final first half Flashcards
1
Q
ischemic stroke
A
- most common sites of thrombotic stroke: branches of cerebral arteries, circle of willis
- thrombus or embolus obstructs a blood vessel
- thrombus- blood clot or cholesterol plaque that forms in the artery
- embolus- clot or plague that forms elsewhere and than breaks off, and obstructs blood flow when it becomes lodged in an artery
- more common
2
Q
hemorrhagic stroke
A
-diseased or damaged vessel rupture
3
Q
hemiparesis
A
- unilateral weakness on opposite side is stroke
- strokes in middle cerebral artery produce hemiparesis
- usually weakness more in arm/face than leg
4
Q
anterior cerebral artery stroke
A
- altered mental status
- impaired judgement
- contralateral weakness more in leg
5
Q
posterior cerebral artery stroke
A
-impaired thought/memory, visual field deficits
6
Q
risk factors of stroke
A
- atherosclerosis leads to turbulent blood flow, increased risk of clot
- blood disorders- sickle cell anemia, polycythemia
7
Q
TPA
A
- TPA- tissue plasminogen activator
- TPA is a medication that is given to dissolve clot that is causing the stroke
- TPA can cause bleeding (many risk factors)
- must be given within 3 hours of LKWT
8
Q
FAST / cincinnati stroke scale
A
- Face drooping
- Arm weakness
- Speech Difficulty
- Time to call 911
- CINCINNATI STOKE SCALE:
- facial droop
- arm drift
- abnormal speech
- if one sign out of 3 is abnormal the probability of stroke is 72%
9
Q
stroke treatment
A
- place pt in low-fowlers or supine position with head slightly raised if ischemic stroke suspected
- regulate BP to maintain MAP at least 60mmHg
- so first they use non contrast -> if there is no bleed use a contrast CT
- fibrinolytic agents at hospital (TPA)
- mechanical thrombectomy
10
Q
cerebrum
A
- conscious thought, memory storage and processing, sensory processing, regulation of skeletal muscle contraction
- Cerebrum divided into two cerebral hemispheres
- Superficial layer of gray matter is the cerebral cortex.
11
Q
cerebellum
A
- coordination, balance, modulation of motor commands from cerebral cortex
- second largest area of brain
12
Q
diencephalon
A
-link between cerebrum and CNS
13
Q
brain stem
A
- processes visual and auditory info maintains consciousness, somatic and visceral motor control, regulates autonomic function
- autonomic control**
- midbrain, pons, medulla
14
Q
meninges
A
- meninges- 3 layers of membranes
- dura mater- outer, strong white fibrous tissue (inner layer of cranial bones’ periosteum)
- arachnoid mater- arachnids: spiders, cobweb-like middle layer.
- pia mater- innermost meninge, adheres to the outer surface of brain and spinal cord, contains blood vessels.
15
Q
delirium / excited / agitated delirium
A
- ACUTE alteration in cognition with impairment of awareness and orientation
- sometimes associated with hallucinations
- more often in women and with illness of very young or older than 60
- appearance, vitals, hydration, evidence of trauma
- check serum glucose levels
- causes: intoxication, infection, trauma, seizure, organ failure, stroke, shock, endocrine disorders or intracranial bleeding, and tumors
- dementia is CHRONIC loss of brain function (different than delirium
- agitated delirium:
- characterized by agitation, aggression, acute distress and sudden death, often in the pre-hospital care setting.
- typically associated with the use of drugs that alter dopamine processing, hyperthermia, and, most notably, sometimes with death of the affected person in the custody of law enforcement.
- Subjects typically die from cardiopulmonary arrest.
