The Nervous System and Altered Mental Status Flashcards
4 Functions of the nervous system
Motor
Senstation
Regulation
Cognitive and intregative functions
Functionality of the nervous system includes what two types of nervous system?
Somatic (voluntary)
Autonomic (involuntary)
Voluntary Nervous system
Somatic
Involuntary nervous system
Autonomic
The autonomic nervous system includes the ___ and ____ systems
Sympathetic and parasympathetic
CSF is produced in the ____ of the brain
ventricles
Large vessels run where?
Between the dura and the brain
CSF drains out through ducts to the _____
Subarachnoid space
The largest part of the brain. Made up of two hemispheres.
Cerebrum
Flip flop of the signals from the hemispheres that occurs in the spinal cord
Contralaterally
Ribbon like strip of tissue that runs on the underside of the cerebrum. Allows the hemispheres to “chat.” Neural pathways between the left and right hemispheres.
Corpus callosum
Frontal lobe is responsible for:
Personality, behavior, higher thought, executive function, speech, certain motor functions, intellect, emotion, “what makes you, you.”
The ____ is in the frontal lobe and takes more time to develop than the rest of the brain. Why teenagers may not make good decisions.
Pre-frontal cortex
The parietal lobe is responsible for:
Sensory response (except sight)
The occipital lobe is responsible for:
Vision, language, coordination
The _____ allows information from the right eye to go to the left brain and visa vera. Allows for depth perception and shading. In the occupital lobe.
Optic and chiasma
The temporal lobe is responsible for:
Hearing, smell, memory, language coordination
The cerebellum is responsible for:
Position, balance, coordination (proprioception)
Muscle memory
Pathways between hemispheres
Proprioception
Positioning. Comes from eyes, inner ears and sometimes joints
Where is the cerebellum?
Posterior, inferior aspect of the brain
The diencephalon is where? And contains what?
On the top of the brainstem
Thalamus
Hypothalamus
Information from the spinal cord goes through here. A type of spinal relay
Thalamus
The hypothalmus is responsible for:
Homeostasis; hormones; emotions
Takes nerve impulses and starts interpreting them
Endocrine gland
Connects the hemispheres (communicates via the corpus callosium)
Sensory processing
Reflexes
LOC
Midbrain
Respiration, pathways to cord, coordinates with cerebrum
Pons
Vital functions
Vasomotor center
Cardiac Center
DRG, VRG
Medulla
The Reticular activating system contains what two nerves? What are their functions?
Excitatory nerves-wakefulness,
Inhibitatory nerves-sleepiness
To have consciousness, need to have:
Intact RAS and one functioning hemisphere
The brain needs a constant supply of:
O2 and glucose
Blood vessels that bring nutrients and blood to the brain. Run on underside of right and left hemispheres
Circle of Willis
The circle of willis creates____
Redundancy
What artery in the circle of willis is where “shit can go bad” if there is a blockage?
Basilar artery
Arteries in the circle of willis
2 internal carotid 2 anterior cerebral 2 vertebral 1 basilar 2 posterior cerebral
Spinal nerve ends where?
Mid lumbar area
Around L2/L3
Nerves that exit distal to the end of the spinal nerve (L2/L3) are the _____
Cauda equina
C
T
L
S
C=7
T=12
L=5
S=5
When the spinal root exits the spinal cord it becomes:
Spinal nerves
Point of attachment for the vertebrae?
Transverse process
Communication in the nerve roots occurs via
electrical and chemical changes
Sensory nerves that send information to the CNS
Afferent
Sends information from the CNS out
Efferent
Dermatomes
Each spinal layer corresponds to a particular level of motor and sensory function. This can give us an guessimtate about where you may be affected in your brain based upon what is affected
Dermatomes corresponding to: C7 T4 T10 L4-L5 S2-S3
Index finger Nipple line Umbilicus Medial and lateral lower leg Genitals
Cervical nerves innervate what?
