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Acute Care NP Exam > Neuro > Flashcards

Neuro Flashcards

1
Q

Different gait abnormalities that are associated with various neurologic disorders

A

Magnetic Gait - normal pressure hydrocephalus
–Wide based, unsteady
–Feet stuck to the floor like magnets

Parkinsonian Gait
–Shuffle, no arm swing, slouched over
–Multiple steps to turn around

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2
Q

Symptoms of ischemic stroke and things you would be worried about

A

Symptoms start suddenly over the course of minutes
–Negative symptoms - take things away
–Unipolar

Facial droop, unipolar arm weakness, speech problems

Symptoms happen on the opposite side of the body from the stroke area

Left sided - Right hemiparesis, speech problems
Right sided - Left hemiparesis, visual/spatial problems

Things you would be worried about are last time known well to determine if tPA is indicated.

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3
Q

What is a hemorrhagic conversion

A

Blood flow is restored to a part of the brain that had been necrotic and when blood returns to this necrotic area, it immediately bleeds

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4
Q

What are the two types of stroke and how do we tell the difference?

A

Ischemic and hemorrhagic

Most common is ischemic caused by emboli

Able to tell difference with a non-contrast head CT stat to look for bleed

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5
Q

What is the Cincinnati Prehospital Stroke Scale

A

Facial droop
Arm drift
Speech difficulty

If 1/3 finds are abnormal, 72% probability of ischemic stroke. If all 3 are abnormal, 85% probability of ischemic stroke

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6
Q

How soon do we want to give tPA (window from last known well and window from arrival to the ED)

A

Want to give tPA within 3 hours of symptom onset and 1 hour of arrival to the ED

Can give up 4.5 hours if meets all criteria

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7
Q

Who might be appropriate for tPA

A

Inclusion criteria:
–Age 18 years or older
–Clinical diagnosis of ischemic stroke with a measurable neurological deficit
–Time of onset less than 3 hours

Exclusion criteria:
–Evidence of intracranial hemorrhage on non-contrast CT
–Clinical suspicion of subarachnoid hemorrhage even with normal CT
–CT shows multilobar infarct
–Hx of intracranial hemorrhage/stroke
–Uncontrolled HTN
–Current use of ACs
–Age >80

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8
Q

What systolic blood pressure should be goal s/p stroke

A

SBP> 140

Can give IV labetalol for treatment of HTN

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9
Q

Anticoagulation s/p stroke

A

Generally not indicated d/t the risk of hemorrhagic bleed.

ASA is the mainstay

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10
Q

Presentation of TIA

A

Sudden dimming or loss of vision (amaurosis fugax) unilaterally - ipsilateral
Half vision
Paresthesia of the contralateral arm, leg or face
Transient Aphasia
Slurred speech
Mental confusion

TIA is often an important warning sign that stroke may occur soon

Lasts less than 1 hour with no residual deficits

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11
Q

Two types of intracranial hemorrhage

A

Intra-axial hemorrhage (within the brain)
–Caused by rupture of aneurysms
–Difficult to treat because need to pass through brain tissue in order to get there

Extra-axial hemorrhage (just outside brain tissue)
–Epidural hemorrhage - between dura mater and skull - caused by trauma
—-Presents as LOC then lucid then deterioration then vomiting then LOC again

–Subdural hemorrhage - tearing of the bridging veins in the subdural space between dura mater and arachnoid mater
—-Can start slowly and progress over several days

–Subarachnoid hemorrhage - can result from trauma, rupture of aneurysms or ateriovenous malformations.
—-Worst headache of my life - sudden onset

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12
Q

Imaging and SAH

A

Non contrast Head CT can show SAH as long as sxs started within the last 6 hours.

A lumbar puncture will need to be done if negative NCHCT to assess for blood in CSF

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13
Q

Lumbar Puncture tubes

A

1: cell count and diff

#2: Chemistry (protein and glucose)
#3: Microbiology studies
#4: Cell count and diff again

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14
Q

Presentation and treatment of Brain Herniation

A

Presents as coma, abnormal posturing, vomiting, unequal pupils

Cushings Triad of Increased ICP:
-Increased SBP
-Decreased HR
-Slowing, irregular RR

Treatment: Hydralazine to lower the BP but not the HR

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15
Q

Intracranial hemorrhage treatment

A

Due to serious threat of respiratory failure, early intubation is often needed
Raise the head of the bed to >30 degrees

Medications:
–AntiHTN treatment to bring MAP <110
–Mannitol and hypertonic saline can reduce swelling of the brain
–Fosphenytoin is given in case of seizures

Surgery:
–If hematoma is greater than 3cm then surgery is required.
–External Ventricular drain (EVD) to drain excess CSF or blood to allow for swelling

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16
Q

Definition of brain death

A

Cerebral death - brain stem is still alive so HR and RR continue without aid but rest of brain is dead

Whole brain death is the death of cerebrum and brain stem - needs life support
–No response to pain
–Absent cranial nerve reflexes
–EEG shows no brainwave activity at all

