CEN Neuro

no resistance to passive movement

little resistance to passive movement

increased muscle resistance to passive movement

gradual increase in tone that causes increased resistance until tone is suddenly reduced

continued rhythmic contraction of a muscle after the stimulus has been applied

chronic condition in which muscles are affected by persistent spasms and exaggerated tendon reflexes because of damage to motor nerves of the CNS

• arms flexed toward body
• legs extended
• indicates cerebral lesion

• arms extended, wrists externally rotated
• legs extended
• midbrain or brainstem lesion

extension of arms and legs with arching of the back and neck

may indicate brainstem injury

inability to recognize objects through the special senses:  may be visual, auditory, or tactile or r/t body parts and their relationships

• anesthesia - loss of sensation
• dysesthesia - impaired sensation
• hyperesthesia - increased sensation

burning or tingling sensation

20 ft from chart or pocket version 14 inches away

record number on lowest line patient can read with 50% accuracy

• III
• controls elevation of eyelids

2-6 mm

1mm

pontine lesions, opiates, miotics (pilocarpine)

midbrain lesion

brainstem lesion, medication:  parasympatholytics (atropine), sympathomimetic (EPI)

anisocoria

parasympathetic:  ipsilateral (same side) pupil dilation

sympathetic:  ipsilateral pupil constriction

• interruption of sympathetic nerve fibers of oculomotor nerve
• 1. pupil constriction
• 2. partial ptosis
• 3 loss of hemifacial sweating

caused by CVA, injury to carotid artery, migraine, or tumor

may precede dilated pupil as a sign of pressure on oculomotor nerve

cranial nerve injury or isolated muscular dysfunction

lesions of the vestibular system or the brainstem

brainstem damage

may indicate cranial nerve V injury

may be decreased in contact wearers

5

• 1. assymmetry of facial expression
• 2. loss of nasolabial fold
• 3. eye remaining open when trying to close

VII

7

• AKA Doll's eyes
• turn head - eyes should go in opposite direction
• abnormal indicates compression in the midbrain-pontine area

damge to laryngeal branch of cranial nerve X

9 and 10

speech and language pathologist

• no fluids
• position on side
• suction equipment available

hypocalcemia, hyperphosphatemia, hpomagnesemia or lower motor neuron lesions

• high Ca, phosphate, or Mg
• upper motor neuron lesions

upper motor neuron lesion

brusing of the mastoid (behind ear)

indicates basal skull fracture

black eyes

indicates basal skull fracture

basal skull fracture

inability of teeth to fit together normally when mouth is closed or inability to close mouth

• c-spine must be clear
• chin to chest and head brought forward

neck pain and involuntary adduction and flexion of legs with attempt to flex neck indicates irritation of meninges by infectoin or blood

• flex thigh toward chest
• inability to fully extend leg when thigh is flexed toward abd indicates irritation of meninges with infection/blood

>50mmHg for >20 min

15 - 20

10-20

60% of serum glucose value

decreased in bacterial meningities

BF to brain will stop

cerebral atrophy - increases risk of intracranial bleeds

• pressure at which brain tissue is perfused
• MAP-ICP = CPP

60-100

60

• ICP
• CPP

• 1. increased systolic BP
• 2. widening pulse pressure
• 3. bradycardia

indicates impending herniation

late as a result of pressure on thermoregulatory center in hypothalamus

paralysis of the upward gaze

• 1. bulging fontanels
• 2. high-pitched cry
• 3. "setting sun" sign:  looks like eyes are sinking into lower lids and there is visible sclera above irises
• 4. persistent vomiting

can cause downward cerebellar herniation with medullary herniation and death

cerebral angiography

on side to prevent aspiration if spine has been cleared

10

increases ICP

use lower tidal volumes and PEEP with intracranial HTN and increased ICP

hypotonic - dextrose 5%, D5W

• aimed at reducing one of 3 components of ICP
• 1. CSF - drain if have intraventricular catheter present
• 2. blood volume:  hyperventilation may be used in dire circumstances b/c alkolosis causes vasoconstriction
• 3. brain mass:  osmotic diuretics:  mannitol, fluid restriction, corticosteroids