Everything from the clavicles up
Cervical nerve that is the major parasympathetic player in the body?
Vagus nerve
The autonomic nervous system regulates:
Heart rate Breathing rate Blood pressure Body temperature Organ functions
Mental status assumption
If someone is altered, assume that normally is alter and oriented unless someone tells us otherwise
Altered mental status: subjective terms
Lethargy: Sleepy, sluggish, easily aroused
Stupor: Decreased responsiveness, noxious stimulus
Semi coma: Unresponsive, noxious stimulus
Coma: Unresponsive, unarousable
Glasgow Coma Scale: Eye opening
Alert
Verbal
Painful
Unresponsive
Glasgow Coma Scale: Speech
Oriented (who, what, where, when, why) Confused Inappropiate Incoherent None
Glasgow Coma Scale: Motor function
Obedience Purposeful Withdrawel Flexion (decorticate) Extension (decerebrate) None
The Glasgow Coma Scale, unlike subjective terms is____. Why is used to evaluate altered mental status.
quantifable
Flexion (decorticate) and extension (decerebrate) indicate____
Brain injury
Under what number is the glascow coma scale concerning?
8
Structural causes and indicators of an altered mental status
Usually rapid/sudden onset
Usually present asymmetrically or signs are focal
Metabolic causes and indicators of an altered mental status
Gradual onset
Signs are generalized and symmetric
Altered mental status causes
Alcohol (M), acidosis (M) Environmental (M) , epilepsy (S) Infection (M) Overdose (M) Urema (M) Trauma (S) Insulin (M) Psychogenic (M) Stroke(S)
Constriction of pupils may be a result of:
Cholinergics
Pontine bleed
Opoid overdose
Types of strokes
Occulsive Event
Hemorrhagic event
Transient event
____ of strokes are occulsive events
____ of strokes are hemorrhagic events
80-85%
15-20%
Adjacent parts of the brain control ____ of the body
Adjacent
Risk factors for a stroke
Atrial fibrillation Smoking Hypertension Stimulants High cholesteral Age-Arterioscelerosis Diabetes Dialysis (b/c prone to hypertension, may throw clots) Sickle Cell
Of the occulsive events, ____ of those will be thrombic
and ___ of those will be the result of embolus
60%
40%
Narrowing of the cerebral arteries
Thrombosis
Thrombosis
Narrowing of the cerebral arteries
Is there typically pain and seizure associated with thrombosis?
No, gradual narrowing
Sudden occulusion of the cerebral artery from a clot
Embolus
ELVIS
Emergent Large Vessle Ischemic Stroke
Why is a first time seizure in an adult concerning?
The seizure may be due to a CVA-occulsive event resulting from an embolus
Why do embolus result in seizures?
Because sudden occlusions result in an electrical activity issue
Clots for CVA embolus result from
Carotid artery, heart (from left side)
Fat (maybe from a long bone fracture)
Tumor
Air (diver)
Onset and signs of CVA-embolus
Rapid onset, seizures common
Ischemic tissue that is not dead
Penumbra
Clot busting drugs that dissolve clots
Thrombolytics
Window for thrombolytics
5-6 hours
Vessels that result from gradual narrowing of the cerebral vessels due to Thrombosis
Collateral vessels
Cautious about giving O2 for CVA because of a potential:
re-perfusion injury
Increasing ICP is associated with a ____ event not a ____ event
Hemorrhagic
Occulsive
CVA, hemorrhagic event that results from a ruptured vessel
Aneurysm
An aneurysm can evolve overtime as a consequence of ____. Aso can be a result of a congential issue called ____
Abteriovenous malformation
Weakened wall of the artery. Like a balloon
Aneurysm
Ruptured vessel in the Intracerebral space versus subararachnoid space
Intracerebral is within the brain tissue. Subarachnoid is in the subarachnoid space
Which is worse, a ruptured vessel in the intracerebral space or subararachnoid space
Intracerebral space
A hemorrhagic event signs:
Sudden onset
Evolving focal signs
Severe headache-“thunderclap”
Signs of ICP:
Unequal pupils (ipsilateral pupil)
Posture-decorticate, decerebrate
Seizure
Cushing’s response (hypertension, bradycardia, cheynes stokes respirations)
Unequal pupil
Ipsilateral pupil
Signs and systems similar to a cerebral vascular accident, but resolves within 24 hours of onset. Warning sign of things to come.
