CCRN - Neuro

If brain swelling occurs, where does it expand toward?

Foramen magnum (where brain stem is attached to the spinal cord)

What artery, formed by 2 vertebral arteries, supplies the lower areas of the brain and the brain stem?

Basilar artery

What arteries supply the upper areas of the brain? Which is dominant for most people?

Carotids

Left internal

Brain function based on anatomic location

Frontal: _________, abstract thought, _____-term memory

Temporal: _________, taste and smell, interpretations

Occipital: _________, visual recognition, reading comprehension

Parietal: _______ recognition by size, weight, shape, touch, body part awareness

Cerebellum: ______, gait, ________

Personality, long

Hearing

Vision

Object

Coordination, balance

Circle of Willis is a circulatory _____________ comprised of various arteries that supply blood to the brain. What is the purpose?

Anastomosis

Allow collateral blood flow to one area from another in the event of an occlusion

T/F: the basilar artery and middle cerebral arteries are part of the Circle of Willis.

False

Arteries include anterior cerebral artery, anterior communicating artery, internal carotid artery, posterior cerebral artery, and posterior communicating artery

Change in _____ is almost always the first sign of a neurological problem. What is the exception?

LOC

Epidural hematoma, pupillary changes occur first

What is included in a LOC assessment?

Arousability - voice, shake, pain

Orientation

Speech/language - dysfunction in dominant hemisphere

• Expressive/Broca’s aphasia - dysfunction in frontal lobe

• Receptive/Wernicke’s aphasia - dysfunction in temporal lobe

Memory

Attention span/judgment

Personality

What is the RAS?

Reticular activating system

Network of neurons that connects brain stem to cortex

Upper = awareness

Lower = sleep-wake

Motor problems are _________ to the brain problem. Pupillary changes occur _________ to the brain problem.

Contralateral

Ipsilateral

Babinski reflex is _________ in adults and is __________ to the brain injury. It’s d/t pressure on the pyramidal/motor tracts in the __________.

Abnormal

Opposite

Cerebrum

What are the brain stem reflexes? When are they assessed?

Cough

Gag

Corneal

When all other reflexes are absent and brain death is suspected

During the doll’s eye test, the patient’s eyes are held open and movement is watched as the head is rapidly turned side to side. This assesses ________ reflex in unconscious or comatose patients. It is positive if eyes move in the _________ direction of the dead turn. This is ______.

Oculocephalic

Opposite

Good, “it’s good to be a doll”

VS changes are a _____ sign of neurological injury.

Late

What are the factors of Cushing’s triad? What is it indicative of?

Increased systolic pressure and widening pulse pressure

Decreased HR

Decreased RR

Sign of brain herniation

Fill in the respiratory issue associated with brain stem abnormalities

Midbrain - ___________

Pontine - ___________ _____________

Medulla - ________ _________

Hyperventilation

Apneustic breathing

Ataxic breathing, leads to arrest

What is assessed in the Glasgow Coma Scale?

Eye opening

Verbal response

Motor response

____________ _________ is a loss of vision in half the field of each eye r/t damage to the _______ nerve, and it occurs __________ to the problem. This causes neglect of the affected side.

Homonymous hemianopsia

Optic (CN II)

Contralateral

Pupil changes are _________.

Visual changes are _____________.

Motor changes are ___________.

Babinski is __________.

Ipsilateral

Contralateral

Contralateral

Contralateral

Uncal herniation is displacement of the ______ ______ (uncus) against the ________ _______ and CN III.

Temporal lobe

Brain stem

Uncal herniation compresses ___________ innervation to the affected side and causes a ________ pupil ipsilaterally, all of which occur before change in LOC. This can lead to ________, coma, abnormal posturing, or death.

Parasympathetic

Blown

Stupor

What are some contralateral findings in uncal herniation?

Babinski

Slight weakness

Pronator drift

Central herniation is swelling on both sides, causing downward displacement of ______________, and usually caused by diffuse _______.

Hemispheres

Edema

What are some s/s of central herniation?

Slight change in LOC

Initially small pupils bilaterally then dilation d/t parasympathetic innervation

Bilateral babinski

What are some types of encephalopathy?

Hypoxic

Metabolic

Hepatic

Drugs

Infection

What are some signs of encephalopathy?

Loss of memory and cognitive ability

Personality changes

Agitation

Inability to concentrate

Progressive loss of consciousness

Seizures

Coma

Brain death

Types of stroke include

Ischemic: ____ within 24 hours or cerebral infarct

Hemorrhagic: intracerebral, ___ malformation, subarachnoid

TIA

AV

In a right brain bleed, eyes deviate toward the _______, and there is ____ sided muscle weakness, ______ homonymous hemianopsia, left babinski, and emotional __________.