16
Q
frontal lobe
A
- frontal association area
- speech
- motor cortex
17
Q
parietal lobe
A
- speech
- taste
- somatosensory cortex
- somatosensory association area
- reading
18
Q
temporal lobe
A
- smell
- hearing
- auditory association area
19
Q
causes of vertigo
A
- central vertigo may be caused by stroke, concussion, tumors, infection, migraine, MS, toxic ingestion/inhalation
- vertigo is a symptom- originates in CNS or vestibular organs
- benign paroxysmal positional vertigo (BPPV) -> migraine headache
- menieres disease -> multiple sclerosis
- labyrinthitis -> mal de debarquement syndrome
- ototoxicity -> cerebellar hemorrhage and infarct
- superior canal dehiscence syndrome -> vertebrobasilar insufficiency, vertebral artery dissection, neoplasm
20
Q
peripheral vs central vertigo
A
PERIPHERAL
-sudden onset
-intermittent with severe symptoms
-affected by head position and movement
-nausea and vomiting more frequent and severe
-motor function, gait and coordination typically intact
CENTRAL
-gradual onset
-constant with milder symptoms
-unaffected by head position and movement
-nausea and vomiting less predictable
-motor function, gait instability and loss of coordination frequent
21
Q
headache
A
- This can be a vague and puzzling symptom
- Note associated symptoms:
- > vision changes (ipsilateral may be temporal arteritis)
- > photophobia, phonophobia, “flashing lights”
- Trauma followed by headache may indicate subdural/epidural hematoma or vertebral artery dissection
- Severe h/a w/sudden onset may be subarachnoid bleeding
- Co-morbidities hypertension, vascular issues, may indicate brain bleeding or aneurysm
- Look for abnormal vital signs: fever could indicate meningitis
- GAIT!
- worry about aneurism and hemorrhage
22
Q
intracranial hypertension
A
-↑ Intracranial pressure (ICP) can compromise brain perfusion
-May be due to mass effect (hemorrhage or edema) or malfunction of ventriculoperitoneal shunt
-pupils dilate
-brain may herniate through foramen magnum (high mortality): with signs of unilateral blown pupil and loss of consciousness
TREATMENT
-A ventriculoperitoneal (VP) shunt is a medical device that relieves pressure on the brain caused by fluid accumulation
-hyperventilation: must be performed carefully, with monitoring patient’s neurological status
1. hyperventilating decreases amount of CO2 in blood which induces cerebral vasoconstriction
2. vasoconstriction decreases blood volume in brain which reduces ICP
- however vasoconstriction also ↓ perfusion to brain, so this must be carefully considered
23
Q
subarachnoid hemorrhage
A
- Arteries on brain’s surface bleed into subarachnoid space
- Caused by cerebral aneurysm, trauma or rupture of arteriovenous malformation
- Sudden & severe h/a, possible loss of consciousness
- Five grades of hemorrhage:
1. mild h/a with or w/out meningeal irritation
2. severe h/a with or w/out pupillary change
3. mild alteration in neurological exam
4. depressed level of consciousness
5. comatose with or w/out posturing
24
Q
subdural hematoma
A
- Collection of blood between dura and arachnoid meninges
- May be acute, subacute, or chronic (2-3 weeks post-injury)
- Mortality rate: 20%, mostly in pt’s over 60 y/o
- Trauma or deceleration injury: tearing of veins between cerebral cortex & venous sinuses
- blood clots in subdural space
25
coup-countercoup head injury: subdural hematoma
- coup (blow) causes trauma to brain, brain recoils after blow and is injured on opposite side after it rebounds
- bleeding/damage to both sides of brain
- Signs/symptoms: loss of consciousness after head trauma, amnesia, personality changes, h/a, visual changes, vomiting, hemiparesis, hemiplegia
26
epidural hematoma
- Accumulation of blood between inner layer of skull and dura mater
- Usually from trauma to subcranial arteries resulting in high-pressure mass effect
- Usually an associated skull fracture
- 80% in temporo-parietal region
- Prompt surgical decompression for pt’s with significant neurological dysfunction
- patient may not lose consciousness or may lose it and then awaken (lucid interval) before becoming unresponsive
- may have severe h/a, vomiting, seizures
- QUIZ
- increased ICP may cause Cushing’s triad ***(patient unresponsive w/imminent death):
1. systolic hypertension
2. bradycardia
3. irregular respiratory pattern
27
head hematoma treatment
- Protect C-spine
- CT or MRI at hospital
- May need lumbar puncture: blood in CSF
- IV line, administer oxygen, cardiac monitor, do not administer fluids unless BP is low -> mostly for epidural hematoma
28
bells palsy
- can mimic strokes
- Unilateral facial paralysis that may mimic a stroke
- Cranial nerve VII (Facial)
- Unknown origin or infection (herpes simplex)
- In stroke: only lower half of face is weak, forehead and upper eyelid have normal motor function
