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coup-contrecoup injury - ANS Dual impacting of the brain into the skull; coup injury occurs at the point of impact; contrecoup injury occurs on the opposite side of impact, as the brain rebounds. Scalp laceration: what, effect, management - ANS Primary head injury profuse bleeding - signs of hypovolemia Apply direct pressure Suture/ staple laceration Lidocaine 1% with epi to contro! bleeding, not close to nose/ ears Skull fracture: types, effect, management-ANS Primary head injury Simple: no displacement of bone. Observe and protect spine Depressed: bone fragment depressing thickness of scull Surgery for debridement. Give tetanus and seizure precautions Basilar: fracture at floor of skull Raccoon eye - periorbital bruising battle's sign: mastoid bruising otorrhea/ rhinorrhea - halo sign: do not obstruct flow Give Ab's Oral intubation and oral gastric instead of nasal Brain injury: types, effect, management - ANS Primary head injury Concussion: reversible change in brain functioning loss of consciousness, amnesia Do not give opioids, admit for unconsciousness greater than 2min Contusion: bruising to surface of brain with edema Frontal and temporal region Brainstem contusion: posturing, variable temp, variable vital signs N/V, dizziness, visual changes seizure precautions Hematoma - neuro: types, effect, management - ANS Epidural hematoma: commonly temporal/ parietal region with skull fracture, causing bleeding into epidural space Loss of consciousness Rapid deterioration: obtunded, contralateral hemiparesis, ipsilateral pupil dilation CT scan (non contrast) Treatment based on Brain trauma foundation. Surgical if greater than 30cm Subdural hematoma most common type of intracranial bleed Acute (hours): drowsy, agitated, confused, headache, pupil dilation, CT scan (noncontrast) surgery for 10mm thickness or 5mm midline shift or for worsening GCS Chronic (days): headache, memory loss, incontinence CT scan (noncontrast) Surgery: burr holes/ crani Cerebral edema/ ICP elevated/ herniation: symptoms, management - ANS decreased level of consciousness Blown pupil Cushing triad: HTN (widening pulse pressure), decreased resp rate, bradycardia (means increased intracranial pressure) Neuro exam components - ANS AVPU: awake, response to verbal stimuli, painful stimuli, unresponsive GCS: & or below is comatose Posturing: decorticate = arms, legs in decerebrate = arms, legs out Electrolyte imbalances in brain injury - ANS Hyponatremia: SIADH and cerebral salt wasting Hypernatremia: DI (give mannitol) Management of traumatic brain injury - ANS - Consult neurosurgery - Limit secondary injury - Prevent hypotension (syst 90) and hypoxemia (PaO2 60). May give blood to improve tissue perfusion. - penetrating trauma: from wound - pathologic fractures (esteoporosis/ cancer) mainly cervical spine. High mortality. More common in men more common in young than old Fractures and vertebrae - ANS Cervical: C1-C7. Flexible and small diameter so many fractures Thoracic (T1-T12): connected to ribs. Not common in fractures Lumbar: L1-L5: Very mobile, requires great force to fracture Sacral Spinal cord trauma assessment - ANS - History: mechanism of injury, pt's complaints, pre-hospital tx - Physical assessment: treat airway, breathing, circulation (ABC) first. Pulm complication common in quadriplegia. Assess respiratory status: injury above C3 is resp arrest. C5 - C6 spares diaphragm so breathing exists. - grade strengthening (0= no muscle contraction, 5 = full strength) - complete lesion: pt lacks all function below level of spinal cord damage. Poor prognosis. - incomplete lesion: parts of spinal cord intact - sensory function: start at no feeling then go to feeling - evaluate back (log-roll) Motor assessment in spinal cord trauma - ANS If unable to do, # above: Deltoids (C4): shrug shoulder Biceps (C5): flex arm and push arms away Wrist (C6): try to straighten wrist while pt tries to flex Triceps (C7): extend arm and try to bend while pt prevents that Intrinsic (C8): fan fingers and push together Hip flexion (L2 - L4): bend knee and apply pressure Knee extension (L2-L4): extend knee with hip/ knee flexed key signs of spinal cord injury - various levels - ANS C2-C3: resp paralysis, flaccid paralysis, deep tendon reflexes loss C5-C6: diaphragmatic brething, paralysis of intercostal muscles, quadriplegia, anaesthesie below clavicle, areflexia, fecal/ urinary retention, priaprism T12-L1: paraplegia, anesthesia legs, areflexia legs, fecal/ urinary retention, priaprism L1-L5: flaccid paralysis, ankle/ plantar areflexia Multisystem impact of spinal cord injury- ANS Cardiovascular: hypotension/ spinal shock. Fluid resuscitation (LR) bradycardia; oxygenate well, normothermia, atropine vasovagal reflex: limit suctioning length Poikilothermy - venous thrombosis: dvt prophylaxis orthostatic hypotension GI: - abdominal injuries: assess for abd distention - curling's ulcer: stress ulcer. Give ranitidine - gastric atony and ileus: NG to LIS - loss of bowel function: initiate bowel program GU: - autonomic dysreflexia: HTN crisis from distended bladder or other noxious stimulu. Decompress bladder. - UTI Musculoskeletal: - paralysis - wounds Psychological: - ineffective coping, powerlessness, denial/ anger/ depression. Be honest with positivity, include pt, interdisciplinary approach Spinal cord lesions/ syndrome - ANS Anterior cord syndrome: weakness/ paralysis with loss of sense of pain and temp Posterior cord syndrome: can't feel touch and vibration Alzheimer's disease - ANS most common form of dementia Neuritic plaques, neurofibrillary tangles, degeneration of cholinergic neurons causing irreversible neuronal damage. B-amyloid present in high levels. Effect: cerebral atrophy. Causes of brain degeneration - ANS Alzheimer's Parkinson's Huntington's Vascular: stroke, arteritis Infectious: HIV, Syphilis, Meningitis, Encephalitis CNS/ toxic: drug overdose Nutritional deficiency: Vit B12, folate deficiency Chronic seizures Lewy body dementia symptoms of dementia- ANS - Slow onset - memory loss and confusion - problems with language - impaired abstract reasoning - aphasia, apraxia, agnosia - disorientation - poor judgement - emotional problems. - sleeplessness Dementia labs/ diagnostics - ANS - History: family/ spouse report - Physical: neuro, cognitive examz: Mini mental State exam (score 23 or less is cognitive impairment), document in 3-6mo intervals. - Labs: glucose, electrolytes, magnesium, calcium, liver tests, BUN/ creat, thyroid, Vit B12, HIV, CBC, ABG, cultures, drug screen - CT head/ MRI: for tumor/ infarction - PET scan: differentiate dementia type - EEG - Lumbar: rule out meningitis, neurosyphilis - XR chest: rule out CHF, COPD - ECG Identify treatable cause DSM-V criteria for dementia- ANS 1. Memory impaired 2. At least two of these: aphasia, apraxia, agnosia, disturbance in executive functioning 3. Disturbance of one or two of these disrupts functioning 4. Disturbance not only during delirium Dementia management - ANS - supportive: living situation - treat underlying illness - stop nonessential meds - maintain nutrition - avoid restraints, except for safety - address safety issues - cholinesterase inhibitors can improve symptoms mildly (because of cholinergic deficiency) - Alzheimer's related: meds very mild and temporary effect Medication for dementia - ANS Mild to moderate Alzheimer's: - Donezepil 5mg. then 10mg after 4-6 wks. Can cause syncope, brady, AV-block, N/V, weightloss - Rivastigmine. With food, can cause hypotension, syncope - Galantimine, 4mg for 4 wks, then 8mg 