Neurological Emergencies Flashcards by Kelly Linskey

AVPU

Alert
Verbal
Pain
Unresponsive

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Cranial nerve: smell (rarely tested)

I: Olfactory

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Cranial nerve: visual acuity, visual fields, detection of light reflex

II: Optic

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Cranial nerve: constriction/dilation of pupil, opens the eyelid, most of the EOMs - up, down, in

III: Oculomotor

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Cranial nerve: EOMs - look down & inward

IV: Trochlear

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Cranial nerve: corneal reflex, sensation of the face, scalp, mouth and nose, chewing and jaw movement

V: Trigeminal

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Cranial nerve: EOMs - move eye laterally

VI: Abducens

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Cranial nerve: smile, closes the eyelid, facial movement, anterior taste (rarely tested)

VII: Facial

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Cranial nerve: hearing and balance

VIII: Acoustic (Vestibulocochlear)

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Cranial nerve: swallow, gag reflex, posterior taste (rarely tested)

IX: Glossopharyngeal

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Cranial nerve: sympathetic/parasympathetic responses (HR, BP, breathing), thoracic and abdominal viscera, gag reflex, speech

X: Vagus

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Cranial nerve: shoulder shrug, head turning

XI: Spinal accessory

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Cranial nerve: tongue movement

XII: Hypoglossal

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Why does a post lumbar puncture patient complain of a headache?

A. Meningitis
B. Subarachnoid hemorrhage
C. CSF leak
D. Herniation

C. CSF leak

(Tx with blood patch)

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Which of the following assessment findings is commonly associated with dementia?

A. Altered mentation
B. Altered gait
C. Impaired visual acuity
D. Paresthesias

A. Altered mentation

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Brain stem integrity reflex: Positive (normal) finding - while turning the head rapidly side to side, the eyes move the opposite direction to which the head is turned.
C-spine integrity must be intact before testing!!!!

Oculocephalic Reflex (doll’s eye)

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Brain stem integrity reflex: Ice water calorics; Positive (normal) finding - the eyes turn slowly toward the ear in which the ice water is injected into,
then rapidly turn away.
Tympanic membrane integrity must be intact before testing!!!

Oculovestibular Reflex

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Brain stem integrity test: Allow CO2 to build up to stimulate the
respiratory system to determine if patients will breath on their own

Apnea test

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MAP - ICP =

Cerebral Perfusion Pressure (CPP)

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Normal ICP

1-15 mmHg

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Normal CPP

60-70 mmHg (must be at least 50 to maintain cerebral perfusion)

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Which is worse:

Decorticate posturing (arms bending and wrists and hands clenched in flexion)
or
Decerebrate posturing (arms and legs held straight out into extension, the toes pointed downward in extension, the head and neck arched and extended backward)

Decerebrate posturing

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Very Late sign of Increased ICP. Consists of increased systolic BP (widening pulse pressure), profound bradycardia & abnormal respiratory pattern

Cushing’s Triad

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Cushing’s Triad

-increased systolic BP (widening pulse pressure)
-profound bradycardia
-abnormal respiratory pattern

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Another sign of increased ICP resulting from shifting of brain tissue. Etiology can be related to tumors, bleeding, swelling. Usually have some altered LOC, posturing, VS changes

Herniation

This type of herniation causes dilated pupils uni or bi-laterally

Uncal herniation

This type of herniation causes constricted pupils equal

Central herniation

GCS Motor Response

-Obeys commands 6 -Localizes to noxious stimuli (pain) 5 -Withdrawal (flexion) from pain 4 -Abnormal flexion 3 -Abnormal extension 2 -No response 1

GCS Verbal Response

-Oriented and converses 5 -Confused but converses 4 -Verbalizes but inappropriate words 3 -Incomprehensible words or sounds 2 -No verbal response 1

GCS Eye Opening

-Spontaneously opens eyes 4 -Opens eyes to speech 3 -Opens eyes to pain 2 -No eye opening 1