- inability to wrinkle brow, drooping eyelid, inability to puff cheeks, drooping mouth
29
Guillain barre syndrome
- A group of acute immune-mediated polyneuropathies
- Demyelinating disorders causing weakness, numbness, or paralysis throughout body
- Can occur at any age
- Autoimmune response to recent infection
- Antibodies formed against peripheral nerves
- paralysis starts at legs and goes up -> goes to lung cavity
- can lead to pneumonia!*
- intubate and ventilate
- Patients may require mechanical ventilation at some point in their illness to compensate for respiratory muscle weakness (Pneumonia is a common side effect)
- Lack of deep tendon reflexes is strong indicator of Guillain-Barre
- Parasthesia in feet and hands
- May have loss of vibratory sense, proprioception and touch
- Most patients at their worst 12 days
- progressive weakness of 2 or more limbs due to neuropathy
- disease course < 4 weeks
- relatively symmetrical weakness
- facial or other cranial nerve involvement
- absence of fever
30
5 categories of stimuli
- insects
- food
- plants
- medication
- chemicals
31
hapten
-too small to be antigenic but can attach to a larger molecule (protein) and cause immune response
32
leukotrienes
- a family of eicosanoid inflammatory mediators produced in leukocytes
- is to trigger contractions in the smooth muscles lining the bronchioles (specifically, leukotriene D4)
- overproduction is a major cause of inflammation in asthma and allergic rhinitis
- more powerful than histamine
33
5 types of antibodies
- 1. IgG: 80% of all antibodies -> resistance against viruses & bacteria
- 2. IgE: attaches to basophil & mast cell surface -> triggers release of histamine, increases inflammation
- 3. IgD: on the surface of B cells
- 4. IgM: 1st antibody secreted by plasma cells after antigen is encountered -> anti-A & anti-B antibodies of blood typing
- 5. IgA: in glandular secretions (saliva, sweat)
34
types of hypersensitivity reactions
- 1. Type I (acute/immediate) hypersensitivity (IgE) -> allergic reaction
2. Type II (antibody-dependant cytotoxic) hypersensitivity (IgG, IgM) -> hemolytic rxns, good pastures, hyperacute graft rxns
- 3. Type III (Ag-Ab immune complex) hypersensitivity-> immune complex deposition, hypersensitivity pneumonitis, systemic lupus erythematosus, polyarteritis nodosa, serum sickness
4. Type IV (delayed) hypersensitivity (T cells, cell-mediated) -> poison ivy, latex, PPD test, nickel
35
histamine
- dilates blood cells -> vasodilation
- chemical mediators
- hypotension
36
wheels vs urticaria
wheels is local
| urticaria is anaphylactic
37
benadryl
- antihistamine
- diphenhydramine
- blocks the effects of the naturally occurring chemical histamine in the body
- helps with urticaria and itching associated with an allergic/anaphylactic reaction
- emergency dosage- 50mg IV
- be careful not to overdose patient if they previously took Benadryl prior to your arrival
38
corticosteroid
- anti-inflammatory
- solu-medrol
- helps to reduce inflammation over the long term as opposed to other medications such as epinephrine that work immediately
- modifies the bodys immune response to various conditions and decreasing inflammation
- long term acting
- emergency dosage- 125 mg IV
39
epinephrine
- reverses vasodilation and hypotension
- increases cardiac contractility and relieves bronchospasms
- adult epipen delivers .3 mg of epinephrine
- the infant-child system delivers .15 mg
- twinject auto injector contains two doses of epinephrine
40
aspiration
- elderly have a reduced gag reflex
- aggressively reduce risk of aspiration when ventilating (and gastric distention) by using nasogastric tube whenever possible (sucks out stomach contents so there is nothing to aspirate)
- suction
- pneumonia
41
foreign body obstruction
-air trapping from partial obstruction of lower airway may lead to pneumothorax
42
epiglottitis
-lift threatening infection -> swelling of epiglottis can obstruct trachea
-adult men are 3x more likely than women
-most common in children 2-4 years of age
-mortality rate 7% in adults, 1% in children
-pathophysiology- more common before H. influenzae type b (Hib) vaccine
-now more likely caused by streptococcus
-begins w/sore throat, progresses to pain on swallowing and muffled voice
-moderate or severe respiratory distress (pt may be in tripod position)
-fever, heavy drooling, stridor, pain on palpating larynx, tachycardia, low O2 saturation
-can be confirmed by plain film radiographs (x-rays) of neck & fiber-optic laryngoscopy
TREATMENT
-administering oxygen
-nebulizers
-ER tx. aimed at oxygenation & ventilation, do not put anything in pt’s mouth, intubate in field only if absolutely necessary, antibiotics & corticosteroids, nebulized epinephrine
-Endotracheal intubation is best achieved surgically w/ ENT nearby.
