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General Surgery 2 > Neurology > Flashcards

Neurology Flashcards

1
Q

Traumatic spinal fractures

A
  • C1
  • C2
  • Cervical, thoracic and Lumbar fractures
  • Spinal cord injury
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2
Q

C1 atlas fracture

A
  • C1 ring articulates with the occipital condyle and C2. Usually axial load
  • Type I: Anterior ring OR Posterior ring fracture
  • Type II: Burst fracture ( Jefferson fracture)- 4 point fracture
  • Type III- lateral mass fracture
  • Associated Condylar fracture
  • Treatment Options:
  • Immobilization, Halo, Surgical Intervention
  • Stability determined by Integrity of the transverse ligament
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3
Q

C2 axis fractures

A
  • Alar ligament, cruciate ligament and transverse ligaments
  • Odontoid fractures
    • Type I- tip of odontoid (rare)
    • Type II- base of odontoid
    • Type III- through the body
  • Hangmans fracture: bilateral fracture through pars, often associated sublux C2-3. Severe extension
  • Treatment: Immobilization vs surgery vs Halo
  • Disruption Transverse ligament, displacement > 5mm or disruption PLL usually result in surgery
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4
Q

other cervical spinal fractures

A
  • Avulsion fracture- anterior fracture usually ant inf.
  • Compression fracture
  • Burst fracture
  • Spinous process, Transverse process
  • Tear drop fracture- posterior fracture with ligament injury
  • Jumped facet/Perched facet- severe flexion injury, unilateral vs bilateral , quad raplegia due to ligamentous injry and SCI
  • Tx: Traction, Surgery, Bracing, IR treatments
  • Special consideration- CVA secondary to vertebral injury occlusion or dissection- evaluated on CTA,angiogram- Tx ASA/Heparin, endovascular repair
  • Look for any injuries to the vertebral arteries
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5
Q

tramatic thoracic and lumbar fractures

A
  • Three Column Model-ant/middle/post.
    • Minor injuries 1 column: Spinous process, Transverse process, Lamina fracture, pars fracture, Compression fractures- can become surgical if kyphotic deformity or >50% loss
    • Moderate to severe: 2-3 column with possible instability
    • Burst fracture-pure axial load, surgical if unstable, retropulsion or Neuro deficit
    • Seat belt fracture- flexion across fulcrum with compression anterior and distraction of posterior or Chance fracture- through and through- surgical often if deformity, distraction or neuro deficit
    • Fracture dislocation- same as above surgical intervention
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6
Q

spinal cord injury secondary to trauma

A
  • “Level” of injury- either the last level of complete normal function or function level most caudal with 3/5 motor with temperature and pain present on exam
  • On PE: Motor weakness, sensation changes, hyperreflexia, loss of sphincter control- if administered within 8 hours on injury possible slight improvement at 1 year compared to non treated
  • Imaging: CT/MRI
  • Treatment: Immobilization until surgical stability, Methylprednisone controversial
  • Complete injury- no preservation of motor/sensory more than 3 segments below injury. If injury above C3 vent dependent
  • Incomplete quadriplegia- any residual motor or sensory for than 3 segments below the level of injury
    • Central cord syndrome- greater motor deficit in UE>LE
    • Brown Sequard syndrome- spinal cord hemisection with ipsilateral motor paralysis and contralateral sensory loss of pain, temp and light touch
    • Posterior cord and Anterior cord injury- rare, pain an paresthesia, infarct of anterior spinal artery respectively
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7
Q

intracranial trauma

A
  • SDH
  • EDH
  • SAH
  • IPH
  • Skull fractures- open/closed
  • DAI
  • Cerebral edema
  • Penetrating trauma
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8
Q

SDH

A
  • Acute vs Chronic
  • Usually result of direct impact
  • Signs usually develop later with slow progression
  • CT scan demonstrates Crescent mass of increased attenuation concave towards the brain
  • Density on imaging changes- isodense around 2 weeks
  • Can cause brain compression with midline shift, more severe in young
  • PE: Weakness, facial droop, speech issues, + Pronator drift, AMS, LOC, low GSC
  • Treatment- Surgical vs observation
  • Considerations: Stop Anticoags
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9
Q

