoms occur more slowly and epidural hematoma
Acute: Signs/Symptoms within 24 hours
Subacute: Signs/Symptoms within 2 weeks
Chronic: Sign/Symptoms more than 2 weeks
Treatment
-Monitor for increase ICP
-May need surgical removal
Intracerebral Hematoma
-Typically caused by a gunshot wound, acceleration-deceleration injury, or laceration of the brain
-Surgery only if neuro status is deteriorating or ICP significantly increased
Skull Fractures
-A linear fracture does not require surgery
-Elevate depressed skull fractures > 5mm
-Basilar Fracture Next card
Basilar Skull Fracture
-A linear fracture that occurs in the floor of the cranial vault resulting in a meningeal tear
Signs/Symptoms
- Raccoon eyes
- Periorbitaedema
- Rhinorrhea (no nose blowing)
- Fluid from ear
- Battles Signs (Discoloration behind ear)
-Rare: loss of smell
-Determine if ear/nose drainage is CSF
-Do this by checking for sugar - positive indicates CSF
-Put drainage on 4x4 to watch for “Halo” sign
-DO NOT pack gauze in nose or ear; gently cover areas
-DO NOT block CSF drainage
-DO NOT insert NG tube (use OG)
Surgery ONLY IF CSF is persistent
Seizures Overview
-Most tonic clonic seizure last less than 3 minutes
-PaCO2 may be high post seizure due to lack of ventilation
-Protect airway and turn to the side
Stop Seizure with
-Ativan or valium (Ativan preferred)
Prevent Seizure with
-Phenytoin, Phenobarbital, Carbamazepine
-Postictal period may follow seizure with transient signs of decreased LOC
Status Epilepticus
-Seizure activity of 5 minutes or more caused by a single seizure or a series of seizures with no return to consciousness between events
-Death due to cerebral hypermetabolism
Meningitis
-inflammation of the tissues surrounding the brain and spinal cord
Signs/Symptoms
-Nuchal Rigidity
-Brudzinski’s Sign: Chin to chest causes legs to raise
-Kernig’s Sign: Legs up and out causes pain in leg + neck
-Antibiotics given for bacterial meningitis
Brain Death
-Complete irreversible cessation of function of the cerebrum, cerebellum, and brain stem
-Apnea Test - 8-12 minutes reconnect ventilator to patient an get an ABG
Provide support to family
Consider organ donation
Guillain-Barre Syndrome (GBS)
-An autoimmune response to a viral infection.
-Causes demyelination of the lower motor neurons
-ASCENDING paralysis
-IV immunoglobulin (IVIG) over 2-5 days
OR
-Plasma exchange for 5 treatments
Myasthenia Gravis
-“Grave muscular weakness”
-An autoimmune attack of the neuromuscular junction
-Often has ocular dysfunction
Separated in to 2 Diagnosis:
Myasthenic Crisis: Deficiency of acetylcholine
-Tensilon will IMPROVE outcome
Cholinergic Crisis: Overtreatment/Excess of acetylcholine
-Tensilon will make symptoms WORSE
*Tensilon is given, paient are told to hold their arms out; wait fro signs of weakness or improvement
