Neurology Flashcards

1
Q

Increased ICP signs

A
  • Early: change LOC, HA, N/V, lethargy, irritability
  • Late: pupillary changes, ipsilateral pupil change, seizure, posturing, coma
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2
Q

Monitoring ICP

A
  • Normal: 0-15 mmHg
  • Calculate cerebral perfusion pressure:
    MAP - ICP = CPP (70-90)
    Goal >60
  • Methods: intra-ventricular catheter (Drain excessive CSF & intermittently monitor ICP); intraparenchymal (monitor only, aka “bolt”)
  • Who? early recognition of increased ICP, Head injuries - GCS <8, cerebral edema, large ischemic stroke, hydrocephalus
  • Waveforms: P1 - percussion, P2 - tidal, P3 - dicrotic (closure of aortic valve); Normal P1>P2>P3
    Increase P2 with decreased compliance/increased ICP
    C wave “common”
    B wave “bad”
    A wave “awful” - cerebral spasm & high ICP
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3
Q

Managing increased ICP

A
  • Positioning for venous drainage: HOB 30-45, good head alignment/midline, straight legs
  • Prevent jugular vein compression
  • Decrease stimuli
  • Manage pain
  • Normothermia (fever–> worse outcome)
  • Mannitol 20% (osmotic diuretic) - ulse filter, monitor osmilality, Na+ & K+
  • Hypertonic saline
  • Loop diuretics
  • No higher than 320 mOm/L
  • Monitor for rebound ICP increase
  • CPP >60 mmHg
  • Surigcal: Burr holes, decompressive craniectomy for refractory intracranial hypertension when all failed
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4
Q

Diagnostics for stroke

A
  • CT w/o contrast within 45 minutes to r/o hemorrhage
  • CT perfusion or MRI perfusion: measures infarct core or penumbra
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5
Q

tPA

A
  • “Door-to-Needle” 60 minutes
  • Symptom onset window: 4.5 hr
    3hr if age>80, taking anticoagulation, history of stroke & DM, NIHSS >25
  • Baseline lab: glucose, CBC, coag, chem, trop, 12 lead ECG
  • Control BP prior to administration SBP<185, DBP <110
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6
Q

Complications of tPA

A
  • conversion to ICH: deteriorating neuro, HA, N/V, acute hypertension
  • STAT CTH, coag, fibrinogen, CBC
  • Transfusion platelet, cryoprecipitate, Transexamic acid (TXA) - antifibrinolytic, FFP
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7
Q

Basilar skull fracture

A
  • A fracture in the floor of the skull; risk of injury to the cranial nerves
  • Avoid NG/OG, oral suctining
  • Battle sign: ecchymosis on mastoid bone
  • Raccoon eyes
  • Rhinorrhea: torn blood vessels in the nose, CSF can leak - tear in meninges, salty taste from Na+ in CSF
  • Otorrhea: test for glucose (positive in CSF), “Halo” fluid on gauze
  • Pneumocephalus - air in head; HOB flat; high concentrated O2 to dissolve nitrogen in air
  • Loss of sense of smell/damage to CN I (olfactory)
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8
Q

Acute epidural hematoma

A
  • Neuro emergency - arterial bleed; usually temporal or parietal region from laceration of the meningeal artery and/or vein
  • S/S: Altered LOC, N/V, agitation, confusion, severe decompensation - uncal (lateral) herniation
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9
Q

Uncal herniation

A
  • uncus pressure on the tentorial notch
  • compression of the midbrain
  • change in LOC
  • unilateral pupil dilation, contralateral hemiparesis, lateral displacement
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10
Q

Brain stem hernation

A
  • downward pressure towards brainstem and medulla
  • Cushing’s Triad: 1. bradycardia, 2. systolic hypertension w/ wide pulse pressure, 3. irregular respiration
  • small pupils
  • ataxic respiration
  • coma
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11
Q

Brain death

A
  • Must be normothermic
  • Narcotics/sedatives cleared from the system
  • Absence of EEG
  • Absence of somatosensory evoked potential
  • ICP>MAP
  • Absence of cerebral perfusion: cerebral angiogram, CT angio, MRI

