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Neurologic Emergencies Flashcards

1. Describe assessments specific to the care of a neurologic patient in an emergency department. 2. State presenting symptoms of common neurologic conditions treated in an emergency department. 3. Describe management of patients with spinal cord injuries. 4. Differentiate complete and incomplete spinal cord injuries.

1
Q

define neuron

A

building block of nervous system

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2
Q

types of neurotransmitters

A

excitatory

inhibitory

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3
Q

excitatory neurotransmitters

A

norepi

acetylcholine

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4
Q

inhibitory neurotransmitters

A

serotonin
dopamine
GABA

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5
Q

what protects the brain?

A 
hair
scalp
skull
meninges
CSF
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6
Q

mengines overview

A

think PAD:

  • pia mater
  • arachnoid mater
  • dura mater
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7
Q

components of the cerebrum

A

frontal
temporal
parietal
occipital

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8
Q

frontal lobe

A

speech on L side (90%)

  • Broca area
  • Wernicke area

judgement, affect, coordinates voluntary motor movements, social behavior

AKA “Mother”

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9
Q

Broca area

A

production of speech

aka “broken words”

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10
Q

Wernicke area

A

comprehension of speech

aka “What?”

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11
Q

temporal lobe

A

memory
hearing
emotions
dominant-hemisphere speech

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12
Q

parietal lobe

A

sensory interpretation

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13
Q

occipital lobe

A

vision

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14
Q

components of brainstem

A

midbrain
pons
medulla

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15
Q

importance of brainstem

A

houses all vital centers:

  • cardiac
  • respiratory
  • vasomotor
  • reticular activating system (RAS)
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16
Q

cerebral blood flow

A

cerebral vessels autoregulate to maintain adequate blood flow based

MAP - ICP = CPP

maintain CPP > 60 mmHg to ensure auroregulation and adequate perfusion

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17
Q

intracranial pressure

A

Monro-Kellie doctrine

fixed cranial vault

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18
Q

Monro-Kellie doctrine

A

to maintain constant intracranial volume, an increase in one element must be accompanied by corresponding decrease in another element (blood, CSF, brain)

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19
Q

fixed cranial vault

A

brain tissue: 80%
CSF: 10%
blood: 10%

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20
Q

myelin sheath

A

surrounds axon

allows nervous or chemical transmission quickly down neuron

damage such as MS

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21
Q

pia mater

A

very thin layer that adheres to brain

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22
Q

arachnoid mater

A

very thin vascular layer like spider-web

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23
Q

where is CSF?