EDH

A
  • Usually in younger patients
  • Often associated with tempoparietal skull fracture injuring the middle meningeal artery
  • “Textbook” presentation- direct head trauma with a + LOC, followed by a “lucid interval”, then become obtunded with contralateral hemiparesis and ipsilateral pupil dilation
  • May be associated with HA, N/V, sz
  • CT scan demonstrates crescent mass of hyperintensity convex to the bone
  • Emergent surgical intervention- Resp distress due to uncal herniation vs observation if small with stable GCS and neuro exam-serial imaging
  • Can occur as a delayed EDH- why monitoring post head traums very important
  • They lose consciousness at first, then wake up and are fine and then decline rapidly
  • This is a surgical emergency if they are altered
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10
Q

IPH

A
  • Most common in temporal, frontal and occipital poles
  • Usually sudden deceleration injury causes brain to hit bony prominences, coup/countercoup injury
  • Exam: LOC, AMS, irritability, HA, N/V, sz activity
  • Concern for blossoming, increased ICP, seizures- sz prophylaxis and close GCS monitoring
  • Treatment: Observation vs surgical treatment- craniectomy, evacuation hematoma
  • Cerebral contusions are always the worst on days 4-14

Pretty much for ANY head injury, you give seizure prophylaxis

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11
Q

SAH

A
  • Trauma is most common cause of SAH
  • High density spread thinly over convexity and filing sulci and basal cisterns
  • If Trauma uncertain R/o other causes with CTA/Angiogram
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12
Q

Skull fractures

A
  • Skull fracture increases probability of surgical intracranial injury
  • Depressed skull fracture-surgery if leading to injury to underlying brain, dura involved, neurologic deficit, or open fracture
  • Basal skull fractures-Difficult to see on imaging without thin cut CT. Pneumocepahlus, CSF ottorhea or rhinnorhea, hemotympanum, CN VII or VIII injury ( usually temporal fracture), Olfactory nerve injury (anterior fossa BSF)
  • Special considerations: NO NG tube! Monitor for CSF leak persistent over 1 week High risk meningitis and needs treatment- bedrest, Diamox, Lumbar drain
  • Consider prophylaxis Abx- controversial for CSF leak
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13
Q

Penetrating trauma brain and spine

A
  • Remove FB in OR- remove in same trajectory as entry
  • Stabilize object for transport
  • Consider angiogram pre op for blood supply, Dural sinus involvement and post op for traumatic aneurysms
  • Empiric and post op Abx treatment
  • GSW- velocity dependent, often left in place in spine, surgery to stabilize spinal fractures, removed if concern for migration, bullet fragments and fracture lead to further reinjury. ICP and IPH treatment. If minimal Neurologic unction (positing, blown pupils) meaningful recovery close to zero- no OR
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14
Q

DAI: diffuse axonal injury

A
  • A primary lesion of rotational acceleration/deceleration head injury
  • CT/MRI- Diffuse edema, hemorrhagic foci of corpus collosum and brain stem, changes in white matter fiber tracts
  • Often cause of LOC when immediately comatose post injury in absence of space occupying lesion on CT ( can also occur with SDH/EPH)
  • Mild if less than 6 hours coma, moderate over 24 hour coma with amnesia, severe- coma lasting months with posturing and severe Neurologic deficit
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15
Q

Cerebral edema

A
  • Normal intracranial content blood, CSF, brain
  • Normal pressure 10-15mmHg
  • Trans-tentorial- lateral displacement of temporal lobe
  • tonsillar herniation-cerebellar tonsils into foramen magnum compression medulla- depressed gag, slow irregular breathing to apnea, decreased cough reflex
  • Cerebral perfusion pressure (CPP)= Mean Arterial pressure (MAP)- Intracranial Pressure (ICP)
  • Sign of elevated - papilledema, abducens nerve palsy, depressed LOC
  • Craniectomy/Cranioplasty
  • Special: Avoid Dextrose fluids, Use NS
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16
Q

Concussion (mTBI)