4 wks, then 12mg. Avoid in renal and liver failure Moderate to severe dementia: - Memantine (N-methyl-d-aspartate rec anatgonist), prevents progression. May be paired with donezepil. May cause Stevens-Johnson's For aggression: - Olanzapine (Zyprexa), Quetiapine (Seroquel), Risperidone, Ziprasidone. Short term. May cause tardive dyskinesia - Haldol may help too for unmanageable aggression. - Benzo's: Clonazepam. May cause paradoxical aggression. Lorazepam For emotional lability: - Imipramine - Setraline - Zoloft - Citalopram multiple sclerosis - ANS Disease with myelin sheath destruction causing disruptions in nerve impulse conduction. - decreased sensation of pinprick, vibratory, temp - Reflex changes: abnormal deep tendon, pos babinski, pos hoffman's - brain stem changes: nystagmus, hearing loss, tinnitus Cerebellar: ataxia, tremor, poor coordination visual field changes frontal lobe: cognitive dysfunction, emotional changes MS diagnostics - ANS - neuro exam - MRI (white matter lesions, lesions spinal cord, T1 and T2 lesions) (diagnostic!) - CSF analysis: elevated igG and oligocional bands in CSF but not serum MS management-ANS - consult neuro - no intervention for mild attack - Acute intervention for relapse with Glucocorticoid (po or iv) - symptom management meds - disease modifying meds: to reduce relapse, delay disability, and decrease MRI lesions: - Fingolimod. For relapsing. May cause brady, AV-block, HTN, diarrhea - Betaseron. For relapsing. May cause depression/ suicidality - Avonex. For relapsing. May cause flu-like symptoms - Rebof. For relapsing. May cause flu like symptoms - Glatiramer acetate. For Relapsing/ remitting. - Mitoxantrone. For sec progressive, progressive, or worsening relapsing/ remitting. Parkinson's disease: what, etiology - ANS Neurodegenerative disorder caused by depletion of dopamine-producing cells causing resting tremor, rigidity, slowness of movement. Age onset: 60 more men than women caucasians Environmental (metals such as copper) and genetic factors. Gene: PARK1 Symptoms and diagnostics of Parkinson's - ANS - Classic triad: resting tremors, rigidity, bradykinesia - Motor symptoms: postural instability can cause falls - Classic gait: diminshed arm swing, shuffling steps, bent forward, frozen gait - neuropsychiatric: depression, dementia, anxiety, psychosis, sleep disruption - autonomic dysfunction: urinary incontinence, sexual dysfunction, constipation. impaired thermoregulation - Craniofacial: masked face/ expressionless, dysphagia, impaired sense of smell, drooling - H&P - CT and MRI to assess for differential Parkinson's treatment - ANS - consult neuro - Pharm to relieve symptoms and improve functioning: Carbidopa-levodopa standard treatment. - Can on/off phenomona with working/ not working of meds. catechol-O-methyltransferase - Adequate nutrition - Exercise Dopaminergic agents and Parkinson's - ANS Carbidopa-levodopa. Most effective drug. Use with rasagiline. May cause on/ off phenomena, dyskinesia, confusion, headache, hallucinatinos. Dopamine agonists and Parkinson's - ANS Pramipexole and Ropinirole May reduce risk for complications and alleviate symptoms. Mono or dual theraoy with levodopa. May cause N/V, dyskinesia, confusion. MAO-B inhibitors and Parkinson's - ANS Rasagiline Adjunct therapy May cause serotonin syndrome, dyskniesia, arthralgia, ataxia Add Amyotrophic lateral sclerosis (ALS): what and etiology - ANS Disease of motor neurons causing asymmetric weakness, in upper or lower extremity. Less likely to present with resp weakness, dysarthria or dysphagia Onset age: 50 Men more likely Familial is 10% of cases unknown Average survival: 2-5 yrs CT for bony imaging Transient Ischemic Attack (TIA): what, etiology - ANS Rapid onset of neurological deficit caused by focal brain, spinal cord, or retinal