43
RSI
- prior to starting RSI, ready endotracheal tube, have forceps handy, prepare suction
- NM-blocking drugs: affect Ach synthesis or block Ach receptors.
- 1. pre-fill patient’s lungs w/high concentration O2
- NRB or BVM attached to 100% oxygen, High flow nasal cannula
- 2. administer neuromuscular-blocking drugs to induce unconsciousness & paralysis
- may see object with laryngoscopy allowing you to grasp the object.
- 3. insert endotracheal tube if all clear
44
ludwigs angina
-Potentially life-threatening connective tissue infection (cellulitis) of submandibular space, often after tooth abscess
-swelling, redness, & warmth between hyoid bone and mandible
-bacterial infection: Streptococcus
- severe gingivitis & cellulitis
- submandibular swelling
- drooling
- airway obstruction
- displacement of tongue
TREATMENT
-maintain airway (may require prophylactic intubation in ER)
-humidified oxygen in the field
-antibiotics -> is it viral or bacterial (viral is not antibiotics)
-ENT surgeon
45
obstructive lung disease
- hard to exhale all the air in the lungs
| - air comes out slower than normal and high amount of air stays in lungs after full exhalation
46
emphysema
- mucus and puss in the alveoli
| - not allowing good gas exchange
47
restrictive lung disease
- lungs restricted from fully expanding
- usually conditions affecting stiffness in lungs or chest wall, weal muscles, damaged nerves
- interstitial lung disease, sarcoidosis (autoimmune), obesity, scoliosis, ALS, MD
48
interstitial lung disease ex.
-idiopathic pulmonary fibrosis. Main symptom of both is shortness of breath with exertion.
49
COPD
- emphysema and chronic bronchitis
| - obstructive and restrictive
50
asthma
- 20-30% of hospital admissions
- high relapse rate
- higher prevalence in children
- 90% of asthmatics had first symptoms by age 6
- tachycardia
- wheezing
- obstructive*
- can grow out of it
- chronic inflammation and constriction of bronchi results in wheezing
- airway becomes overly sensitive to allergens, viruses, environmental irritants
- inflammation is prime cause of symptoms: dyspnea, wheezing, coughing
- bronchoconstriction**
- Body responds to persistent bronchospasm with edema & mucous secretion, results in bronchial plugging and atelectasis
- wheezing
- dyspnea
- chest tightness, discomfort, pain
- cough
- signs of exposure to allergens
- patient initially hyperventilates -> results in decrease CO2 levels (respiratory alkalosis)
- continued airway narrowing, exhalation more difficult -> increase in CO2
- progressive increase in tachypnea, tachycardia, wheezing and may see retractions
- accessory muscle recruitment
- decrease O2 saturation < 90%
- corticosteroids
51
asthma treatment
- inhaled beta-2 agonists: albuterol, levalbuterol (Xopenex) used in early wheezing
- terbutaline or epinephrine: IV or injection added for more severe attacks
- IV corticosteroids reduce inflammation in bronchi, but may take hours to work (long acting)
- even with aggressive pharmacologic therapy, some pt’s may still progress to severe respiratory distress or failure
- Beta 2 agonists: smooth muscle relaxation, bronchodilation
- 1. inhaled beta-2 agonists:
- albuterol- 2.5-5 mg every 20 mins for 3 doses or continuously, followed by 2.5-10 mg every 1-4 hours as needed
- 2. parenteral beta-2 agonists:
- terbutaline: 0.25 mg
- 1:1,000 epinephrine: 0.3 mg
- nebulizer
- inhaler
- spacer
52
COPD
- Chronic airflow obstruction caused by chronic bronchitis or alveolar destruction from emphysema
- 14 million people have COPD: 12.5 million have chronic bronchitis, rest have emphysema
- Cigarette smoking is leading cause
- 15% of all smokers will develop clinically significant COPD
- characterized by wheezing and airway edema like asthma, but different mechanism
- usually not born with
- minor genetic risk
- chronic inflammation from exposure to inhaled particles damages airway
- body's repair process results in scarring and narrowing
- alveoli become enlarged with thickened has exchange membrane of associated capillaries
- mucus-secreting glands and cells multiply, increasing mucus production
- cilia destroyedq
- barrel chest results from airway restriction and air trapping
- chronic cough and shortness of breath
- chronic hypoxia results in chemoreceptors unable to react to fluctuations in blood O2 level
- lung function declines, sputum production increases
- air trapping from lungs’ inability to move air out of airways
- lungs become hyper-inflated w/ limited gas exchange: results in hypoxia and hypercarbia
- chronic hypercarbia effects chemoreceptor sensitivity, hypoxic drive takes over
- body maintains a slightly alkalotic to compensate
- pH affected and patient prone to infections and intolerant of exercise.