A
  • Alteration in consciousness without structural damage due to traumatic brain injury (TBI)
  • Alterations: Confusion, amnesia or LOC
  • Sx: vacant stare, delayed verbal or motor responses, difficulty focusing, disoriented, speech alterations, incoordination (tandem gait difficult), exaggerated emotion, memory deficit (repeative)
  • Imaging negative
  • Second Impact syndrome- rare condition in athletes, second injury sustained while still symptomatic from first- athlete walks off field on own with second insult rapidly declines due to cerebral edema within 1-5 minutes comatose, mortality >50%
  • No agreed classifications and guidelines- any LOC seek medical attention and return when 1-2 weeks no symptoms, no LOC pulled from game that day and observed, symptoms last over 15 minutes pulled form game and must be asymptomatic 1 week to return
  • Multiple concussion:
    • If 2 within 1 season- recommend imaging and if WNL 1 month no play
    • If 3 concussions or 2 severe( LOC) then season ending injury and consider ending all contact sports
  • Post concussive syndrome
    • Collection of symptoms following head trauma
    • HA, dizziness, visual changes, anosmia, hearing changes, balance issues, cognitive changes- difficult concentrating, mild dementia, memory problems, impaired judgment, easy fatigue, depression
  • Post traumatic Alzheimer’s disease
  • Chronic Traumatic Encephalopathy
    • mild to severe dementia pugilistic
    • Motor, cognitive an psychiatric impairments- mental slowing, emotional lability, violent outburst, paranoia, slowness sin though and speech, parkinsonism, dysarthria, tremors, ataxia
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17
Q

spinal disorders

A
  • Low back pain
    • Herniated Disc
    • Degenerative Disc disease
    • Lumbar spondylosis/spondylolisthesis
    • Spinal stenosis secondary to above
    • Cauda equina syndrome
  • Neck pain- same conditions of lumbar spine can occur in cervical region
  • Ankylosing spondylitis
  • Scoliosis
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18
Q

low back pain

A
  • Second most common reason people seek medical attention
  • Most common cause of disability for persons >45 yo
  • Lumbar nerve roots exit level below i.e L3-4 causes L4 radiculopathy
  • Most common disc issues at L4-5, L5-S1 followed by L3-4
  • Disc anatomy- annulus fibrosis with nucleus pulpous
    • Annular tear- separation of annular fibers
    • Degeneration- desiccation, narrowing of disc space, changes in endplates and osteophyte formation
    • Bulging- generalized displacement of disc material, can lead to lateral recess or focal stenosis
    • Herniation- localized displacement of disc material, can extrude leading to specific nerve compression
  • Sometime surgery not an option- pain management options- Spinal cord stimulator
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19
Q

history and PE of back pain

A
  • OPQRST- new vs old pain, acute exacerbation, describe pain location and quality. Radiating pain- radiculopathy- muscle weakness, sensation changes. Bowel/bladder dysfunction. Ability to walk far ( claudication)
  • Previous treatments- Medrol, PT, Chiropractor, NSAIDs, Oral pain meds, conservative treatments, etc
  • Important to address social situation and underlying psychological issues associated with chronic pain
  • PE:
  • Inspection- spine for deformity, Muscle tone and bulk- specific atrophy noted, Motor and sensory exam. Hyporeflexia vs hyperreflexia, gait, +SLR
  • L4- knee reflex, quads weak, L5- foot drop S1- diminished Achilles reflex, weak plantar flexion
  • Imaging: Xray, CT, MRI
  • Lateral, vs foraminal vs central stenosis
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20
Q

disc displacement

A
  • HNP- Herniated nucleus pulposus
    • Foraminal narrowing leading to nerve root impingement
    • Extrusion leading to above or below nerve impingement
    • Weakness in myotome
    • Usually direct trauma or sudden onset back pain with radiculopathy
    • Treatment options: oral steroids, time, PT, EPI, surgery
  • Degenerative Disc Disease
    • Slow progression of disc changes associated with facet disease, ligamentous changes
    • Broad based disc displacement
    • Can lead to lateral/foraminal recess stenosis over time or central stenosis with symptoms of radiculopathy or neurogenic claudication
    • Tx: Conservative treatments unless severe stenosis
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21
Q

lumbar spondylosis/spondylolisthesis

A
  • Degenerative vs congenital condition with misalignment of vertebral bodies with anterior subluxation of one vertebral body on another
  • Most common L5-S1 followed by L4-5
  • Spondylolisthesis- pars defect (neck of the “scotty dog”
  • Graded I-IV- III and IV usually surgical due to nerve root impingement and possible cauda equina syndrome
  • Grade I-II based on patients exam tx of surgery vs conservative treatments
  • Tx: Surgery: PLIF/TLIF/ALIF vs conservative treatments
22
Q