• 1. prophylactic anticonvulsants
• 2. normothermia or therapeutic hypothermia:  antipyretics, cooling therapies
• 3. sedatives, paralytics, and barbiturates
• 4. calm, quiet environment

brief alteration in the level of consciousness/rticular activation system that causes brief loss of awareness

impact occurs on one side whch causes brain to move and hit opposite side of skull and injuring opposite side of brain

extensive generalized damage to white matter of brain

lg enough that it can be id'd macroscopically

diffuse microscopic damage

• bulging fontanel
• if retinal hemorrhages - abuse possible

• altered LOC >6h
• memory loss

may initially be normal

• immediate LOC that takes >6 hours to resolve if it resolves ever
• amnesia, confusion, behavior changes, may have brainstem damage s/s

• 1. secondary brain inury:  edema, ischemia
• 2 intracerebral hematoma/hemorrhage
• 3. subarachnoid hemorrhage with contusion
• 4. fluid and electrolyte imbalance
• 5. ADH imbalance:  DI, or SIADH

return if HA, NV confusion, s/s ICP

may need to wake pt every 2-4 h and assess orientation at home

tear middle meningeal artery and lead to epidural hematoma

tear occipital artery and lead to epidural hematoma

• anterior fossa:  rhinorrhea (lasts 2-3 days), racoon sign (tks 3-4 h to occur), may have cranial nerve 1 damage and anosmia
• middle fossa:  otorrhea or rhinorrhea, CSF/blood behind tympanic membrane, hearing deficit, Battle sign (4-6 h to occur), may have cranial nerve injuries
• posterior fossa:  may have epidural hematoma -> intracranial HTN, cerebellar/brainstem/cranial nerve signs

• 1. Don't obstruct flow - mustache dressing
• 2. elvate HOB 30
• 3. discourage sneezing, blowing  nose, valsalva, breathe out while turning, cough with mouth open
• 4. do not put anything in nose

collection of blood in subdural space

collection of blood b/t skull and dura mater

bleeding directly into brain tissue

• 1. may be spontaneous - esp. with coagulation disorder or anticoagulants
• 2. older adults and alcoholics

linear skull fractures that cross major vascular channels

• usually venous bleed
• acute:  onset within 48 hours of  injury
• subacute:  within 2 wks
• chronic:  weeks to months after injury

usually arterial

missile inury or severe accel-decel force

• 1. HA
• 2. increasing irritability progressing to confusion then decreased LOC
• 3. ipsilateral oculomotor paralysis
• 4. contralateral hemiparesis or hemiplegia

• 1. short period of unconsciousness followed by lucid interval then rapid dterioration - lucid period may be absent if significant blow
• 2. HA
• 3. ipsilateral oculomotor paralysis
• 4. contralateral hemiparesis/hemiplegia

varies with area of brain involved

may or may not show s/s of increased ICP

increased ICP and intracranial htn

interruption of BF to brain as a result of vessel rupture

htn

blood leakage into subarachnoid space that comes in contact with meninges

hydrocephalus

rebleeding

• Aneurysm:
• 1. atypical HA occuring days or weeks prior to rupture
• 2. sudden/severe HA, radiates to neck/back
• 3. weakness
• 4. ptosis diplopia, blurred vision
• 5. NV

Arteriovenous malformation:  hearing contant swishing sound in head with each heartbeat, dizziness/syncope

restlessness progressing to altered LOC

hyponatremia r/t SIADH or cereral salt wasting

if CT is ondiagnostic and no indication of intracranial htn

• flat, peaked, or inverted T wave
• prominent U
• prolonged QT
• dysrhythmias esp. torsades

dx of vasospasm

maintain within 10% of prehemorrhage levels

alpha and beta blockers, vasodilators, vasopressors, Ca channel blockers to prevent/reduce vasospasm