Right

Left

Left

Lability

Note: eyes deviate toward pathology

BP is not treated in acute ischemic stroke until it is outside of what parameters? Why?

SBP >220 or DBP >120

Sudden decrease in BP will decrease perfusion to underperfused area of the brain

rtPA can be used if symptom onset was less than <___ hours ago, CT scan __________, and no contraindications.

4.5

Negative

What are some contraindications of rtPA?

Evidence of hemorrhage

Stroke or head trauma in previous 3 months

Hx of ICH

Major surgery in previous 14 days

Active bleeding in previous 21 days

MI in past 3 months

Seizure at onset of stroke (seizure hx ok)

Plt <100,000/mm³

BG <50

INR >1.7 if on warfarin

Persistent HTN

What BP goal is for the first 24 hours after rtPA?

SBP <180

DBP <105

What is the drug of choice for BP control in stroke pts?

Labetalol

What’s the worst complication of rtPA?

Intracerebral hemorrhage

Watch for change in LOC

What are some important considerations post stroke?

Elevate HOB >45º

Dysphagia screening tool

NPO until swallow screen completed

BG 80-150

What is the most common cause of subarachnoid hemorrhage?

Aneurysm, often middle cerebral artery

The ____ and ____ Scale provides a score based on the pt’s neuro status during a SAH and helps predict outcome and treatment. LOC doesn’t change until the score is >___.

Hunt and Hess

3

Note: Surgery delayed >4

What is the triad of symptoms for a ruptured brain aneurysm?

Sudden explosive headache

Decreased LOC

Nuchal rigidity, positive Kernig’s sign

___________ can develop after SAH because chorionic villi in the subarachnoid space reabsorb CSF.

Hydrocephalus

How is vasospasm prevented in aneurysmal SAH?

CCB Q4

CPP 60-70

Avoid hypotension

Monitor hyponatremia (can precede vasospasm)

An early manifestation of brain tumors is _________. Treatment of tumors also includes __________ like ____________ because it prevents elevated ______.

Seizures

Steroids

Dexamethasone

ICP

What is a normal ICP? What is considered high?

0-10

>20

How is CCP calculated? What is normal? What is minimum for perfusion?

MAP - ICP

Normal is 60-80

50

Note: hypotension in the presence of elevated ICP can be devastating

• Ex: pt with MAP 110 and ICP 30 has a CPP of 80, whereas pt with MAP 55 and ICP of 30 has a CPP of 25—>brain death

S/s of increased ICP

Altered LOC

Restlessness/agitation

HA

NV

Seizures

Visual disturbances

Pupillary changes

Motor dysfunction

Cushing’s triad

Where is the transducer leveled to in ICP monitoring? What waves are found on the monitor and what do they mean?

External auditory meatus

A = awful

• Caused by cerebral vasospasm and high ICP

B = bad

C = common

ICP is lowered by

Decreasing volume: upright positioning, ___ saline, ____________, _____________

Preventing _____________ (low pH dilates cerebral vessels)

Reduce CSF: _____________

Prevent secondary brain injury

Prevent ________ and agitation with ___________ (can reduce ICP by up to 15 mmHg)

3%, mannitol, furosemide

Acidosis

• Keep pH ~7.35 because alkalosis causes vasoconstriction and decreased blood flow

Ventriculostomy

Pain, propofol

Why is 0.45% NS or D5W contraindicated with increased ICP?

Hypotonic fluids bring fluid into the cells, causing swelling

Use isotonic fluids

What are some other things avoided in increased ICP?

Hyperextension of neck —> suboptimal jugular venous outflow

PEEP —> increases thoracic pressure, prevents jugular venous outflow

Low protein —> decreases oncotic pressure, fluid goes into cells from vasculature

Restraints

Agitation and noxious stimuli

Fever

Types of TBI

________: concussion, diffuse axonal injury

________: contusions, intracranial hematomas, skull fractures, open head injuries

Diffuse

Focal

Epidural hematoma is usually d/t __________ __________ artery bleed secondary to temporal bone trauma and is always ________. This can cause ________ herniation.

Meningeal

Acute

Uncal

S/s of epidural hematoma

HA

Irritability and confusion

Vomiting

Ipsilateral pupil dilation BEFORE decreased LOC

Contralateral hemiparesis

Most intracerebral hematomas are ___________, which can be acute, subacute, or chronic.

Subdural

Subdural hematomas have similar symptoms to epidural, minus what?