lumbar stenosis

A
  • Above conditions can contribute to stenosis along with congenital narrow canal
  • Usually slow progression, can delay pts from getting care
  • Leads to Neurogenic claudication-
    • pain/increased numbness with short distances or standing to the legs/buttock
    • Alleviated by sitting to rest or bending forward for a period of time
    • Increased heaviness and weakness in legs with walking
    • Prefer to lean forward on object such as cart
    • Not associated with edema but often leg cramping in calves
    • No skin/hair changes, not in stocking distribution, normal pulses
  • Severe stenosis can lead to nerve compression leading to loss of sensation, motor weakness, b/b issues
  • Tx: oral meds, Pain management PT, EPI, Surgicla intervention – laminectomy
23
Q

cauda equina

A
  • SURGICAL EMERGENCY
    • Compression of cuada equine leading to neuro deficits. Can be due to Herniated disc, lesions, infections, trauma/fracture.
    • Symptoms: weakness or loss of function LE, Decreased or loss of sensation to LE, Bowel/bladder dysfunction, impotence/sexual dysfunction(late finding)
    • PE: Weakness to LE, diminished/loss of sensation, absent sphincter tone, saddle anesthesia
    • Images: MRI
    • Plan: Surgical decompression- emergent in most cases
    • Post op concerns for lumbar spine- rare complication of epidural hematoma- watch for increase pain or decline in exam, dural tears with CSF leaks, injury to nerve, hardware failure
24
Q

neck pain

A
  • Similar conditions to lumbar spine however greatest concern cervical stenosis leading to cervical myelopathy
    • Cervical HNP. DDD, disc displacement
    • Cervical spondylosis
    • Cervical subluxation
  • Symptoms: related to nerve root impingement radiating pain or radiculopathy, neck pain, radiating pain to posterior head, shoulders and arms, weakness in grips, balancing issues, b/b issues if severe, dexterity issues.
  • PE: limited ROM, crepitus, muscle spasm, weakness and/or decreased sensation, muscle atrophy, hyperreflexia- Hoffman’s and Babinski, Difficulty with finger tapping, difficulty with tandem gait
  • Imaging: Xray, CT, MRI. EMG studies
  • Tx: Conservative treatments vs Surgery. Surgery is severe stenosis, myelopathy or cord signal
  • Surgeries: Anterior ACDF , posterior decompression
  • Post op concerns: Recurrent laryngeal nerve injury, post op hematoma causing compromise, hardeware failure
25
Q

ankylosis spondylitis

A
  • Seronegative arthropathy (ANA, RF negative)
  • Spineprimary site involved starting at SI joints and moving rostrally
  • Ligament replaced with bone resulting in calcificed intervertral discs, ossified liagments causing square veretral body appearance and bridging osteophyts, so called “Bamboo spine”
  • I-3/100,000, M>F, peak incidence 17-35yo
  • Sx: nonradaiitng back pain , morning back stiffnessm hip pain, worse with inactivity and improved with exercise
  • Imaging: CT, XRAy and MRI- evlaute for stenosis, high risk with trauma
  • Tx: Surgery if cauda equina syndrome, SCI following fracture/trauma, spinal stenosis (rare)
26
Q

scoliosis

A
  • Degenerative vs idiopathic
  • Names by side of convexity of curvature- dextroscoliosis- convex to right, levoscoliosis- convex to left
  • Cobb angle used to measure degree of curvature
  • Fusion correction
27
Q

primary brain tumors

A
  • Adults: WHO grading I-IV
    • Astrocytoma
      • GBM- most common, most malignant
    • Oligodendroglioma
    • Skull base- Craniophharyngioma, cordoma, germ cell
  • Pediatrics
    • Astrocytoma
    • Medulloblastoma
    • Craniophyringioma
28
Q

imaging of primary brain tumors

A
  • Head Ct scan
  • head MRI with and without contrast
29
Q

schwannomas

A
  • Vestibular-
    • Benign lesion
    • Symptoms: hearing loss- insidious and progressive, tinnitus, disequilibrium. Can also develop V and VII CN palsy if large enough due to location-otalgia, facial numbness, facial weakness, taste changes. If large enough can cause brain stem compression leading to ataxia, HA, N/V, diplopia, cerebellar signs- threatens brain stem functions- resp. distress, coma, death
    • PE: Wber lateralizes to uninvolved side, = Rhine test, CN III deficit(hearing test prior to OR), nystagmus, facial weakness or parasthesias
    • Imaging: MRI thin cut with and without
    • Treatment: Surgery, Radiosurgery, Observation
  • Other locations: Spine, Trigemnal
  • Associated with NFII
30
Q