Everything is negative, except the apnea test.
- Oculocephalic reflex (doll’s eyes) - CN III, VI, VIII; normally eyes move with head turn
- Oculovestibular reflex (cold caloric test) - Normally look toward the stimulus
- Absent gag/cough
- Absent pupillary response
- Abnset corneal reflex
- Apnea Test: hyper oxygenate with 100% FiO2, remove ventilator, assess for absence of breathing

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12
Q

Aneurysms

A
  • Most occur in the Circle of Willis
  • Rupture when >8-10 cm
  • Dx: CT w/o contrast
  • S/S: asymptomatic until rupture - sudden “worst headache of my life”, N/V, photophobia, diplopia, nuchal rigidity (Kernig’s and/or Brudzinski’s sign) from meningeal irritation, seizure, decrease in LOC, coma
  • Tx: treat HTN (keep SBP 140-180), monitor re-bleed, monitor for cerebral artery vasospasm (transcranial doppler) and prevent with prophylactic CCB (Nimostop/Nimodipine for 1 month)
  • Aneurysm clip or stent
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13
Q

Status epilepticus

A
  • Seizures more than 30 minutes
  • patent airway
  • Identify underlying cause: toxicology screen, assess electrolyte & glucose
  • Benzodiazepines: Lorazepam (Ativan), Diazepam (Valium), Midazolam (Versed)
  • Phenytoin (Dilantin) - monitor of bradycardia & hypotension, use filter
  • Valproic acid, Fosphenytoin, Ketamin
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14
Q

Guillain-Barre Syndrome

A
  • An autoimmune disorder that attacks the peripheral nervous system
  • Many follow from an illness or virus usually 1-3 weeks after
  • Temporary damage to the myelin sheath - impulse travel slowly causing slow movement or ascending paralysis
  • Monitor - Vital capacity for impending respiratory failure, UO for urinary retention
  • Dx: LP
  • Tx: plasmapheresis, IVIG, intubation, mechanical ventilation for respiratory failure, corticosteroid
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15
Q

Meningitis

A
  • Inflammation of meninges
  • S/S: HA, fever, altered LOC, photophobia, photophobia, nuchal rigidity (+ Brudzinski’s, + Kernig’s)
  • Dx: LP - viral vs. bacterial
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16
Q

Brudzinski’s sign

A

severe neck stiffness when the knee and hip flex when the neck is flexed

17
Q

Kernig’s sign

A

severe stiffness of the hamstrings causes an inability to straighten the leg when the hip is flexed 90 degrees

18
Q

Viral meningitis

A
  • CSF: + protein, normal glucose
  • Lymphocytes
19
Q

Bacterial meningitis

A
  • CSF: +++ protein, low glucose (CSF glucose/serum glucose <= 0.4)
  • Neutrophils, WBCs
  • Increased lactate
  • Rash
20
Q

Autonomic Dysreflexia

A
  • aka hyperreflexia
  • a damaging event below the level of injury causes communication disruption between brain & body above level of injury
  • Causes: bladder distension, UTI, constipation/fecal impaction
  • S/S: sudden increase in BP, bradycardia, diaphoresis/sweating, piloerection, HA, visual changes, flushing, anxiety
  • Tx: bowel & bladder training, treat BP
21
Q

Cerebral Perfusion Pressure

A

MAP - ICP
Normal 60-100

22
Q

Myasthenia Gravis

A
  • Chronic auto-immune neuromuscular disease that causes progressive skeletal muscle weakness
    Early: easily fatigued
    Later: paralysis
  • 70% have ocular dysfunction - ptosis, diplopia, difficulty keeping eyes closed
  • Dysarthria, dysphagia
  • Acetylcholine receptors are blocked

Tx:
- plasmapheresis, IVIG
- Pyridostigmine (Mestinon) - acetylcholinesterase inhibitor; prevents cholinesterase from breaking down acetylcholine
- Corticosteroids/immunosuppressants
- Removal of the thymus gland

23
Q

Myasthenic Crisis

A
  • D/t being undx/untx or acute exacerbation
  • Deficiency of acetylcholine
  • Tensilon test: Tensilon 2 mg IV → clinical improvement
24
Q

Cholinergic Crisis

A
  • D/t overtreatment; excess of acetylcholine
    Tensilon 2mg IV → increased muscle weakness (asked to hold arms out)→ SLUDGE
    S - salivation
    L - lacrimation
    U - urination
    D - defecation
    G - gastrointestinal distress
    E - emesis