72 hours

progressive damage to penumbra

at night - wake up with s/s

when active

noncontrast CT within 25 min of entering ED doors and read within 20 min of procedure

• <185
• <110

• labetalol mainly
• nitroprusside, hydralazine, nicardipine

• 1. waking with s/s
• 2. seizure at onset
• 3. age >75
• 4. NIHS >22
• 5. hypodensities on CT
• 6. subacute bacterial endocarditis
• 7. H of hemorrhagic stroke, intracranial neoplasm, atrioventricular malformation, or aneurysm
• 8. known bleeding disorder
• 9. suspected aortic aneurysm
• 10. systolic BP <200 or diastolic <120
• 11. prolonged >10min or traumatic CPR
• 12. pregnancy
• 13. streptokinase:  not if have received it or had stre infection in last 6-9 months

• activase
• 0.9mg/kg IV with max dose of 90mg

admin 10% of dose as bolus over 1minute.  Infuse remaining amnt over 60 minutes

contraindicated for 24 hours after IV fibrinolytics

stop infusion and have immedicate repeat CT

• 1. fibrinolytic complications
• 2 persistent neurologic trauma
• 3. brain edema
• 4. seizures
• 5. fluid/electrolyte imbalances:  DI & SIADH

• 1. male
• 2. age 16-30
• 3. alcohol & drug use

• chin forced to chest
• usually C5 and C6
• from sudden decceleration

• head thrown backward
• usually cervical area
• forces of acceleration and decel

all parts of vertebral column affected

• falling or jumping and landing directly on feet or head
• feet:  Fx of low thoracic and lumbar vertabrae
• head:  Fx of cervical vertabrae

• high:  affects breathing
• low:  affects ability to take deep breath, cough, and sigh

within an hour after injury

loss of neurologic function below level of injury

• 1. flaccid paralysis
• 2. areflexia
• 3. loss of sensation
• 4. loss of autonomic function (sweating)

hypotension and bradycardia

cervical and high thoracic

ventilatory cessation and immediate death

quadriplegia with total loss of ventialatory function

• depend on ventilator
• C3, 4, and 5 keep the diaphragm alive

• quadriplegia with gross arm mvmts
• diaphragm spared:  diaphragmatic breathing with no accessory/abd assistance to cough

• quadriplegia with biceps muscles intact but no function of intrinsic hand muscles
• diaphragmatic breathing with no intercostal/abd help with cough

• quadriplegia with triceps and biceps intact but no function of hand muscles
• diaphragmatic breathing
• no intercosta/abd for cough

paraplegia with loss of varying amnt of intercostal and abd muscle

cauda equina injury:  mixed picture of motor and sensory loss with bowel and bladder dysfunction

• loss of sensory and motor function below level of lesion - irreversible
• flaccid paralysis
• areflexia
• urinary retention or priapism

varying degrees of paralysis and sensory loss below level of injury with varying degrees of bowel and bladder dysfunction

within minutes

several days to months

• 1. loss of all motor, sensory, and reflex responses
• 2. bradycardia, hypotension
• 3. loss of autonomic control
• 4. trasient reflex depression below level of injury
• 5. flaccid paralysis of all skeletal muscles below injury
• 6. urinary and fecal retention
• 7. impairment of temp regulation *vasodilation, inability to shiver), poikilothermia
• 8. priapism may occur

• motor:  weakness of all extremities but greater motor loss in upper extremities
• sensory:  varies depending on number of undamaged SC tracts
• hyperextension injury

• motor:  ipsilateral motor loss below the lesion
• sensory:  isilateral loss of position and vibratory sense, contralateral loss of pain and temp sensation
• rotational with dislocation of Fx fragements, penetrating, tumor