The provider has an ethical responsibility, absent one’s own personal beliefs, to discontinue life support to a dead person

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17
Q

How to manage status epilepticus

A

Defined as seizure lasting longer than 30 mins

Given risk for threatened airway, should be intubated immediately

Medicines:
Diazepam 10mg IV over 2 minutes, may be repeated after 10 mins

Regardless of response to diazepam should give either:
–Phenytoin 18-20mg/kg IV at a rate of 50mg/min
or
–fosphenytoin 18-20 PE/kg at a rate of 150PE/min

If no response to diazepam and phenytoin:
Phenobarbital 10-20mg/kg IV at a rate of 50mg/min

Should be getting EEG

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18
Q

Symptoms of brain tumors

A

Generalized or focal disturbances of cerebral function
increased ICP
Personality changes
Intellectual decline
Emotional lability
Seizures
Headaches
Nausea

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19
Q

Types of brain tumors: Glioblastoma Multiforme

A

Presents commonly with nonspecific complaints and increased ICP
Rapidly progressive with a very poor prognosis

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20
Q

What is the most common primary tumor to metastasize to the brain

A

Lung carcinoma

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21
Q

Pathophysiology of Parkinson’s Disease

A

Caused by death of dopamine generating cells in the substantia nigra

The net effect of dopamine depletion is to produce hypokinesia, an overall reduction in motor output

22
Q

What are the 4 cardinal signs of Parkinson’s Disease

A

Tremor - tremor at rest that disappears with movement
Rigidity - often cogwheeling rigidity
Bradykinesia and akinesia
Postural instability

23
Q

Treatment for Parkinson’s Disease

A

Levodopa - increases dopamine. Combined with carbidopa to help reduce side effects of levodopa - Sinemet

Dopamine agonists
-Pramipexole
-Ropinirole

Monoamine oxidase inhibitors (prevent the breakdown of dopamine)
-Selegiline
-Rasagiline

Amantidine

Deep Brain Stimulators

24
Q

Red flags for Cauda Equina

A

Severe back pain
Saddle anesthesia
Bladder and bowel dysfunction
Sciatica-type pain on one side or both sides, although pain may be wholly absent
Weakness of the muscles lower legs
Achilles reflex absent
Sexual dysfunction
Absent anal reflex
Gait disturbance

25
Q

Canadian C-Spine Rule

A

Determines if patient should receive dedicated spinal CT

Any high risk factors? (If yes, CT)
–Age >65
–Dangerous mechanism
–Parasthesias in extremities

Any low risk factor which allows safe assessment of range of motion? (If not able to range, CT)
–Simple rearend MVC
–Sitting position in the ED
–Ambulatory at any time
–Delayed onset of neck pain
–Absence of midline c-spine tenderness

Are they able to actively rotate neck 45 degrees?
–If no, CT
–If yes, no radiography

26
Q

Know the different types of Peripheral Neuritis

A

Zoster - Shingles, reactivation of varicella zoster virus in a specific dermatomal pattern.
—Treatment is Valacyclovir 1000mg PO TID x 7 days

Bell’s Palsy - facial paralysis of CN VII (facial nerve)
—Often caused by preceding viral infection (or bacterial - Lyme).
—Often improves with no treatment but steroids can help speed the recovery

Guillain-Barre Syndrome - inflammation of the motor neurons, usually following a viral infection.
—Increasing numbness and paralysis sometimes as far as the diaphragm, causing the need to intubation
—Treatment is either plasmapheresis or steroids

27
Q

Basics of myasthenia gravis: Pathophysiology, Symptoms, Diagnostics, Treatment

A

Muscle weakness is caused by circulating antibodies that block acetylcholine receptors at the postsynaptic neuromuscular junction, inhibiting the excitatory effects of the neurotransmitter acetylcholine.

Most often arise from a tumor of the thymus - thymoma

Symptoms include ptosis, diplopia, difficulty chewing or swallowing, respiratory difficulties, limb weakness

Symptoms are worse when the patient is tired

If sxs are severe, they can cause difficulty breathing, this is called Myasthenic Crisis

Diagnosis is made by administering anticholinesterase inhibitor, Edrophonium 10mg IV x1 and if the sxs abruptly stop, the diagnosis can be made

Treatment includes:
—Maintenance doses of pyridostigmine several times per day
—Thymectomy
—Immunosuppressive therapy
—Plasmapheresis in Myasthenic Crisis

28
Q

Duchenne Muscular Dystrophy

A

Gene mutation of the dystrophin gene located on the short arm of the X chromosome

DMD is a progressive disease which eventually affects all voluntary muscles and involves the heart and breathing muscles at later stages

Life expectancy is approximately 25 years old.