Glascow Coma Scale

Motor = 6 Verbal = 5 Eye = 4

Pupillary changes with: -Metabolic imbalances, diencephalic dysfunction -Third cranial nerve dysfunction, anoxia -Midbrain dysfunction -Pontine dysfunction, opiates, miotic drugs

-Metabolic imbalances, diencephalic dysfunction = small, reactive, regular shape -Third cranial nerve dysfunction, anoxia = fixed and dilated -Midbrain dysfunction = misposition and fixed -Pontine dysfunction, opiates, miotic drugs = pinpoint, nonreactive

Respiratory rate/pattern: Regular cycles of resp. that gradually increase in depth and then decrease in depth to periods of apnea. Caused by lesions deep in cerebral hemispheres, diencephalon or basal ganglia

Cheyne-Stokes

Respiratory rate/pattern: Deep, rapid respirations caused by problems in the lower midbrain or upper pons

Central Neurogenic

Respiratory rate/pattern: Prolonged inspiration followed by a 2-3 sec pause caused by problems in the pons

Apneustic

Respiratory rate/pattern: Irregular, unpredictable, shallow, then deep respirations with pauses caused by problems in the upper medulla or lower pons

Ataxic

8 assessment findings in shunt malfunction

-Vomiting *Headache *Irritability *Inconsolable *High pitched cry * Fever *Redness along shunt line * Fluid around shunt valve

What are the causes of VP shunt malfunction?

*Infection (fever, warmth/redness/swelling near reservoir, other s/s of increased ICP) *Obstruction (altered LOC, emesis often w/o nausea, pupil changes, VS changes indicative of increased ICP)

Normal until ~age 2. Occurs after the sole of the foot has been firmly stroked. The big toe then moves upward or toward the top surface of the foot and the other toes fan out.

Babinski (plantar) Reflex

When does the anterior fontanel close? Posterior?

Anterior: 9-18 months Posterior: ~2 months

This may be caused by a history of Group B strep or herpes exposure during delivery. Symptoms in baby are a sharp/shrill cry, irritable, loss of appetite.

Meningitis

Type of headaches with no organic cause. Types include migraine, cluster HA, tension HA.

Primary

Type of HA with organic etiology, likely from tumor or aneurysm

Secondary

Primary HA that can last up to 7 days (CONSTANT NON-PULSATING PAIN), rarely have N/V or photophobia, cervical muscle tenderness

Tension

Primary HA that occur in groups followed by a period of remission, very excruciating (BURNING SENSATION BEHIND THE EYES), associated with lacrimation and rhinorrhea on the affected side

Cluster

Primary HA: May have aura (visual or somatosensory), throbbing/pulsating in nature, +n/v, +photophobia / phonophobia, difficulty concentrating, visual changes. Often brought on by precipitating events such as emotional events, metabolic (fever or menses), flickering lights or TV, foods, fatigue, alcohol abuse, sleep deprivation

Migraine

4 diagnostics for HA if organic cause is suspected

*Skull X-rays *CT Scan *MRI *EEG

Treatment of headaches (7)

-Heat (muscular) * Cold (vascular) * Dark room * Massage * Analgesics * Oxygen * Preventive drugs (vasoconstrictors, beta blockers, anticonvulsants)

Bacterial or viral infection that affects the pia and arachnoid meninges. Can be viral (short lived and mild) or bacterial (more severe & life threatening). Causes: Streptococcus pneumoniae, Haemophilus influenzae (H. Flu), Neisseria meningitides. Infants and elderly often don’t show classic signs.