ischemia, resolves in 24hours. atherosclerotic disease cardiac emboli, from afib, mi, valvular disease vasculitis, from lupus - hematologic causes (sickle cell, oral contraceptive) - high risk: older than 45, hx of thrombolytic event, history of spontaneous abortion, autoimmune, family hx - intracranial causes (brain tumor, seizures) - cocaine abuse - migraines TIArisk factors - ANS Important risk factor for stroke, especially in first week after Risk factors for TIA: - HTN - Cardiac disease (afib) - smoking - obesity - hyperlipidemia - elderly - DM - alcohol, recr drugs TIAsymptoms -ANS Carotid artery syndrome: - hemianopia, ipsilateral blindness - visual field cut - parasteshia/ weakness of contralateral arm/leg/ face dysarthria, aphasia confusion carotid bruit Vertebrobasilar artery syndrome: - bilateral visual disturbances - vertigo and ataxia - NV - drop attacks TIA diagnostics - ANS - Lab: CBC, incl PT, PTT/INR, electrolyres, lipid profile - CT: may reveal ischemia or infarct - MRI: more sensitive than CT. Preferred for vertebrobasilar TIA - duplex US: to identify carotid stenosis - CT angio: to evaluate neck/ brain vessels (normal renal function required) - MR angio: can assess vessels. Good replacement for CTA. - echo or holter for cardiac concern/ assessment - TEE to assess aortic arch, left atrium, patent foramen ovale - cerebral angio if candidate for carotid endarterectomy TIA management - ANS_ - Address underlying risk factors (HTN, DM. hyperlipid, smoking, obesity) - Carotid TIA: surgery if more than 80% occluded. No surgery if less than 50% (cand do stent then). - anticoagulation: heparin - warfarin. Though newer agents (Eloquis). PTT 1.5 - 2.5 xX patient's baseline. - Antiplatelet therapy: aspirin or plavix Stroke: what, etiology - ANS Rapid onset of neurological deficit lasting longer than 24hours. Leading cause of disability. Ischemic or hemorrhagic. 80% ischemic. - HTN - Cardiac disease (afib) - smoking - obesity - hyperlipidemia (ischemic, low cholesterol hemorrhagic) - elderly - DM - alcohol, recr drugs - female on contraception and smoking Education on stroke - five "suddens" - ANS Sudden: weakness speech difficulty visual loss dizziness severe headache - CTA: vascular anatomy. Combine with CT perfusion which can show old infarct and salvageable areas. Ischemic stroke treatment - ANS - appropriate time goals - BP control: Only treat if higher than 220 syst and 120 diast., aortic dissection, or receiving t-PA. For t-PA goal goal is less than 185 syst/ 110 diast, before t-PA and less than 180 syst/ 105 diast. after. Use repeat labetolol or nicardipine drip. - Anticoagulation: IV Heparin, bridge to Warfarin (PTT 1.5-2.5 baseline). But newer meds better: Dabigatran, Apixaban (Eliquis - for stroke prevention in afib), Rivaroxaban (stroke prevention afib). No routine labs necessary for those. Not for hemorrhage, cautino after GI bleed - Antiplatelet: Aspirin or Clopidogrel - Mannitol and hypertonic saline for cerebral edema, on second on third day. Monitor serum osmolality. - Corticosteroids to reduce cerebral edema from tumor burden. - surgery for high grade extracranial carotid artery disease (greater than 70%) Time goals of stroke - ANS - ED eval within 10min - notify stroke team within 15min - CT scan within 25min - CT scan interpretation within 45min - Thrombolytic (if appropriate) within 60min - Transfer to bed within 3 hrs t-PA-ANS - Pt needs to be in 3 - 4.5 hr window - Prior CT to assess for hemorrhage - need to have "last well known" - older than 18 - ischemic stroke - neurochecks q15min for 2hrs, q30min for 6 hrs, qth till 24hrs Contraindications: - age greater than 80 - previous hemorrhage - previous stroke within 3mo - major surgery last 14 days - Urinary/ GI hemorrhage within 24 days - seizure - PTT and PT elevated - oral anticoag/ heparin with elevated PTT/ PT - glucose less than 50/ greater than 400 - SBP greater than 185 or DBP greater than 110 - active internal bleeding last 22 days Hemorrhagic stroke; what, etiology - ANS Resulting from bleeding into subarachnoid space or brain parenchyma SAH: ruptured saccular aneurysm arteriovenous malformation ICH: HTN Predisposing: HTN anticoag/ thrombolytic cocaine alcohol hematologic disorders Symptoms SAH - ANS Sudden severe headache "thunderclap headche" or "worst headache of my life". Graded Hunt and Hess): 1: asymptomatic 2: moderate/ severe ha, stiff neck, no focal signs other than CN palsy 3: drowsy, mild focal deficit 4: stupor, hemiparesis 5: deep coma, decerebration Graded (Fisher): 1: no blood detected 2: diffuse/ vertical layers less than 1mm 3: localized clot/ vertical layer 1mm or more 4: intracerebral intraventricular clot with diffuse or nob SAH Symptoms ICH - ANS - HTN - ha - vomiting (especially cerebral) Basal ganglia: - maintain SBP less than 160, may use nicardipine drip, labetolol push, hydralazine of brady - cerebral edema: mannitol or hypertonic saline. - surgical cliiping or coil asap treat cerebral vasospasm rebleeding: between day 2 - 19. Repeat CT. - cerebral salt wasting: hyponatremia. Crystalloid fluid replacement when euvolemia: 3% saline for hyponatremia - manage fever ICH management-ANS - ABC, intubate/ give 02 - Control HTN. SBP: 140 - 150. Nicardipine, labetolol - CPP: keep at 50 - 70 - pressors if SBP less than 90: Dopamine, epi, levo - maintain ICP less than 20 mannitol for cerebral edema. For 5 days or less. check serum osmolality. Or 3% saline. - ventricular drain for hydrocephalus - keep euvolemia - seizure precautions (phenytoine, levetiracetam) - control fever - surgery if hemorrhage greater than 3cm cerebral vasospasm - ANS - cerebral vasospasms: between day 7 - 10 after aneurysm lasting till day 21 - symptoms: confusion, ams, neuro deficits, ha, increased icp. May cause infarction. - treat: calcium channel blocker: nimodipine. Symptomatic: tripe H. Hypervolemia, hypertension, hemodilution. Meningitis, what and etiology - ANS inflammation of arachnoid, dura mater, pia mater or spinal cord due to viral, bacterial, or fungal infection - predisposing: sinusitis, otitis, pneumonia, trauma, congenital malformation Bacterial meningitis - ANS Bacterial: - may be fatal in hours - exudate in subarachnoid space, thus thickened CSF and decreased flow Most commonly caused by: - streptococcus pneumoniae (infants) - neisseria meningitidis (school, college, spread of drainage/ blood) - haemophilus influenzae (daycare children - vaccine) - Escherichia coli/ emterobacter/ klebsiella (infants, elderly, imnmunocompromised) - Atypical: mycobacterium, listeria viral meningitis, what and etiology - ANS Pia and arachnoid space filled with lymphocytes but not with exudate. benign and self-limited. In late summer/ early fall. Transmission via cough, saliva, fecal matter Caused by: enterovirus, mumps, varicella, herpes, rubella, cmv, epstein barr, HIV Fungal meningitis, what and etiology - ANS Most common in immunocompromised Causes: candida cryptococcus histoplasma aspergillus Meningitis findings and diagnostics - ANS - severe ha - stiff neck/ nuchal rigidity phtophobia - fever - ams - cranial nerve palsy - seizures - kernig's sign: flex at knee, then hip, and extend knee. Causes pain and spasm of hamstring muscles - brudzinski's sign: flex head and neck to chest. Causes legs to flex at hips - nv - purpura/ petechiae on trunk and le - exaggerated deep tendon reflexes - LP - CT before LP, for ams or focal neuro signs or for CSF bacterial meningitis signs but no organism - bld culture, sputum cult, che, bmp - antigen tests and HIV testing LP in bacterial versus viral meningitis - ANS Bacterial: 