No treatment but steroids can help delay the eventual progression to complete immobilization

29
Q

Basics of Botulism

A

The toxin Clostridium botulinum prevents the release of ACh at the neuromuscular junction and autonomic synapses

Often occurs from ingestion of home canned foods containing the bacteria

Symptoms begin within 72 hours and involve total cranial nerve palsy that leads to difficulty breathing

Treatment is supportive care and request for the antidote

30
Q

What is the workup of a TIA? What is the priority diagnostic

A

Priority diagnostic is CT Head in order to distinguish between ischemia, hemorrhage and tumor
MRI can better visualize ischemic infarcts however takes longer
Cerebral angiography - can be done after a CT shows an ischemic stroke.

31
Q

Treatment of TIA

A

In the first few days:
ASA and Clopidogrel (Plavix)

After discharge:
Usually will choose one agent

Treat HTN

32
Q

In a CVA, how long from last known well can we do mechanical embolectomy for all patients

A

Up to 6 hours from last known well

33
Q

Indications for ICP monitoring

A

Severe head injury (GCS <8) with an abnormal Head CT

Severe head injury (GCS <8) with a normal head CT with two of the following:
-Age >40
-SBP <90
-Abnormal motor posturing

34
Q

What should the MAP be after a CVA?

A

Should be maintained between 110-130 to prevent cerebral vasospasm

Can help increase MAP by giving more fluids

35
Q

How do you measure cerebral perfusion pressure (CPP)?

A

CPP=MAP-ICP

Want to keep ICP <20
Good CPP is 70

36
Q

What is a medication used to counter vasospasm by preventing calcium from entering smooth muscle cells and causing contraction?

A

Nimodipine

37
Q

Classic presentation and physical exam findings of multiple sclerosis

A

Sxs:
-Weakness, numbness, tingling or unsteadiness
-Spastic paraparesis
-Diplopia
-Disequilibrium
-Urinary urgency or hesitancy
-Optic atrophy
-Nystagmus

38
Q

What is the physiological cause of MS?

A

Body’s immune system attacks myelin therefore causing decrease in the speed in which nerves interact.

39
Q

Diagnostics and management of MS

A

LP: Slightly elevated protein and IgG in CSF
MRI of the brain

Management:
No treatment to prevent progression of the disease
Recovery from acute phases is hastened by steroids
Immunosuppressive therapy
Plasmapheresis in severe cases
Interferon
Antispasmotics

40
Q

What are the common bacteria that cause meningitis

A

Strep pneumoniae
Hemophilus influenzae
Neisseria meningitidis

41
Q

What is Kernig’s Sign

A

Pain and spasms of the hamstrings found in meningitis

42
Q

What is Brudzinski’s Sign

A

Legs flex at both the hips and knees in response to flexion of the head and neck to the chest found in meningitis

43
Q

What labs and diagnostics are done when considering meningitis?

A

LP should be done immediately:
—If bacterial, CSF will be cloudy or xanthochromic (yellow in color) with:
—–elevated pressure
——elevated protein
——decreased glucose
——presence of WBC

CSF in viral will have normal glucose and normal protein

Head CT

44
Q

What is the management of meningitis?

A

If the pt is <50 years old:
Vancomycin + Ceftriaxone

If the pt is >50 years old:
Vancomycin + Ceftriaxone + Ampicillin

45
Q

What is Cushing’s Triad

A

Seen in traumatic brain injury patients that are decompensating:
-Widening pulse pressure
-Decreased respiratory rate
-Decreased heart rate

46
Q

Complications of Spinal Cord Injury based on the following areas:
-Cervical spine vs thoracic spine injury
-C4 injury or above:
-T4-T6:

What is the treatment for T4-T6 complication

A

Cervical spine - tetraplegia
Thoracic spine - paraplegia

C4 injury and above: respiratory compromise
T4-T6: May lead to autonomic dysreflexia
-emergency conditions
-Caused by exaggerated autonomic response to a stimulus (bladder or bowel distention, hot or cold stimulus, restrictive clothing)
–Diaphoresis and flushing above the level of injury
–Chills and severe vasoconstriction below the level of injury
–HTN
–bradycardia
–Headache
–Nausea

Treatment is stimulus removal

47
Q

What is Brown Sequard Syndrome and treatment

A

Caused by damage to one half of the spinal cord:
Sxs:
-Ipsilateral upper motor neuron paralysis and loss of proprioception
-Contralateral loss of pain and temperature

Order MRI and give steroids

48
Q

Management of suspected cauda equina

A

MRI
Steroids
Surgery for decompression

49
Q

What is the most common form of neurocognitive disorder?

A

Alzheimer’s

50
Q

Clinical diagnostic criteria for Alzheimer’s

A

Memory impairment and one or more of the following:
-Aphasia
-Apraxia
-Agnosia - inability to recognize an object
-Inability to plan, organize, sequence and make abstract difference

51
Q

Medications used to treat Alzheimer’s Disease

A

Cholinesterase inhibitors:
-Donepezil (all stages of AD)
-Galantamine (mild-moderate disease)
-Rivastigmine (mild-moderate disease)

NMDA antagonist:
-Memantine (Namenda) - moderate to severe disease

Combinations:
-Memantine and donepezil - moderate to severe disease

Acute Care NP Exam (22 decks)

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