Transient ischemic Attack
Etiology of a TIA
Plaque, embolus, spasm
RIND and what it is associated with
Reversible ischemic neurologic deficit
TIA
Signs and symptoms of a CVA
Aphasia (random words) Dysarthria (slurred speech) Facial droop Dysphagia (difficulting swallowing) Sensorium (changes are unilateral-visual changes, tactile changes, hearing in one ear) Hemi or mono plegia or paresis involving the grip or gait Neglect Balance (vertigo)
Why may a stroke patient’s balance be affected?
The cerebellum is affected
Random words
Aphasia
Slurred speech
Dysarthria
Difficulty swallowing
Dysphagia
Inflammation of the facial nerves. Unable to raise eyebrow or furrow forehead
Bell’s Palsy
What position do you want to put a stroke patient in if they cannot manage secretions?
Lateral recumbent
FAST ED can help determine if there is a ____
Large Vessel Occulsive (LVO) stroke
LVO can have what type of intervention?
Surgical
Large Vessel Occulsions
Middle cerebral artery (MVA)
Anterior cerebral artery (ACA)
Posterior cerebral artery (PCA)
Basilar artery
Middle cerebral artery (MCA) signs:
Aphasia (left) Neglect (right) Hemiparesis Deviated gase Visual field deficit
Anterior cerebral artery (ACA) signs:
Hemiparesis
Posterior cerebral artery (PCA) signs:
Visual field deficit
Basilar artery signs:
Vertigo (because blockage in the cerebral artery will result in blockage in the cerebellum)
Dysconjugate gaze
Coma
Respiratory changes (perfusion to pons going down as well due to blockage)
FAST ED
Facial palsy: normal or minor droop=0, partial or complete droop=1
Arm weakness: Normal, no drift=0, drift/some effort=1, no effort against gravity=2
Speech deficit: normal=0, mild/moderate=1, severe asphsia=2
Time
Eye deviation: Normal/absent=0, partial=1, forced deviation=2
Denial/neglect: Normal/absent=0, extinction to bilateral stimulaneous stimulation in only 1 sensory modality=1, does not recognize own affected limb or orients only to one side=2
Benign headaches
Tension headache
Migraine
Cluster headache
Why is it important to ask about the onset of a migraine?
Most of the time a migraine’s onset will follow the individual’s predictable pattern. Goot to know because onset is similar to that of a stroke
Serious headache signs/symptions
Fever and neckstiffness-Meningitis
Sudden onset/thunderclap
Change in mental status
Change in neurologic function/change in focal deficits
New headache, different headache
Underlying disease: HIV, cancer, pregnancy
Why is a headache with HIV concerning?
Possible brain abscess due to bacterial infection
Why is a headache with cancer concerning?
Space occupying lesions lead to increased pressure in the skull
Why is a headache when pregnant concerning?
Hormonal changes, prone to emboli
What is a seizure?
