Neurological Emergencies Flashcards
Define Pia Mater
Thin cerebral cortex cover, Inner most layer
Subarachnoid space
Located between Arachnoid and Pia Mater. Contains CSF
Define Dura Mater
Tough outer covering. (2 layers, outer covering adhesed to skull.)
Epidural space
Potential space between skull and dura mater. (requires high pressure to create bleed, usually arterial and eye shaped on CT scan)
Subdural space
Potential space between dura mater and the arachnoid
Normal ICP
0-10 mmHg
Transducer location for monitoring ICP
Even with the Foramen of Munro (even with ear canal)
Normal CPP
> 60 mmHg
CPP formula
CPP = MAP - ICP
MAP formula
MAP = DBP + 1/3 pulse pressure
Pulse pressure formula
SBP - DBP
S/S of increased ICP
Change in LOC, pupil size and reaction Abnormal motor response Decorticate posturing Decerebrate posturing Cushing's Triad
What is Decorticate posturing?
Adduction of arms towards core.
Indicates damage above cerebellum and brainstem
What is Decerebrate posturing?
Extension and hyperpronation of arms.
Indicates damage to brainstem or compression of thalamus and brainstem
Cushing’s Triad
Hypertension
Bradycardia
Respiratory changes
(Widening pulse pressure)
Treatment of ICP
Position patient (eyes forward with c-collar)
Limit noxious stimuli (suction, noise, pressure change, invasive procedures)
Maintain euvolemia, normothermia, electrolytes
Sedation (benzos, Propofol)
Analgesia (opioids, fentanyl)
NMBA (non-depolarizing)
Subdural Hematoma
Blood between dura and arachnoid layer (usually venous)
3 types of subdural hematoma
Acute = symptomatic within 24 hours Subacute = symptomatic within 2-10 days Chronic = symptomatic after 2 weeks
Subdural hematoma in different age groups
Elderly = larger subdurals with slowly developing symptoms due to cerebral atrophy
Younger = Rapid onset of symptoms with marked increased ICP
Pediatric = Typically occur <18 months, look for bulging fontanelle and retinal hemorrhage
Epidural Hematoma
Bleeding between skull and dura mater (usually arterial)
Laceration of the middle meningeal artery in the temporal lobe
Classical symptom of Epidural hematoma
Transient loss of consciousness followed by lucid period
Define Subarachnoid Hemorrhage
Bleeding between arachnoid membrane and pia mater.
Common causes of subarachnoid hemorrhage
#1 - Trauma #2 - Berri aneurysm (rupture due to HTN)
Classical symptoms of subarachnoid hemorrhage
Worst headache of my life
N/V, stiff neck, vision disturbances, altered LOC
(commonly confused with meningitis, do not do lumbar puncture)
Define Intracerebral hemorrhage
Hemorrhage in the brain parenchyma
Produced from shearing and tensile forces
Frequently occurs in the white matter of the frontal and temporal regions
Define Intraventricular hemorrhage
Bleeding in the ventricles due to trauma
Results from shearing forces
Greatly increased mortality rate
Define mild concussion
Short duration of retrograde amnesia
Define classic concussion
Brief LOC, retrograde and post-traumatic amnesia
Define Diffuse Axonal Injury (DAI)
Usually coma
Increased ICP
Profound neuro, psych, personality deficits
Three classifications of stroke
Emboli
Hemorrhagic
Thrombotic
Stroke treatment
Thrombolytic therapy within 3 hours of onset (clot only)
Maximize cerebral blood flow, control ICP, supportive care
Linear fracture
A line that extends towards base of skull
Linear Stellate fracture
Multiple fractures that radiate from the compressed area
Diastatic fracture
Separation of the bones at a suture line
Depressed skull fracture
May be closed or open
Define basilar skull fracture
Fracture at base of skull
S/S of basilar skull fracture
Battle’s sign (bruising behind ears - late)
Periorbital ecchymosis (Raccoon eyes - late)
Otorrhea - bleeding from ear with CSF leak (early or late)
Rhinorrhea - bleeding from nose with CSF leak (early or late)
Skull fracture complications
Pneumocephalus (Boyle’s law can increase)
Infections, hematoma, nerve damage, palsies
Lefort I fracture
Fracture of maxillae
Lefort II fracture
Fracture of nose and maxillae
Lefort III fracture
Fracture of midorbit, nose, and maxillae
Presentation of Lefort fractures
Epistaxis
Trismus
Rhinorrhea
“Floating facial regions”
Treatment of Lefort fractures
Secure airway
Avoid accessing nose (ETT, NG, NPA)
Neurogenic shock
Flaccid paralysis immediately or shortly after injury
Parasympathetic dominance below lesion
S/S of neurogenic shock
Hypotension
Warm red skin below injury
Absence of tachycardia
Anterior cord injury S/S
Complete motor, pain, and temperature loss below the lesion
Brown-Sequard injury S/S
Loss of movement on the same side as the cord damage.
Loss of pain, temp, and sensation on opposite side
Central cord injury S/S
Greater motor weakness in upper extremity than in lower extremity with varying degrees of sensory loss
Autonomic dysreflexia S/S
Urinary retention, massive increase in sympathetic tone causing HTN, treat with foley
Cranial Nerve I
Olfactory: Smell
Cranial Nerve II
Optic: Visual acuity
Cranial Nerve III
Oculomotor: constricts pupil, opens eyelid
Cranial Neve IV
Trochlear: look down and outward
Cranial Nerve V
Trigeminal: forehead, cheek, and chin movement
Cranial Nerve VI
Abducens: rotate eyeball outward
Cranial Nerve VII
Facial: smile, close eyelid, facial movement
Cranial Nerve VIII
Acoustic: hearing and balance
Cranial Nerve IX
Glossopharyngeal: swallow and gag reflex
Cranial Nerve X
Vagus: sympathetic / parasympathetic responses - HR, BP, Breathing
Cranial Nerve XI
Spinal Accesory: shoulder shrug, head turning
Cranial Nerve XII
Hypoglossal: toungue movement
GCS of 13-15 indicates?
Minor injury
GCS of 9-12 indicates?
Moderate injury
GCS of <8
Severe injury
TPA administration
IV TPA if <3 hours
Intrarterial TPA <6 hours
MERCI if 8-12 hours (roto-rooter)
