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
Degrees of sensory loss: anesthesia, dyesthesia, and hyperesthesia?
- anesthesia - loss of sensation
- dysesthesia - impaired sensation
- hyperesthesia - increased sensation
burning or tingling sensation
Snellen chart use?
20 ft from chart or pocket version 14 inches away
record number on lowest line patient can read with 50% accuracy
Ptosis may indicate cranial nerve ___ injury?
- controls elevation of eyelids
Normal pupil size?
Clinically significant pupil size change?
What can cause pinpoint and nonreactive pupils?
pontine lesions, opiates, miotics (pilocarpine)
What can cause midsize and nonreactive pupils? (2-6mm)
What can cause unilateral >6mm pupils and nonreactive?
brainstem lesion, medication: parasympatholytics (atropine), sympathomimetic (EPI)
Word that means unequal pupils?
What will occur with injury to parasympathetic fibers of the oculomotor nerve?
Sympathetic fibers of the oculomotor nerves?
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
What may oval shaped pupil indicate?
may precede dilated pupil as a sign of pressure on oculomotor nerve
Abnormal extraocular movements indicates what?
cranial nerve injury or isolated muscular dysfunction
Indications of nystagmus?
lesions of the vestibular system or the brainstem
What may disconjugate gaze indicate?
Decreased or absent corneal blink reflex?
may indicate cranial nerve V injury
may be decreased in contact wearers
Asymmetry of facial muscle strength may indicate damage to what cranial nerve?
S/S of Bell's Palsy?
What cranial nerve is affected?
- 1. assymmetry of facial expression
- 2. loss of nasolabial fold
- 3. eye remaining open when trying to close
Inability to taste indicates cranial nerve ___ injury.
- AKA Doll's eyes
- turn head - eyes should go in opposite direction
- abnormal indicates compression in the midbrain-pontine area
Hoarseness indicates damage to what cranial nerve?
damge to laryngeal branch of cranial nerve X
Involuntary swallow or gag when palate is stroke indicates intactness of what cranial nerves?
9 and 10
Consultation needed if neuro pt fails water test?
speech and language pathologist
Interventions for patient with no gag reflex?
- no fluids
- position on side
- suction equipment available
Causes of hyporeflexia?
hypocalcemia, hyperphosphatemia, hpomagnesemia or lower motor neuron lesions
Causes of hyperreflexia?
- high Ca, phosphate, or Mg
- upper motor neuron lesions
Babinskin reflex in adults indication?
upper motor neuron lesion
brusing of the mastoid (behind ear)
indicates basal skull fracture
indicates basal skull fracture
With what type of skull fracture may ottorhea or rhinorhea be seen?
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
ICP poor prognosis?
>50mmHg for >20 min
Dilantin therapeutic level?
Normal serum glucose?
60% of serum glucose value
decreased in bacterial meningities
What will occur if ICP exceeds Map
BF to brain will stop
Consideration with older adults and alcoholics and brain bleeds?
cerebral atrophy - increases risk of intracranial bleeds
- pressure at which brain tissue is perfused
- MAP-ICP = CPP
CPP of >___ is considered minimum desirable CPP for pt with brain injuries
Increased ____ and decreased ____ decrease cerebral BF.
- 1. increased systolic BP
- 2. widening pulse pressure
- 3. bradycardia
indicates impending herniation
When may hyperthermia occur in pat with intracranial HTN?
late as a result of pressure on thermoregulatory center in hypothalamus
paralysis of the upward gaze
S/S of intracranial HTN in infants?
- 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
Why is lumbar puncture contraindicated in intracranial HTN/ increased ICP?
can cause downward cerebellar herniation with medullary herniation and death
What test may show cause of intracranial HTN?
Positioning of patient with intracranial htn?
on side to prevent aspiration if spine has been cleared
Suction should be limited to ____ seconds.
Positive pressure mechanical ventilation effect on ICP?
use lower tidal volumes and PEEP with intracranial HTN and increased ICP
What fluids should be avoided with intracranial HTN and increased ICP?
hypotonic - dextrose 5%, D5W
Tx of intracranial HTN?
- 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
Ways to decrease metabolic demands of the brain?
- 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
Diffuse axonal injuries?
extensive generalized damage to white matter of brain
lg enough that it can be id'd macroscopically
diffuse microscopic damage
S/S of TBI specific to infants?
- bulging fontanel
- if retinal hemorrhages - abuse possible
S/S of brain contusion?
- altered LOC >6h
- memory loss
CT head with brain contusion?
may initially be normal
Diffuse axonal injury?
- immediate LOC that takes >6 hours to resolve if it resolves ever
- amnesia, confusion, behavior changes, may have brainstem damage s/s
Complications of TBI?
- 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
Discharge instructions with concussion and brain contusion?
return if HA, NV confusion, s/s ICP
may need to wake pt every 2-4 h and assess orientation at home
What may occur with linear fractures of the temporal and parietal bones?
tear middle meningeal artery and lead to epidural hematoma
what may occur with linear Fx of the occipital bone?
tear occipital artery and lead to epidural hematoma
s/s of basal skull fracture?