• complete motor loss below lesion
• sensory:  loss of pain and temp sensation below lesion, sparing of proprioception, vibratory sense, and touch
• hyperflexion

• motor:  function intact
• sensory:  loss of touch, vibratory sense, and proprioception below lesion
• hyperextension or disease processes

• motor:  varying amnt of motor loss in LE, bowel and bladder probs
• sensory:  varying amnt of loss in LE
• indirect trauma to peripheral nerves associated with Fx

children <8 years old

immobilize for 1 to 3 wks

pt hypotensive with normal fluid volume - increased fluids can increase SC edema

careful fluid admin

may manage hypotension with pressors

hypotonic

log roll

• elevate legs
• TEDs

• 30mg/kg over 15 min pause 45min
• maintanance dose 5.4mg/kg/h X23 hours

• infuse X24h if Tx within 3 h of inury
• infuse 48 h if Tx within 3-8 h of injury

• 1. injury >8 h
• injury below L2
• 3. injury to cauda equina

BP with spinal cord injury above T6 becomes excessively high as a result of overactivity of autonomic NS

• 1. eliminate noxious stimuli - full bladder/bowel
• 2. admin antihypertenisve agens

nerves supposed to carry msgs from brain to bladder don't work

intermittent bladder preferred to use of Foley cath

seizure activity of >/= 30 minutes caused by a single seizure or series of seizures with no return of consciousness b/t seizures

not temp but how fast it rises

rapid increase in temp >102

6months to 3 years

50%

• 1 major head trauma
• 2. stroke
• 3. CNS infection
• 4. brain tumors
• 5. encephalopathy
• 6. Electrolyte imbalance:  hyponatremia, hypocalcemia, hypomagnesemia
• 7. drug toxicity:  lidocaine, demerol, theophylline, salicylates, tricyclic antidepressants, cocaine
• 8. sepsis
• 9. perinatal problems:  anoxia or hypoglycemia at birth

may deplete brain of O2 and glucose -> hypoxia and neuronal death

• 1. cerebral BF unable to keep up with cerebral demands
• 2. bradycardia, hypotension, dysrhythmias, and hypoglycemia
• 3. marked dlevations of creatine kinase and K
• 4. Vfib may occur
• 5. rhabdomyolysis-induced renal failure

hyperkalemia with prolonged seizures

increased early and decreased late

increased esp if prolonged

may have hypercapnia or hypoxemia

may show myoglobinuria esp if prlonged

may need oral or nasopharyngeal airway to hold tongue

screen for barbituarates, alcohol, tricyclic antidepressants, cocaine

• 1. hypoxemia
• 2. acid-base imbalances
• 3. electrolyte imbalance
• 4. hyperthermia
• 5. hypermetabolism

thiamine and D5W

to prevent Wernicke Encephalopathy

• lorazepam:  6-10min/12-24h
• diazepam:  1-3 min/30min
• phenytoin sodium:  30min/24h
• fosphenytoin/cerebyx:  15min/24h
• phenobarbital:  20-30 min/48h

prolonged muscle contraction

rapid succession of alternating contractions and partial relaxations

• 1. sudden onset with rapid worsening
• 2. no previous Hx of similar HA
• 3. fever
• 4 altered LOC
• 5. indications of meningeal irritation
• 6. age >50
• 7. immunosuppression

tight pressure around the head  - no throbbing

usually starts in occipital area and moves toward frontal area

may have neck tension

• often unilateral and throbbing
• may have aura
• NV
• photophobia
• speech difficulties may occur

• 1. cyclic HA
• 2. unilateral
• 3. periorbital or temporal
• 4. describied as severe, sharp, burning, or boring
• 5. patting or rubbing affected area may relieve some of the discomfort

r/o meningitis

CT first to r/o subarachnoid hemorrhage

alpha adrenergic blockers:  dihydroergotamine - constricts cerebral blood vessels - may cause reflex tachycardia and HTN, contraindicated in pregnancy

imitrex- cranial vasoconstriction - tingling and hot sensations are common - caustious in pt with CAD