Meningitis

Meningitis S&S (13)

* Illness or exposure * Altered LOC * Headache (occipital) * Fever, chills * Vomiting, diarrhea * Seizures * Bulging fontanel in infants * Cyanosis, mottled skin * Neck and back pain * Restless / Irritable * Lethargic * High pitched cry * Anorexia, poor feeding

5 meningeal signs

*Nuchal rigidity *Pain upon neck flexion *Photophobia *Positive Brudzinski’s sign (knees & hips flex involuntarily when neck is flexed) *Positive Kernig’s sign (leg is flexed at hip and patient cannot completely extend leg)

-Meningeal sign: knees & hips flex involuntarily when neck is flexed -Meningeal sign: leg is flexed at hip and patient cannot completely extend leg

*Brudzinski’s sign *Kernig’s sign

What does a meningococcal meningitis rash look like?

Purpuric lesions

What does this CSF indicate? *Clear appearance *Normal pressure *WBC < 500 *Glu and Protein normal *Negative gram stain

Normal or viral infection

What does this CSF indicate? *Cloudy appearance *Elevated pressure *WBC > 1000 *Decreased Glu *Elevated Protein *Bacteria on gram stain

Bacterial infection

How do we treat meningitis?

-Strict Isolation - Mask, Gown, Gloves *Undress completely - check skin *ABC’s, O2, frequent V/S, seizure precautions *IV’s ASAP *Antipyretics *Antibiotics EARLY!!!!!!!! *Monitor mental status *Treat any family members or health care providers exposed if bacterial within 24 hrs

Patients at greatest risk for CVA (8)

-Hyperlipidemia -CHF -obesity -MVP -A-Fib -smokers -drug use (cocaine) -Uncontrolled HTN

CVA that occurs by atherosclerosis or clot which prevents adequate cerebral blood flow to the brain

Ischemic

CVA that occurs due to a weakened blood vessel ruptures and leaks into the brain and/or subarachnoid space

Hemorrhagic

What does BEFAST stand for?

-Balance -Eyes -Face -Arms -Speech -Timing

-Stoke with progressive development of a deficit over time -Stroke with immediate maximization of deficit, no improvement or decline

-Stroke in evolution/progressive stroke -Completed stroke

What are 5 S&S of an anterior stroke (CAROTIDS)?

-Altered LOC *Motor Deficit (contralateral hemiparesis or hemiplegia) *Sensory deficit (contralateral) * Dysphasia: expressive or receptive, or global *Visual deficit (loss of vision in half of vision field)

What are 5 S&S of a posterior stroke (VERETEBRAL/BASILAR SYSTEM)?

* Altered LOC * Motor deficit in more than one limb * Visual deficit (field deficits, cortical blindness, diplopia) * Loss of coordination (cerebellum = ataxia, vertigo, dizziness) * Cranial nerve deficit: -Dysphonia (difficulty producing voice sounds) -Dysarthria (difficulty with articulation) -Dysphagia (difficulty swallowing)

-Ischemic stroke target BP? -Hemorrhagic?

Ischemic: ≤ 185/110 Hemorrhagic: ≤160-140

How long after onset of stroke symptoms can a mechanical clot retrieval procedure be done per the FDA?

8 hours

How long after onset of stroke symptoms can tPA be given per the FDA?

3 hours (evidence says ok up to 4.5 hours)

How is tPA administered?

-Not to exceed 90 mg total dose of tPA – 0.9 mg/kg *10% of dose over 1 minute (max 9mg) *Rest of drug over one hour

Sudden discharge of a group of neurons resulting in transient impairment of consciousness, movement, sensation or memory. Patients at risk: head trauma, CVA, CNS infections, MS, Alzheimer's.

Seizures

Series of seizures without recovery to baseline neurological status, can increase mortality R/T acidemia, hypoglycemia, autonomic dysfunction, hypercalcemia. MEDICAL EMERGENCY

Status Epilepticus

Seizures phases: -Contraction of voluntary muscles, body stiffens -Violent, rhythmic contractions

* Contraction of voluntary muscles, body stiffens = tonic phase * Violent, rhythmic contractions = clonic phase

Treatment for seizures (8)

-Maintain ABC’s * Turn on side * Protect from Injury * Suction nearby * IV access * Benzo’s: Diazepam or Lorazepam * Phenytoin or Fosphenytoin * Barbiturates: Phenobarbital