A

between pia and arachnoid mater

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24
Q

dura mater

A

tough, fibrous membrane

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25
cerebellum
posture coordination muscle memory
26
reticular activating system (RAS)
determines level of alertness and attention
27
how does motor and sensory information travel?
crosses at level of brainstem aka L side injury affects R side
28
primary determinant of cerebral blood flow autoregulation
CO2 - high levels causes vasodilation - lower levels cause vasoconstriction
29
normal MAP and normal ICP
MAP: 100 ICP: 10
30
AVPU
alert responds to voie responds to pain unresponsive
31
Glasgow Coma Scale
best eye opening best verbal response best motor response
32
eye opening in GCS
4 spontaneous 3 verbal 2 pain 1 none
33
verbal response in GCS
``` 5 oriented 4 confused 3 inappropriate words 2 incomprehensible sounds 1 none/intubated ```
34
motor response in GCS
``` 6 obeys 5 localizes pain 4 withdraws to pain 3 flexes to pain 2 extends to pain 1 none ```
35
FOUR score overview
to assess neuro status includes resp pattern useful for ventilated patients out of 16
36
components of FOUR score
eye movement motor response brainstem reflex respiratory quality
37
purpose of NIH stroke scale
to determine if tPA is an option and to predict outcomes
38
components of NIH stroke scale
``` LOC best gaze visual fields facial palsy motor ataxia sensory language/dysarthria extinction/inattention ```
39
blood glucose in neuro assessment
hypoglycemia can mimic sx of neuro emergency
40
pupil assessment
test both direct and consensual response
41
causes of pinpoint pupils
opioids organophosphates uveitis
42
causes of unilateral pupil dilation
pressure on cranial nerve III
43
causes of bilateral, fixed pupils
impending tentorial herniation
44
causes of nystagmus
drugs MS tumor
45
causes of ovioid pupils
glaucoma
46
decorticate posturing
abnormal flexion lesion in cerebrum
47
decerebrate posturing
abnormal extension lesion in brainstem
48
otorrhea/rhinorrhea in neuro assessment
clear drainage from ear or nose may indicate CSF lea check for glucose
49
Babinski reflex
+ result is dorsiflexion of great toe w/ fanning of remaining toes in response to stroking lateral aspect of foot
50
Brudzinski sign
sx of meningitis flexion of hips and knees in response to flexion of neck
51
Kernig sign
sx meningitis inability to extend knee in response to hip flexion
52
doll's eyes
+ test in comatose patient will have eyes move in opposite direction when head is rotated to one side, indicating intact brainstem
53
CN I
olfactory | smell
54
CN II
optic | vision
55
CN III
oculomotor | pupil size, extraocular movement
56
CN IV
trochlear | extraocular movement
57
CN V
trigeminal | facial sensation, jaw movement
58
CN VI
abducens | extraocular movement
59
CN VII
facial | facial movement
60
CN VIII
vestibulochoclear/acoustic | hearing
61
CN IX
glossopharyngeal | swallowing
62
CN X
vagus | gag
63
CN XI
accessory (spinal) | shoulder shrug
64
CN XII
hypoglossal | tongue movement
65
mnemonic for names of cranial nerves
``` Only - Olfactory Once - Optic One - Oculomotor Takes - Trochlear The - Trigeminal Anatomy - Abducens Final - Facial Very - Vestibulochoclear/acoustic Good - Glossopharyngeal Vacations - Vagus Are - Accessory (spinal) Had - Hypoglossal ```
66
mnemonic for functions of cranial nerves
some say marry money, but my brother says bad business marrying money S - sensory M - motor B - both
67
function of CN II, III, IV, VI
sight, pupils, eye movements
68
function of CN IX, X, XII
gag, speech, swallow
69
function of V, VII
raise eyebrows, facial sensation
70
function of XI
shoulder shrug
71
HA sx indicating serious underlying cause
``` sudden onset peak intensity in min no hx of similar HAs concurrent infection w/w/o fever altered LOC > 50 yo HA with exertion stiff neck paiplledema toxic appearing ```
72
two types of HAs
primary | secondary
73
define primary HA
no identifiable organic cause
74
types of primary HAs
migraine | cluster
75
migraine HAs
``` w/w/o aura trigger unilateral photo, phonophobia N/V ```
76
cluster HAs
``` episodic excruciating unilateral burning, severe, sharp pain (periorbital, temporal) <1 hr, 1-8x/day unilateral tearing, nasal congestion flushing more in men ```
77
causes of secondary HAs
tumor aneurysm meningitis
78
assessing HAs
CBC, ESR CT/MRI lumbar puncture
79
HA interventions
``` analgesics (NSAIDs, opioids) antiemetics antihistamines vasoconstrictors anticonvulsants education ```
80
define stroke
rapid or gradual neurologic deterioration that affects a known vascular territory, resulting in focal deficits
81
types of stroke
ischemic (80%) | hemorrhagic (10%)
82
causes of ischemic strokes
atherosclerosis | emboli
83
types of hemorrhagic strokes
intracerebral | subarachnoid
84
define transient ischemic attack
brief episode of neurologic dysfxn d/t focal cerebral ischemia not associated with infarction
85
concerns with TIAs
not benign 10-15% have stroke w/in 3 mo of those, 50% w/in 48 hrs
86
sx TIA
``` sudden onset unilateral weakness/paralysis abnormal sensation altered speech facial weakness AMS visual changes dizziness ```
87
conditions mistaken for stroke
``` hypoglycemia migraines sepsis Bell's palsy peripheral neuropathy benign positional vertigo conversion disorder seizures ```
88
Bell's Palsy overview
occurs after infection unable to close eye weak blink facial droop