- 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
Tx of rhinorrhea or otorrhea?
- 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
Subdural hematoma predisposing factors?
- 1. may be spontaneous - esp. with coagulation disorder or anticoagulants
- 2. older adults and alcoholics
Epidural hematoma often associated with what type of skull fractures?
linear skull fractures that cross major vascular channels
Patho of subdural hematoma?
- usually venous bleed
- acute: onset within 48 hours of injury
- subacute: within 2 wks
- chronic: weeks to months after injury
Epidural hematoma patho?
Causes of intracerebral hemorrhage?
missile inury or severe accel-decel force
S/S of subdural hematoma?
- 1. HA
- 2. increasing irritability progressing to confusion then decreased LOC
- 3. ipsilateral oculomotor paralysis
- 4. contralateral hemiparesis or hemiplegia
S/S of epidural hematoma?
- 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
S/S intracerebral hemorrhage?
varies with area of brain involved
may or may not show s/s of increased ICP
When is LP contraindicated with brain injuries?
increased ICP and intracranial htn
interruption of BF to brain as a result of vessel rupture
90% of ruptured aneurysms are associated with ____
What bleeding causes meningeal irritation?
blood leakage into subarachnoid space that comes in contact with meninges
______can develop as a result of the obstruction of CSF outflow through the arachnoid villi.
What may occur as a clot around an aneurysm is broken down by body's natural firinolytic processes?
S/S of brain 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
What electrolyte imbalance may occur with aneurysm rupture?
hyponatremia r/t SIADH or cereral salt wasting
When may LP be performed with aneurysm?
if CT is ondiagnostic and no indication of intracranial htn
ECG with subarachnoid hemorrhage?
- flat, peaked, or inverted T wave
- prominent U
- prolonged QT
- dysrhythmias esp. torsades
What is the purpose of transcranial dopplar?
dx of vasospasm
What drugs are used to maintain BP in aneurysm rupture?
What is target BP?
maintain within 10% of prehemorrhage levels
alpha and beta blockers, vasodilators, vasopressors, Ca channel blockers to prevent/reduce vasospasm
In CVA brain edema develops over first ____ h.
What effect does this have?
progressive damage to penumbra
When do thrombotic strokes usually occur?
at night - wake up with s/s
When do embolic strokes usually occur?
CT goals with CVA patient?
noncontrast CT within 25 min of entering ED doors and read within 20 min of procedure
With CVA, maintain systolic BP ____ and diastolic BP ____.
Drugs used for HTN in CVA?
- labetalol mainly
- nitroprusside, hydralazine, nicardipine
Contraindications for TPA?
- 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
- 0.9mg/kg IV with max dose of 90mg
admin 10% of dose as bolus over 1minute. Infuse remaining amnt over 60 minutes
Platelet aggregation inhibitors and fibrinolytics?
contraindicated for 24 hours after IV fibrinolytics
What should be done if pt experiences change in LOC during fibrinolytic infusion?
stop infusion and have immedicate repeat CT
Complications of CVA?
- 1. fibrinolytic complications
- 2 persistent neurologic trauma
- 3. brain edema
- 4. seizures
- 5. fluid/electrolyte imbalances: DI & SIADH
Risk factors for traumatic SC injuries?
- 1. male
- 2. age 16-30
- 3. alcohol & drug use
Hyperflexion SC injury?
- chin forced to chest
- usually C5 and C6
- from sudden decceleration
Hyperextension SC injury?
- head thrown backward
- usually cervical area
- forces of acceleration and decel
SC rotation injury?
all parts of vertebral column affected
SC vertical compression injury?
- falling or jumping and landing directly on feet or head
- feet: Fx of low thoracic and lumbar vertabrae
- head: Fx of cervical vertabrae
High and low cervical injuries affect on breathing?
- high: affects breathing
- low: affects ability to take deep breath, cough, and sigh
When does edema develop with SC injury
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)
BP and HR that may occur with SC injuries?
hypotension and bradycardia
Spinal shock may be seen with ___ and ____ injuries.
cervical and high thoracic
C1 - C2 SC lesion?
ventilatory cessation and immediate death
C3-C5 SC lesion?
quadriplegia with total loss of ventialatory function
- depend on ventilator
- C3, 4, and 5 keep the diaphragm alive
C5-C6 SC lesion?
- quadriplegia with gross arm mvmts
- diaphragm spared: diaphragmatic breathing with no accessory/abd assistance to cough
C6-C7 SC lesion?
- quadriplegia with biceps muscles intact but no function of intrinsic hand muscles
- diaphragmatic breathing with no intercostal/abd help with cough
C7-C8 SC lesion?
- quadriplegia with triceps and biceps intact but no function of hand muscles
- diaphragmatic breathing
- no intercosta/abd for cough
T1-L2 SC lesion?
paraplegia with loss of varying amnt of intercostal and abd muscle
Below L2 SC lesion?
cauda equina injury: mixed picture of motor and sensory loss with bowel and bladder dysfunction
Complete SC lesion?