53
COPD treatment
- mainly maintaining oxygenation & ventilation
- nasal cannula or venturi mask to maintain O2 sat minimum 94%
- if still hypoxic: nonrebeathing mask w/high flow O2, aggressive airway/ventilation mgmt.
- CPAP may be indicated prior to intubation in alert, acutely hypercapnic patient
- severe cases: endotracheal intubation w/RSI or nasotracheal
- once airway is secured, administer beta-2 agonists early and often
- adding anticholinergic agents can provide an additional 20-40% bronchodilation
- systemic corticosteroids (injectible) in moderate or severe cases
- if acute respiratory failure: NPPV required or endotracheal intubation w/invasive ventilation thru a ventilator
- 3 nebulized doses 20 minutes apart or consecutively in severe cases. NPPV: non invasive positive pressure ventilation.
54
pneumonia
-lung infection that causes fluid build up in alveoli
-resulting inflammation can cause fever, dyspnea, chills, chest pain, productive cough
-Three broad causes of pneumonia:
-1. community acquired
-2. hospital acquired- : nosocomial- begins 48 hours or more after hospitalization.
-3. Ventilator associated: viral, bacterial, fungal, chemical (stomach contents) -> more susceptible
TREATMENT:
-supplemental oxygen in clinically significant cases (by nasal cannula to maintain sat above 94%)
-more intensive oxygenation: CPAP
-early antibiotic intervention
55
respiratory syncytial virus
- RSV- major cause of illness in young children
- infection in lungs and airways
- more serious illness in premature babies and children with suppressed immune systems
- can lead to other more serious illnesses that affect heart and lungs
- RSV infection can cause bronchiolitis and pneumonia
- highly contagious
- spread through droplets from cough
- virus can survive on surfaces (hands, clothes)
- dehydration**
- can cause severe upper respiratory infections and asthma symptoms in adult
- supplemental oxygen (humidified is better)
56
pleural effusion
-collection of fluid outside lung on one or both sides of chest
-lung gets compressed, causes dyspnea
-may occur in response to any irritation, infection, CHF, or cancer
-should be considered as a contributing dx in any patients with lungs cancer and shortness of breath
-caused by fluid collecting between visceral and parietal pleura
-sac of fluid similar to a blister
-with each breath, tissues rub against each other causing inflammation and more fluid to accumulate in the space
-some can contain several liters of fluid and can decrease lung capacity
-dyspnea
-also chest pain, cough, orthopnea, dyspnea on exertion
-decreased breath sounds over region where fluid have moved lung away from chest wall
-patient usually feels better sitting upright
-fluid must be removed to completely resolve
TREATMENT:
-if CPAP doesnt work
-fluid can be extracted by needle thoracentesis for dx and symptomatic relief
-in rare cases tube thoracostomy
57
pulmonary embolism
-sudden blockage of lung artery with a blood clot
-DVT (deep vein thrombosis) is most common cause- blood clot travels to lungs from leg
-pulmonary circulation may be compromised by clot, fat embolism from broken bone, or air entering circulation from a laceration in neck or improver IV
-usually lodges in major branch of pulmonary artery
-most challenging diagnosis to make in ED because of vague, general symptoms
-risk post surgery or trauma or with catheters
-chest pain, dyspnea, tachycardia, syncope, hemoptysis (coughing blood), new onset wheezing, new cardiac arrhythmia, thoracic pain
-may evolve quickly and lead to cardiac arrest
TREATMENT
-bedridden patients are often prescribed anticoagulants to reduce risk of clot formation
-patients who have numerous clots can be treated with tPa (tissue plasminogen activator)
-few patients survive cardiac arrest caused by large emobolus
58
causes of intubation malfunction
- DOPE
- D- displaced tube
- O- obstructed tube- plugged with secretion or patient biting on it
- P- pneumothorax- can occur during positive pressure ventilation