89
assessing stroke
``` ABC glucose labs last known normal CT, CTa ```
90
stroke time goals
last known normal, sx onset door to physician: 10 min door to CT: 45 min door to needle: 60 min door to floor: 3 hrs
91
criteria for tPA
``` institutional criteria negative head CT NIH 4-20 or 4 with visual/speech sx door to needle 60 min sx onset <3-4.5 hrs ago ```
92
intervene for ischemic stroke
BP < 185/110 - labetalol - nicardipine tPA
93
administering tPA
``` 0.9 mg/kg (max 90mg) bolus 10% over 1 min, remainder over 1 hr BP < 185/110 VS, neuro q 15 min for 1 hr monitor for bleeding, angioedema ```
94
sx intracerebral hemorrhage
focal deficits | rapid deterioration
95
intervene intracerebral hemorrhage
ABCs BP limit bleeding
96
BP in intracerebral hemorrhage
can lower systolic to 140 aggressively
97
limiting bleeding in intracerebral hemorrhage
vit. K fresh frozen plasma frequent reA
98
define subarachnoid hemorrhage
bleeding into subarachnoid space usually d/t aneurysm or AV malformation
99
sx subarachnoid hemorrhage
``` "worse HA of life" altered LOC N/V focal deficits photophobia nuchal rigidity ```
100
intervene subarachnoid hemorrhage
ABCs BP surgery SBP @ 160
101
define seizure
sudden, excessive, abnormal electrical discharge
102
sx seizure
involuntary movement altered sensation/behavior possible altered LOC
103
causes of seizures
``` pH, electrolytes alcohol withdrawal, drugs hypoglycemia, hypoxia fever, meningitis trauma, tumor stress, stroke vascular insufficiency ```
104
classifications of seizures
``` partial general simple complex convulsive nonconvulsive ```
105
define status epilepticus
series of seizures or one continuous seizure lasting greater than 5 minutes that is unresponsive to traditional treatments
106
concerning sequelae of status epilepticus
hypoxia acidosis hypoglycemia
107
intervene for status epilepticus
ABCs | cause
108
meds for active seizures
lorazepam | phenytoin
109
meds to prevent seizures
phenytoin fosphenytoin thiamine antipyretics
110
define meningitis
acute inflammation of meninges
111
bacterial causes of meningitis
meningococcus strep. pneumoniae group B beta hemolytic streptococci
112
viral causes of meningitis
enteroviruses
113
sx meningitis
AMS fever, nuchal rigidity nonblanching petechial rash
114
rash in meningitis
usually on torso and legs assume bacterial, isolate septic work up abx ASAP
115
intervene meningitis
droplet | abx ASAP
116
peds specific sx for meningitis
``` poor feeding irritable, high-pitched cry lethargy bulging fontanels seizures ```
117
purpose of ventricular shunt
divert CSF from lateral ventricle to low-pressure area such as peritoneum, atriumm
118
complications of ventricular shunt
infection obstruction mechanical failure
119
infection of ventricular shunt
sepsis meningitis ventriculitis
120
obstruction of ventricular shunt
plugging by choroid plexus blood clot debris
121
mechanical failure of ventricular shunt
detachment malposition growth of pediatric patient
122
define Guillain-Barre
acute peripheral neuropathy causing ascending weakness autoimmune disease causing damage to myelin sheath
123
sx Guillain-Barre
extremity tingling loss of deep tendon reflexes ascending symmetric paralysis
124
Guillain-Barre interventions
25% require ventilation | supportive care
125
define multiple sclerosis
autoimmune disease that attacks CNS and demyelinates axon
126
sx multiple sclerosis
changes in sensation complete/partial vision loss, double vision weakness unsteady gait, balance
127
intervene multiple sclerosis
steroids immunosuppressants antineoplastics
128
define myasthenia gravis
autoimmune disease of neuromuscular junction causing decreased receptor sites for acetylcholine binding
129
sx myasthenia gravis
slowed innervation - muscle fatigue weak eye muscles - ptosis weak pharyngeal muscles - dysphagia weak resp muscles - resp paralysis
130
define Parkinson's disease
chronic degenerative disease affecting dopamine pathway less dopamine produced loss of modulating effect of dopamine on voluntary motor pathways
131
sx Parkinson's disease
``` tremor at rest rigidity resistance to passive movement cogwheel extremity movement facial "mask" ```
132
intervene Parkinson's
carbidopa/levodopa | sx management
133
define ALS
genetic mutation causing progressive loss of voluntary muscle control
134
sx ALS
``` limb weakness gait/grip strength loss dysarthria dysphagia dyspnea resp insufficiency ``` does not affect personality, intelligence, eye function
135
define Alzheimer's/dementia
loss of global cognitive ability for 6 mo or more
136
sx Alzheimer's/dementia
changes or loss in: - memory - attention - language - problem solving
137
differential diagnoses with Alzheimer's/dementia
delirium encephalopathy depression
138
causes of primary traumatic brain injury
``` direct neuronal/glial disruption compression stretching shearing brain lacerations ```
139
causes of secondary traumatic brain injury
``` cellular changes hypoxia hypercarbia cerebral edema hypotension ```
140
mild TBI overview
GCS 13-15 LOC < 30 min no deficits no changes on imaging
141
moderate TBI overview
GCS 9-12 + LOC focal deficits pathology on imaging
142
severe TBI overview
GCS < 8 significant LOC abnormal posturing, pupils pathology on imaging
143
early sx of increased ICP
``` altered LOC HA N/V amnesia of injury restlessness, drowsiness changes in speech loss of judgement ```
144
late signs of increased ICP