Acute Inflammatory polyneuropathy that primarily affects the motor component of peripheral nerves. Considered to be an immune-mediated response to a bacteria or virus that triggers destruction of the myelin sheaths. 75% of all patients with this had a mild febrile illness 2-3 weeks prior. Neuropathy begins in lower extremities and ascends in symmetrical pattern. Symptoms peak in 1-4 weeks. Motor function returns in descending fashion. May cause motor weakness or paralysis, diminished or absent reflexes, respiratory Insufficiency, urinary retention.

Guillian-Barre Syndrome

Where does neuropathy begin with GBS? How does motor function return?

-Neuropathy begins in lower extremities and ascends in symmetrical pattern -Motor function returns in descending fashion

Treatment for Guillain-Barre (6)

-Continuous monitoring of respiratory status * Monitor sensory & motor function * Elevate HOB * Frequent repositioning to prevent pressure ulcers * Pain management * Plasmapheresis or IV immunoglobulin

How is GBS diagnosed?

-Diagnosed by rule-outs! -CT -MRI * LP * Nerve conduction studies (EMG) * Pulmonary function testing

*Defect in neuromuscular transmission, autoimmune disease *Occurs mainly in women age 20-30 *Ocular dysfunction (80% of cases) *Ptosis – eyelid drooping *Diplopia with directional gaze *Difficulty keeping eye closed *Does not affect the pupil

Myasthenia Gravis

-EMERGENT CONDITION: causes sudden onset of respiratory paralysis, increased fatigue & delayed muscle strength, weak eye & facial muscles, inability to swallow

Myasthenia Gravis Crisis

What is the ice pack test? What does it diagnose?

Put ice over the eye, remove it and see if eye movement improves. If eye can move better and ptosis improves it is likely myasthenia gravis.

What is the tensilon test? What does it diagnose?

Diagnostic test to check for MGC*10mg Tensilon (1ml) * Inject 2mg IV over 15-30 seconds. If no reaction after 45 seconds, inject the remaining 8 mg *Considered cholinergic crisis if patient exhibits a cholinergic response (parasympathetic effect – low B/P, AV block, bradycardia), muscle fasciculations or increased muscle weakness *Considered myasthenic crisis if patient condition improves

How do we treat Myasthenia Gravis?

-Support Airway and Ventilation (Non-invasive vs. Intubation) *Plasmapheresis *IV immunoglobulin *High dose steroids *Pyridostigmine (Mestinon): Increases concentration of acetylcholine by inactivating acetylcholinesterase, 60 mg PO TID and follow with titrated maintenance dose, 1/3 of PO dose may be given IV

-Chronic CNS demyelination *No clear etiology but probably a T cell mediated autoimmune disorder * Plaques develop in the white mater * Symptoms: muscle weakness, diplopia, vertigo, paresthesias *Management: Steroids, Muscle Relaxers

Multiple Sclerosis

*Degenerative disease of the motor neurons, causes loss of peripheral motor function and paralysis moves central *Etiology is unknown *Most die from respiratory complications -Does not effect cognition

Amyotrophic Lateral Sclerosis (ALS) “Lou Gehrig’s Disease”

What are the 4 primary motor symptoms (TRAP) associated with Parkinsons?

* Tremor at rest * Rigidity * Akinesia (Bradykinesia) * Postural instability

-Occurs due to dopamine deficiency -Symptoms: tremor at rest, rigidity, akinesia (Bradykinesia), postural instability, “Masked face” appearance, dysphagia, constipation, dementia -Treatment: Dopaminergics, Dopamine Agonists, Anticholinergics

Parkinson Disease

* Traumatic reversible deficit with or without temporary loss of consciousness with some amnesia * Strong rapid acceleration - deceleration stimulus or sudden blow to the skull * Last minutes to hours * Signs & Symptoms: LOC after injury, Dizziness, H/A, N/V, Amnesia, Asking same questions over and over * Risk of Secondary Impact Syndrome -Typically symptoms last 2 days, post-concussive syndrome can last up to 3 weeks

Concussion, "mild TBI"

Happens when the brain swells rapidly shortly after a person suffers a second concussion before symptoms from an earlier concussion have subsided. This event is rare, but when it does happen, it is most often fatal. The few who do not die from such an event are usually left severely disabled for life.