meningioma

A
  • Extra-axial lesion
  • Slow growing
  • Most benign (1.7% malignant)
  • Arise from arachnoid with attachment to the dura
  • Enhance on MRI with contrast
  • A third are incidental fidnings, peak age 45, F>M
  • Most common primary intracranial tumor
  • Sx: depend on location if any
  • Images: CT, MRI with and without contrast
  • Treatment: Observation vs surgical resection
31
Q

treatment of brain tumors

A
  • Surgery
    • Cranitomy for resection vs debulking
      • Neuromonitoring
      • Awake craniotomy
  • Radiosurgery
  • Chemo/Radiation with Oncology
32
Q

pituitary tumors

A
  • Most are benign adenomas arising from anterior pituitary
  • Most resent due to horomonal effects- hyperprolocatomenia (amenorrhea, galactorrhea, impotence), acromegaly, Cushings, Optic chism compression(mass affect) leading to vision loss (bitemptal hemiopspsia)
  • Considerered macroadenoma if >1cm
  • Work up:
    • Labs: Go Look For The Adenoma- GH, LH, FSH, TSH, ACTH. Prolactin, cortisol.
    • Formal visual field testing
  • Prolactenoma- treated medically with Endocrinology
  • Surgery- if causing symptoms, if increasing in size rapidly, visual changes on formal visual field testing.
    • Transpheloidal, Translabial resection
    • Post op concerns- SIADH- watch Na+, Panhypopit- check endocrine labs and consutl endocrine
33
Q

metastatic brain tumors

A
  • Overall metastatic lesions are the most common brain tumor seen
  • At tim of onset of neuro symptoms, 70% of patients will have more than one metastatic lesion
  • If solitary brain lesion in pt with hx of CA, bx needed (11% of lesion not a met but primary lesion)
  • In pts with no known hx of CA, 15% initially present due symptoms related to cerebral met
  • Most common mets in order: Lung CA, Breast CA, renal cell CA, GI, melanoma in adults
  • Others: CNS lymphoma
  • Lung cancer is the number one met to the brain and breast cancer
  • Prostate cancer is the most common met to the spine
34
Q

spinal tumors

A
  • Pathologic fractures
  • Spinal cord tumors
35
Q

cerebral vascular accident

A
  • Hemorrhagic:
    • RF: HTN, Cocaine use, Cigarette smoking, high consumption ETOH, anti platlet therpy
  • Ischemic CVA
    • RF: Carotid Stenosis, Vertebral stenosis, Cerebral stenosis, hyperlipidemia
  • Others:
    • Moya moya- progressive bilateral occlusion of ICAs with collateral compenstoy cappilaries, on angio look lik e”puff of smoke”
    • Amyliod disease- deposits of amyloid proteins, recurrent lobar hemorrhages, often elderly
  • Symptoms: Facial palsy, Motor weakness, ataxia( difficulty with finger to nose if cerebellar), paresthesia, aphasia/fluency/word finding, dysarthria, neglect, AMS, Coma
  • Imaging: CT, MRI-best for acute stroke, CT angiogram/MR angiogram, Cerebral angiogram
  • Intervention: Decompressive craniectomy if large hemoorghae or cerebral edema, Endovascualr options for stenosis, medical management( T-PA, HTN control, anticoag reversal, etc. )

Special: Always rule out underlying lesion

36
Q

vascular malformations

A
  • Arteriovenous anomoly
  • Cavernous Malformation
  • Cerebral Aneurysms
37
Q

arteriovenous malformation

A
  • Abnormal collection of blood vessels with arterial blood flow directomy into draining veins ( no capillary bed)
  • Congenital
  • Increase in size and pressure over time
  • Average age at diagnosis 33 ( 10 years younger than Aneurysms)
  • Often Present after hemorrhage- 10% mortality, 30-50% morbidity with Neurodeficit. Risk of hemorrhage higher in small AVM due to increased pressure. Avg risk of hemorrhage is 2.4% a year.
  • Often develop seizures/epilepsy
  • Imaging: CT- r/o acute hemorrhage, MRI- evaluate draining veins and feeding arteries, evaluate for edema, Angiography
  • Tx:
    • Surgery- eliminates bleeding risk and sz control. high risk, invasive
    • Radiation-stereotactic for small deep AVMs, noninvasive, outpatient. Can take years to work and continued risk of bleeding in that time
    • Endovascular embolization- usually used to help shrink lesion followed by above
38
Q