unresponsive to verbal/pain abnormal motor posturing dilated/nonreactive pupils Cushing triad
145
cingulate hernia
midline shift
146
central hernia
uniform increase in ICP pushes on ventricles both hemispheres through tentorium
147
uncal hernia
pressure on CN III ipsilateral/same side pupil dilation contralateral muscle paresis
148
cerebellotonsillar hernia
cerebellum pushes toward tentorium
149
upward hernia
increased pressure in posterior fossa tissues moves upward
150
transcalvarial
pushes through skull fracture site
151
hernia interventions
``` airway prevent: -hypoxia -hypotension -hyperventilation -hyperglycemia -hypo, hyperthermia ``` surgical decompression
152
definitive increased ICP treatment
``` sedation, paralysis elevate HOB mannitol ICP monitoring CSF drainage ```
153
define diffuse axonal injury
significant deterioration of neurologic fxn with no focal lesions characterized by microscopic damage to axons
154
sx diffuse axonal injury
immediate LOC | abnormal posturing
155
sx basilar skull fractures
HA | altered LOC
156
sx anterior fossa basilar skull fractures
periorbital ecchymosis (raccoon eyes) rhinorrhea
157
sx middle fossa basilar skull fractures
mastoid ecchymosis (Battle's sign) otorhea
158
define epidural hematoma
collection of blood between skull and dura secondary to temporal impact with laceration of middle meningeal artery
159
sx epidural hematoma
brief LOC lucid interval then 2nd LOC contralateral hemiparesis ipsilateral pupillary dilation
160
define subdural hematoma
collection of blood between dura and subarachnoid layer
161
MOI in subdural hematoma
acceleration/deceleration | tear of bridging veins
162
risk factors for subdural hematoma
older chronic alcohol use anticoags
163
types of subdural hematomas
acute - 48 hrs subacute - 2-14 days chronic - > 2 weeks
164
sx acute subdural hematoma
HA | focal deficits
165
sx subacute subdural hematoma
confusion | ataxia
166
assessing spinal trauma
``` motor function -tone -strength sensory function dermatomes ```
167
assessing tone in spinal trauma
``` flaccid spastic rigid hypertonia hypotonia ```
168
assessing strength in spinal trauma
``` 0 no movement 1 trace movement 2 muscle movement not against gravity 3 muscle movement not against resistance 4 weak muscle movement against resistance 5 normal ```
169
assessing sensory function in spinal trauma
sharp/dull light touch absent
170
dermatomes
``` 8 cervical 12 thoracic 5 lumbar 5 sacral 1 coccygeal ```
171
vertebrae and anatomical landmarks
``` C3 - diaphragm C6 - deltoid T4 - nipple line T10 - umbilicus T12 - symphysis pubis L4 - toe L5 - perianal area ```
172
define spinal cord injury (general)
bruising or tearing of cord from trauma, fracture/dislocation of vertebrae, MVC, falls, sports, violence
173
types of spinal cord injuries
``` hyperflexion hyperextension axial load/compression rotation penetration ```
174
SCIWORA
spinal cord injury without radiographic abnormality more in children d/t more flexible bones
175
define incomplete spinal injury
some degree of motor fxn or sensation below level of injury
176
cause of central cord syndrome
hyperextension | falls in older adult
177
sx central cord syndrome
upper extremities more affected than lower extremities sensory deficit varies
178
causes of anterior cord syndrome
hyperflexion
179
sx anterior cord syndrome
paralysis below level of injury loss of pain and temp sensation intact touch and proprioception
180
corticospinal tract
descending motor pathways from cortex to periphery cross at brainstem - contralateral injury
181
dorsal column
position sense | cross at brainstem but with ipsilateral injury
182
spinthothalmic tract
from periphery to cortex cross at/near level of injury contralateral injury
183
Brown-Sequard syndrome
hemisection of cord (knife, gun)
184
sx Brown-Sequard syndrome
ipsilateral paralysis ipsilateral los of light touch, proprioception contralateral loss of pain, temp
185
define complete spinal cord injury
loss of all motor/sensory fxn and reflexes below level of injury bilateral external rotation of legs at hips loss of voluntary bowel/bladder fxn priapism
186
spinal shock overview
injury at any level loss of motion/sensation below level of injury
187
sx spinal shock overeview
flaccid paralysis loss of reflexes bowel/bladder dysfxn
188
neurogenic shock overview
injury at T6 or above | loss of sympathetic innervation and vasomotor tone
189
sx neurogenic shock
hypotension bradycardia warm, flushed skin
190
intervene for complete spinal cord injury
``` ABCs spinal motion restriction normothermia emotional support highdose steroids? ```
191
define autonomic dysreflexia
after spinal shock resolved, strong sensory input from below level of injury causes massive sympathetic discharge T6 or above
192
causes of autonomic dysreflexia
over-distended bladder bowel distention/impaction skin breakdown/pressure intra-abdominal pathology
193
sx autonomic dysreflexia
``` HA HTN nasal congestion flushed head and neck pupil constriction sweating ```
194
intervene autonomic dysreflexia
treat cause and HTN
195
define cauda equina syndrome
"horsetail" bundle of nerves at base of spinal cord is compressed, trauma, or damaged
196
sx cauda equina syndrome
``` weakness, paralysis sensory impairment pain saddle anesthesia bowel/bladder sx ```
197
assessing cauda equina syndrome
emergent CT/MRI

CEN (12 decks)

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