Less vomiting

Pupil change does not precede LOC

Types of skull fractures

___________: does not require surgery

_____, ________: raised if segment is decreased greater than 5 mm, immediate intervention with gross contamination, dural tear with pneumocephalus, or underlying hematoma

__________: occurs in the floor of the cranial vault and results in a meningeal tear

• Requires more force to cause

• Rare

Linear

Open, depressed

Basilar

S/s of a basilar skull fracture

Raccoon eyes: periorbital edema and ecchymosis

Battle’s sign: discoloration at the back of the ear

Rhinorrhea d/t meningeal tear —> no nose blowing

How is ear/nose drainage identified as CSF?

Check for sugar; + = CSF

Put drainage on gauze, CSF if positive halo sign

___________ may be elevated post-seizure because normal ventilation does not occur.

PaCO2

What is the preferred drug to stop seizures?

Lorazepam/Ativan

Longer acting than diazepam

What meds are used for seizure prevention?

Phenytoin

Carbamazepine/Tegretol

Phenobarbital

Patients may experience transient signs of decreased LOC during the _______ state.

Postictal

Status epilepticus is seizure activity of ____ minutes or more cause by a single seizure or series of seizures with no return to __________ inbetween.

5

Consciousness

Early stages of SE involve _______ cerebral blood flow, tachycardia, increased _____ and _____ (d/t stress), as well as __________ K+ from destruction of skeletal muscle cells.

Increased

PaCO2

BG

Increased

Late stages of SE (30 mintues) involve inadequate cerebral blood flow, _____________, ______glycemia, very elevated ____, and ___________l

Arrhythmias like VF

Hypo

K+

Rhabdomyolysis

Death from SE is usually d/t what?

Cerebral hypermetabolism

Causes of SE

Withdrawal from anticonvulsants

Acute alc withdrawal

Toxic drug levels

CNS infection

Brain tumor

Metabolic disorders

Stroke

Where is CSF produced?

Choroid plexus in 4th ventricle

What does CSF look like in bacterial meningitis?

LP pressure elevated >180

Purulent

Decreased glucose

Large increase in protein and WBCs

What does CSF look like in viral meningitis?

LP pressure normal

Clear

Normal glucose

Increased protein and WBCs (less than bacterial)

Signs of meningeal irritation include

___________

________ __________: flex pt’s head to chest, if pain or stiffness occur it is positive

__________ sign: move pt’s chin to chest, if leg’s come up it is positive

__________ sign: move legs up and out, if pain in neck and leg it is positive

Headache

Nuchal rigidity

Brudzinski’s

Kernig’s

Brain death is complete cessation of function of what parts of the brain?

Cerebrum

Cerebellum

Brain stem

The following must be confirmed in brain death

______ is irreversible with known cause

Absense of CNS _________ drugs on tox screen

No evidence of residual __________

Absense of severe ______-_____ abnormality

Normo_____

SBP >____ mmHg

No spontaneous respirations

Coma

Depressant

Paralytics

Acid-base

Thermia

100

What are the components of a clinical examination of brain death?

Pupils are _________ to bright light

Absent _________ reflex

Oculocephalic reflex is absent

Oculovestibular reflex is absent

No ________ movement to noxious stimuli at supraorbital nerve

Absent _____ reflex

Absense of motor responses in all extremities

Nonreactive

Corneal

Facial

Gag

A _________ apnea test supports brain death. There are absent ___________ movements and PaCO2 >___ or >20 over baseline

Positive

Respiratory

60

GBS is an __________ response to a viral infection. It results in ___________ paralysis that is usually symmetrical. It can involve the ____________, resulting in ventilatory failure. The LP will be positive for __________.

Autoimmune

Ascending

Diaphragm

Protein

How is GBS treated?

IVIG 2-5 days

Corticosteroids

Monitor breathing, UOP, and dysphagia

Myasthenia gravis an __________ of the neuromuscular junction. It causes __________ skeletal muscle weakness, fatigue, and paralysis later on. 70% of pts have ________ dysfunction, like ptosis, diplopia, and difficulty keeping eyes closed.

Autoimmune

Progressive

Ocular

What are the two types of MG crisis?

___________ crisis: exacerbation, deficiency of ____________

___________ crisis: overtreatment, excess of _____________

Myasthenic

Acetylcholine

Cholinergic

Acetylcholine

How are the two types of MG crisis differentiated?

Tensilon test —> hold arms out during med admin

MC: clinical improvement

CC: salivation, lacrimation, urination, defecation, GI distress, emesis (SLUDGE)

What is the acetylcholinesterase inhibitor used in MG crisis?

Pyridostigmine