- E- equipment failure- ventilator run out of oxygen
59
RSI medication
- rapid sequence intubation medication
- these medications stop breathing so you can intubate
- sedate
- paralyze
- more sedation
- pain management
60
miller and Macintosh blades
- miller blades are used for pediatrics -> miller blades are straight
- epiglottis of a child is much bigger (thats why it can become obstructed easier)
- miller blades go under the epiglottis
- macintosh blades are used for adult patients -> curved
- macintosh blades goes into the velicular space
61
respiratory system
- 1. ventilation- moving air in and out of lungs
| - 2. respiration- gas exchange
62
pharynx
- 1. nasopharynx- air passage with pharyngeal tonsil
- 2. oropharynx- common rout for food and air
- 3. laryngopharynx - extends to the larynx
- differing types of epithelial tissue here
63
larynx
- keeps food and drink out of airway
- marks where the upper airway ends and the lower airway begins
- extrinsic muscles connect larynx and elevate it during swallowing
- intrinsic muscles control vocal cords
- epiglottis
- cartilage
- hypoid bone
- ligaments
64
ventilation
- regulation of ventilation is primarily by the pH of the cerebrospinal fluid
- directly related to the amount of carbon dioxide in the plasma
- failure to meet the bodys need for oxygen may result in hypoxia
- patients with COPD have difficulty eliminating carbon dioxide through exhalation
- CO2 is prime regulator
- respiratory center in brainstem has sensors for CO2 levels in blood and CSF
- when CO2 levels increase, pH decrease -> medulla signals phrenic nerve to move diaphragm
- chemoreceptors monitor blood/body fluid for change in H+, CO2 and O2
65
wheezing
brochcoconstriction
66
tidal volume
- amount inhaled or exhaled in one breath under resting conditions
- giving someone too much tidal volume on a ventilator can cause pneumothorax
- 500ml is average
- 5-6cc per kilo = tidal volume
67
cheyne stokes respirations
- cheyne-stokes respirations are often seen in stroke and head injury patients
- breathing normal for a minute (ex. 20/mins) then breathing drops (ex. 6/mins)
68
kussmals respirations
- deep and fast gasping respirations
- lacking any apneic periods
- associated with metabolic/toxic disorders (diabetes mellitus)
69
Oxygen delivery
- nasal cannula- 1-6 L/min -> 24-44%
- nonrebreather- 10-15L/min -> 60-95% oxygenation
- BVM- 10-15 L/min -> 75-100%
70
CPAP
- noninvasive
- be careful with patients with low BP
- increases intrathoracic pressure -> aspiration, pneumothorax
71
OPQRST
- onset
- provocation- does anything make it better
- quality
- region/referral/radiation
- severity
- time
72
SAMPLER
- signs and symptoms
- allergies
- medications
- past medical history
- last oral intake
- events leading up
- risk factors
73
AVPU
- alert
- verbal stimuli
- painful stimuli
- unresponsive
74
glasgow coma scale
- assessment tool
- used to measure the cognitive function of the pt
- looks at eye opening, verbal response, and motor response
- 1. eye opening- spontaneous (4), to verbal command (3), to pain (2), no response (1)
- 2. verbal response- oriented and converses (5), disoriented conversation (4), speaking but nonsensical (3), moans or makes unintelligible sounds (2), no response (1)
- 3. motor response- follows commands (6), localized pain (5), withdraws to pain (4) decorticate flexion (3), decerebrate extension (2), no response (1)
- higher GCS (15)- no neurologic disability
- 13-14- mild dysfunction
- 9-12- moderate to severe dysfunction
- 8 or less- severe dysfunction (lowest possible is 3)
75
aortic aneurysm
- may be seen pulsating in the upper midline
- do not palpate an obvious pulsatile mass -> could burst
- dilates -> aneurysm
- wall of aorta burst or starts to expand
- bursts -> dissection (once it starts penetrating the wall
76
cranial nerves
- olfactory
- optic
- oculomotor
- trochlear
- trigeminal
- abducens
- facial
- auditory (vestibulocochlear)
- glossopharyngeal
- vagus
- accessory
- hypoglossal