Second impact syndrome

If clear or bloody rhinorrhea/otorrhea s/p head trauma, what test should we do?

Clear = check glucose, +glucose = CSF Blood = halo test

Periorbital ecchymosis 2/2 basilar skull fracture

Raccoon Eyes

Mastoid bruising that occurs hours after a basilar skull fracture

Battle Sign

Brain hematoma: -Collection of blood between the skull and the dura *Laceration in the Middle Meningeal Artery with a temporal skull fracture *Arterial bleed is under high pressure, it does not tamponade - leads to increased ICP *50% Mortality rate *Initial period of Unconsciousness, then a LUCID INTERCAL that lasts 5min - 6hrs; patient is awake and then RAPID decline to unconsciousness -S&S: Pupils: unilateral, fixed or dilated; contralateral paresis or paralysis progressing to posturing , cushing’s response (LATE)

Epidural Hematoma

Brain Hematoma: *Collection of blood between the dura mater and the subarachnoid layer of the meninges * Veins that bridge the subdural space are torn and venous blood collects beneath the dura -Usually caused by trauma *Can be acute (< 48 hrs), subacute (2-14 days), or chronic (> 14 days) -Seen more in alcoholics and elderly due to brain atrophy - brain gets smaller and moves around more

Subdural Hematoma

Type of subdural hematoma: -H/A, drowsy, confusion * STEADY decline in patient’s LOC * Ipsilateral, unilateral pupil dilation, with lack of response to light * Contralateral hemiparesis

Acute subdural

Type of subdural hematoma: -Gradual nonspecific changes * Alteration in Mentation * Ipsilateral or contralateral hemiparesis * Papilledema * Dilated ipsilateral pupil, sluggish to light

Chronic subdural

Brain Hematoma: -Diffuse collection of blood between the arachnoid mater and the pia mater *Aneurysms are a result of thinning of the medial layer of the arterial wall *Precipitated by hypertensive event caused by straining, sexual intercourse, heavy lifting, or excitement *Clinical presentation depends on the vessel involved *Signs/Symptoms: sudden alteration in LOC, H/A – “Worst of my Life”, not relieved by anything – “Thunderclap HA”, Nausea, Photophobia, Sudden Seizure, Meningeal signs

Subarachnoid Hematoma

Treatment for brain hematomas (8)

-Maintain ABC’s *Monitor Neuro status *BP Management * Elevate HOB (or reverse Trendelenburg if must lay flat) *Quiet Environment * Sedation, Analgesics, and Anticonvulsants *Medical decompression of cranial vault to decrease ICP (with mannitol or hypertonic saline) *Prepare for emergency surgery for clot evacuation or coiling procedure

*Bruising or tearing of spinal cord from trauma or a fracture/dislocation of the spinal column *Common in 15-35 yr age group *Trauma: Falls, MVC, GSW, Sporting accidents *Mechanisms: Axial loading, hyperflexion, Hyperextension, Penetrating, Rotational -Can be complete or incomplete

Spinal Cord injuries

Mechanism that causes a spinal cord injury - occurs from landing head or feet first

axial loading

Type of spinal cord injury: Total transection of the cord with no preservation of sensorimotor function below the level of the injury

Complete

Type of spinal cord injury: Partial Injury with some cord sparing. Can be classified as Brown-Sequard, anterior cord, dorsal column, central cord -More commonly seen with penetrating trauma