Chaotic discharge of electricity int he brain
Presentation of a seizure:
Varies by where the chaotic activity in the brain is occuring-focal event
- follows a predictable pattern for each person
- if changes, indicates something is different and is a cause for concern
Causes of seizures:
Epilepsy-congenital Head injury (recent or remote) Tumor Hypoxia Hypoglyemia Infection (abscess, meningitis) Febrile OD/poisons EtOH withdrawl Electrolytes (hypernutremia) Pregnancy (eclampsya)
Primary seizures tend to be ____. Example:
Idiopathetic
Epilepsy
If an alcohalic, DT’s can start around ___ hours after your last drink
9
Seizures due to a remote head injury
Have persistent seizures due to a head injury from the past. Scar tissue due to injury may not resolve
Generalized seizures and sequence
Involve both hemispheres of the brain, usually involve loss of posture and/or consciousness, involves the RAS Sequence: Aura Loss of consciousness Tonic-hypertonic Convulsion Post ictal
Tonic seizure
Increased muscle tone, sudden onset, short duration (1/2 minute-minute), no LOC
Clonic seizure
Alternating contraction and relaxation of muscles. LOC varies
Myoclonic seizure
Sudden brief muscle spasm (when falling asleep or waking up)
Atonic seizure
Sudden loss of muscle tone, “drop” seizure, no LOC
What is the most common type of seizure?
Tonic and clonic or some combination
What type of seizures generally involve the RAS?
Generalized, why you are unconsious
Signs of generalized seizure
Loss of consciousness, oral trauma, trismus, incontinence
Treatment of generalized seizure
OPA/NPA
Protect patient
High flow oxygen
Lateral recumbent (if no trauma)-left lateral is best
Seizure where patient is “daydreaming”
Short duration
Altered mental status but no loss of posture
Absence, petit mal
Absence, petit mal seizures are common in what population?
Children
Simple partial, focal
Seizure where there is no loss of posture or consciousness. Isolated body part but seizure will begin to spread to adjacent body parts as adjacent areas in brain are affected. Jacksonian march.
Jacksonian “march”
When focal event spreads to adjacent part of body. Can (rarely) jump to other hemisphere and become a generalized seizure
Complex partial, psychomotor seizure
More of a behavioral component. Altered mental status. May be combative
Automatisms
Automatisms
Repetitive behavior, stuck in loop
Lip smacking
Pseudoseizure
Psychogenic non-epileptic seizure
Purposeful behavior
Responds to voice
Not a post ictal period, no incontinence, will not accept an OPA or hurt themselves
Status epilepticus
Prolonged seizure activity (more than 5 minutes)
More than one seizure without a lucid period
Consider what for status epilepticus
Aggressive airway management
Ventilation
ALS
Entry note
Medications for seizures
Dilatin (phenytoin) Depakote Phenobarbital Keppra Tegretol (Carbamazapine) Topamax (Toperamate) Neurontin Lamictal (Lamotragine)
Neuromuscular disorders
Cerebral palsy Multiple sclerosis ALS Muscular dystrophy Parkinsons
Cerebral palsy
Congenital-due to some abnormality of developing brain
Higher likelihood in pre-term births
Variable presentation
Variable cause; prematurity, low birth weight, intrauterine infection, placental pathology, hypoxia (during development)
Multiple sclerosis
Autoimmune demyelinating disease Women, child bearing age, Northern European Average 30 years old Highly variable Changes in symptoms in time and in place Weakness, numbness, blindness Progressive or intermittent Myline sheath covers nerves, as it degenerates, ability to conduct electricity and have neuromuscular interfaces decreases
Amyotrophic lateral sclerosis (ALS)
Progressive, incurable Weakness, muscle atrophies Spascity, no change in sensaton Most commonly present in 60-70s M=W (men and women in equal proportion) Respiratory failure, inability to swallow Death 3-5 years after diagnosis Muscular atropy because neuromascular junctions are not working very well
Muscular Dystrophy
Family of genetic/inherited disorders Progressive muscle weakness Most commonly present in childhood M>F Weakness (of muscle), cardiomyopathy Death in early 20s and 30s More prone to CHF and other cardiac events
Parkinsons disease
Some genetic genetic predispositions Chronic progressive disease Movement disorder Resting tremor Rigidty Slow movements Gait distrurbance Average age 70 year old Neurotransmitters in brain, usually dopamine (decrease in dopamine) Lose control of muscle group