• 100% O2 for up to 15 minutes
• - intranasal lidocaine 4% topical or 2% viscous
• - Ca channel blockers

acute, rapidly progressing symmetrical demyelinating polyneuropathy in which body's immune system attacks part of the peripheral NS

• 1. viruses:  cytomegalovirus, varicella-zoster virus, and Epstein-Barr virus
• 2. Bacteria: campylobacter jejuni, and mycoplasma pneumoniae
• 3. vaccines:  rabies and H1N1 influenza
• 4. trauma or surgery

• 1. Hx of recent illness
• 2. sudden weakness and mild sensory disturbances of legs - progressses in symetrical ascending manner - evolves days to wks
• 3. paresthesia
• 4. muscle cramping or ache in hips, thighs, or back
• 5. dyspnea
• 6. dysphagia
• 7. wide blood pressure changes:  may have orthostatic changes
• 8. respiratory distress
• 9. tachycardia progressing to bradycardia
• 10. facial flushing
• 11. loss of sweating or episodic profuse diaphoresis
• 12. bell palsy or facial paresis
• 13. symmetric proximal and distal weakness
• 14. areflexia or decreased depp tendon reflexes
• 15. no muscle atrophy

peak effects occur b/t 1 and 4 wks

hypercalcermia seen with immobilization

protein

elevated HOB

• 1. DVT
• 2. PE
• 3. urinary retention
• 4. acute respiratory failure

progressive neurodegenerative disease of upper and lower motor neurons of the cerebral cortex, brainstem, and spinal cord that results in total paralysis

progressive demyelination of the CNS

progressive dgeneration of the neurons in the motor area of the brain

progressive disorder of the peripheral NS that affects the transmission of nerve impulses to the voluntary muscles

can occur when fetus acquires antibodies from a mother who is affected with myasthenia gravis

• more common in men
• average age at Dx 55

• affects women more than men
• age of onset is 20 to 40 years

family Hx of autoimmune disorder

seen in adult women <40 and men >60

progressive neurodegnerative disease that affects nerve cells in the brain and spinal cord

immune system attacks protective myelin sheaths that surround the nerve cells of the brain and spinal cord

breakdown of the nerve cells in the motor area of the brain which results in a shortage of dopamine

deficiency of dopamine in basal ganglia affects regulation of body movements

• acetylcholine receptor antibodies are present in 80to 90% of pt with generalized form of myasthenia gravis
• immunoglbulin G autoantibodies prevent acetyl-choline from binding with receptor at the neuro-muscular junction

muscle weakness and stiffness is earliest sign

muscle weakness in arms, legs, or chest (trouble breathing) is hallmark sign

twitching and cramping of muscles - impairment of the use of arms and legs

muscle twitches, thick speech, difficulty projecting the voice,

advanced stages:  probs with breathing and swallowing

muscle weakness in arms, legs, and chest (trouble breathing)

high-resolution serum protein electrophoresis, thyroid and parathyroid levels

urine - 24h collection for heavy metals

• 1. visual disturbances:  diplopia, blurred vision
• 2. muscle weakness, numbness, prickling sesations, and ataxia
• 3. facial hypesthesia and paresthesias
• 4. memory and concentration probs
• 5. charcot triad:  nystagmus, intention tremor, and scanning speech
• 6. abnormal reflexes:  increased deep tendon reflexes, positive Hoffman sign, positive Babinski sign, and decreased cremateric reflex
• 7. Lhermitte sign:  when pt laing down, flexion of the neck causes electrical shock radiates bilat down arms, back, and trunk
• 8. high steppage gait and scissors gait
• 9. decreased vibration and position sense
• 10. ataxia
• 11. decreased muscle stregth and paralysis

increased total protein and immu noglobulin G levels