cavernous malformation

A
  • Benign vascular lesions with thick irregular vascular channels, large feeding arteries and large draining veins.
  • 50% have more than 1 lesion
  • Hemorrhage, calcify or thrombose
  • Sporadic and hereditary types
  • Sx: Sz, neuro deficit related to hemorrhage of hydrocephalus, incidental finding often
  • Images: CT- acute hemorrhage, MRI
  • Treatment: Observation, Surgery if hemorrhage
39
Q

cerebral aneurysm

A
  • “worst headache of my life”- thunderclap HA, AMS, obtunded, 3rd nerve palsy (P-comm aneurysm), sentinel HA
  • Associated with some connective tissue disorders (Marfans) polycystic disease, hereditary association- first degree relatives should be tested if rupture
  • Images: CT/MRI -SAH on imaging, CT Angio, Cerebral angiogram
  • LP done for RBC
  • Tx: Observation vs surgery
    • Surgical intervention if rupture, young age, first degree relative with rupture, Aneurysm >5mm, symptoms related I.e 3rd nerve palsy, enlargement on observation
    • Surgery options- clipping, endovascular coiling/stent coil assist
    • Special: Vasospasm post op require increase fluids and vasopressors to increase perfusion
40
Q

hydrocephalus

A
  • Congenital
  • Secondary to trauma, infections, mass effect, underlying diagnosis
  • 20cc CSF made q 1 hour, drains in Dural sinus. When insult to brain able to make CSF but disrupted clearance causing hydrocephalus
  • Requires diversion with shunting system, usually ventriculoperitoneal shunt
  • WET, WACKY, WOBBLY!!! These are the three sxs of hydrocephalus
41
Q

brain and spinal infections

A
  • Brain abscess- teeth, ear infections/mastoiditis, sinusitis, heart vegetations
  • Spinal abscess/Osteomyelitis- drug use, skin laceration/abrasions
  • Valley fever- Disseminated cocidiomycosis
  • TB/ Potts disease
42
Q

NPH

A
  • Condition of ventriculomegaly without increased pressure
  • Wet, wacky, wobbly
  • Can do opening pressure on LP – normal, pull of 30 cc fluid and observe pt function for improvement in above
  • Family input
  • PT consult
  • Consider VP shunt if improvement
43
Q

spinal deformity

A
  • Spina bifida
    • Occulta
    • Myelomeningocele
    • Meningocele
    • Encephalocele
  • Function disorders
    • Cerebral palsy
  • Development anomaly
    • Arachnoid cyst
    • Chiari malformation
    • Aquaductal stenosis- causes hydrocephalus
  • Cranial deformity:
    • Craniosynostosis
44
Q

chairi malformation

A
  • They will have Babinski, Hawkins, clonus, etc.
  • The risk to having this can cause a CSF buildup in the spinal cord
45
Q

child abuse

A
  • Suspected non-accidental head trauma with retinal hemorrhages
  • \multiple bony fractures
46
Q

deep brain stimulation

A
  • Epilepsy
  • Headaches
  • OCD
    Movement disorders:
    • Parkinson’s
    • Essential tremor
    • Dystonia
47
Q

trigeminal neuralgia

A
  • Severe facial pain
  • Compression of trigeminal surgery to decompress
  • Medication options
48
Q

peripheral nerve injury

A
  • Carpel Tunnel
  • Ulnar entrapment
49
Q

postop concerns

A
  • Pain not well controlled- see the patient
  • Drains not working- check them yourself
  • Any decline in GCS should be notified and repeat imaging immediately
  • Avoid NSAIDs with effusions
  • Avoid antociags as long as possible for ICH
50
Q

call the doctor: EVDS

A
  • Hypertension
  • Changes in RR, irregularity
  • Bradycardia
  • Severe HA
  • Decline in neuro exam – speech, motor, etc.
  • Decline in GCS >2 pts (eyes, motor, verbal)
  • Anisocoria
  • Elevated ICP >20 for >5mins
  • No output from EVD >2hr period

General Surgery 2 (8 decks)

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