Incomplete

Incomplete SCI: * Hemi-section of the cord causes s&s on both sides * Loss of motor function, light touch, vibration, and position sense (proprioception) on the ipsilateral (same) side to the lesion * Loss of sensation of pain and temperature, on the contralateral (opposite) side of the body

Brown-Sequard

Incomplete SCI: * Damage to the anterior horn cells and the spinothalmic and corticospinal tracts with sparing of posterior column * Loss of motor function, pain, and temperature sensation at or below the level of the injury * Sensation of light touch, proprioception, position, and vibration remain intact -Opposite of dorsal

Anterior cord

Incomplete SCI: -Damage to the dorsal (posterior) aspect of the spinal cord *Loss of position sense and vibration at or below the level of the lesion *Motor function along with pain and temperature sensation are preserved -Opposite of anterior

Dorsal Column

Incomplete SCI: *Damage to the central structures of the cervical spinal cord *Injury to the central gray matter and the most medial portion of the lateral corticospinal tract *Results in loss of (fine) motor & sensation more in the upper than the lower extremities; bladder dysfunction (can walk to the table but can't feed themselves)

Central Cord

*Injury to the spinal nerve roots *Typically associated with fractures or herniations at L1-L2 *Symptoms: saddle Anesthesia, bowel/bladder/sexual dysfunction * Progressive leg weakness -was previously treated with steroids but this is no longer the standard of care

Cauda Equina

-Seen after neurogenic shock has resolved *Complication of spinal cord injury at or above level of T-6 *Caused by noxious stimuli below the level of the injury: Full bladder, full rectum, decubitus ulcer *Over reaction of sympathetic nervous system *Symptoms: sudden severe headache, HTN, sweating & flushing above level of injury, coolness below level of injury, bradycardia and/or arrhythmias *Treatment involves identifying & relieving cause & administration of vasodilators, if needed

Autonomic Dysreflexia

A patient is brought into your ED and has a spinal cord injury. He is unable to move below the level of the injury. The ED nurse inserts an indwelling urinary catheter because: A. The bladder is areflexic B. The patient is unable to ambulate C. Voluntary reflex bladder emptying occurs D. Hematuria may be present

A. The bladder is areflexic

A patient presents to the triage desk after a motorcycle crash without a helmet. You note bruising to the mastoid process and periorbital ecchymosis, what type of head injury is most likely present? A. Epidural hematoma B. Subdural hematoma C. Depressed skull fracture D. Basilar skull fracture

D. Basilar skull fracture

A patient arrives via EMS in full tonic-clonic seizures. His airway is patent and suction is at the bedside. The patient’s phenytoin (Dilantin) level is 3. (Normal is 10-20 mcg/ml.) You are ready to infuse phenytoin (Dilantin) 1 gram IVPB. The ED nurse should: A. Infuse in D5W B. Infuse quickly C. Infuse in NS at 50mg per minute D. Infuse in NS at 100mg per minute

C. Infuse in NS at 50mg per minute (no more than 50mg/minute; also can cause arrhythmia so must be on monitor)

A 48 year old woman presents to the ED complaining of pain in her jaw. You note facial drooping to the corner of the mouth on the left side. Which cranial nerve is affected? A. Cranial nerve VI B. Cranial nerve VIII C. Cranial nerve V D. Cranial nerve III

C. Cranial nerve V

A day care worker with a recent viral illness presents to the ED complaining of numbness and paresthesias of her hands, and feet, and of lower leg muscle weakness. This patient should be assessed for: A. Myasthenia gravis B. Guillian-Barré syndrome C. Botulism poisoning D. Organophosphate poisoning

B. Guillian-Barré syndrome

Four patients with the complaint of headache present to your triage desk within minutes of each other. The ED nurse should consider which patient to be more emergent? A. “I have a throbbing headache, can you turn off the lights?” B. “I have had this headache all day and its getting worse.” C. “I have a bad headache and my neck hurts.” D. “I have a headache right behind my eyes and in my temple, can’t you do something?”

C. “I have a bad headache and my neck hurts.”