- loss of sensory and motor function below level of lesion - irreversible
- flaccid paralysis
- urinary retention or priapism
Incomplete syndromes of SC?
varying degrees of paralysis and sensory loss below level of injury with varying degrees of bowel and bladder dysfunction
When does spinal shock occur after injury and how long does it last?
several days to months
S/S of spinal shock?
- 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
Central cord syndrome motor/sensory loss and type of injury?
- motor: weakness of all extremities but greater motor loss in upper extremities
- sensory: varies depending on number of undamaged SC tracts
- hyperextension injury
Brown-Sequard syndrome motor/sensory loss and type of 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
Anterior cord syndrome motor/sensory loss and type of injury?
- complete motor loss below lesion
- sensory: loss of pain and temp sensation below lesion, sparing of proprioception, vibratory sense, and touch
Psterior cord syndrome motor/sensory loss and type of injury?
- motor: function intact
- sensory: loss of touch, vibratory sense, and proprioception below lesion
- hyperextension or disease processes
Cauda equina syndrome motor/sensory loss and type of injury?
- 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
Spinal cord injury without radiographic abnormality accounts for up to 2/3 of severe cervical injuries in what group of ppl?
children <8 years old
If suspect SC injury in children 8 and under with no radiographic evidence what is intervention?
immobilize for 1 to 3 wks
Fluid admin with SC injury?
How is BP managed?
pt hypotensive with normal fluid volume - increased fluids can increase SC edema
careful fluid admin
may manage hypotension with pressors
What type of fluids should be avoided with SC injury?
How should pt with SC injury be moved?
Interventions to help with venous return in SC injury pt?
Methylprednisolone admin after SC injury?
- 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
Contraindications for steroid / methylprednisolone with SC 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
Interventions for autonomic dysreflexia?
- 1. eliminate noxious stimuli - full bladder/bowel
- 2. admin antihypertenisve agens
nerves supposed to carry msgs from brain to bladder don't work
Intervention for neurogenic bladder?
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
What induces a seizure with elevated body temp?
not temp but how fast it rises
rapid increase in temp >102
Age of febrile seizures?
6months to 3 years
___ % risk of developing seizures after major head trauma
Causes of seizures?
- 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
What occurs with prolonged generlized seizures?
may deplete brain of O2 and glucose -> hypoxia and neuronal death
What occurs after 25-30 min of seizure?
- 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
Electrolyte imbalances with seizure?
hyperkalemia with prolonged seizures
glucose levels with seizures?
increased early and decreased late
Creatinine kinase with seizure?
increased esp if prolonged
ABG with seizure?
may have hypercapnia or hypoxemia
Urine with seizure?
may show myoglobinuria esp if prlonged
Airway mngmt with seizures and decreased LOC?
may need oral or nasopharyngeal airway to hold tongue
UDS for seizures?
screen for barbituarates, alcohol, tricyclic antidepressants, cocaine
Contributing factors that lower seizure threshold and need to be corrected?
- 1. hypoxemia
- 2. acid-base imbalances
- 3. electrolyte imbalance
- 4. hyperthermia
- 5. hypermetabolism
Consideration with seizure activity r/t alcohol?
thiamine and D5W
Why is thiamine given with D5W?
to prevent Wernicke Encephalopathy
Seizure meds time until seizure stops and duration of anticonvulsant effect?
ativan, diazepam, phenytoin sodium, fospheytoin/cerebyx, phenobarbital
- 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
Characteristics of HA that is likely to have a serious cause?
- 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
- 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
LP with HA?
CT first to r/o subarachnoid hemorrhage
Drugs for migraine?
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
Tx of cluster HA?
- 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
Predisposing factors Guillian-Barre?
- 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
S/S of Guillain-Barre?
- 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 of Guillain-Barre weakness?
peak effects occur b/t 1 and 4 wks
What electrolyte imbalance occurs with Guillain Barre?
hypercalcermia seen with immobilization
What is seen in LP of guillain Barre?
Postioning of pt with Guillain-Barre
Complications of Guillain-Barre?
- 1. DVT
- 2. PE
- 3. urinary retention
- 4. acute respiratory failure
Amyotrophic Lateral sclerosis (Lou Gehrig disease)?
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
Predisposing factors of ALS?
- more common in men
- average age at Dx 55
Who is more prone to multiple sclerosis?
- affects women more than men
- age of onset is 20 to 40 years
Predisposing factors for myesthenia gravis?
family Hx of autoimmune disorder
seen in adult women <40 and men >60
Patho of ALS?
progressive neurodegnerative disease that affects nerve cells in the brain and spinal cord
Patho of MS?
immune system attacks protective myelin sheaths that surround the nerve cells of the brain and spinal cord
Patho of Parkinson disease?
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
Patho of myasthenia gravis?
- 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
S/S of ALS?
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
Hallmark sign of ALS?
muscle weakness in arms, legs, and chest (trouble breathing)
Dx of ALS?
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
CSF with multiple sclerosis?
increased total protein and immu noglobulin G levels