coup-contrecoup injury
Dual impacting of the brain into the skull; coup injury occurs at the point of impact; contrecoup injury occurs on the opposite
... [Show More] side of impact, as the brain rebounds.
Scalp laceration: what, effect, management
Primary head injury
profuse bleeding - signs of hypovolemia
Apply direct pressure
Suture/ staple laceration
Lidocaine 1% with epi to control bleeding, not close to nose/ ears
Skull fracture: types, effect, management
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
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
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
decreased level of consciousness
Blown pupil
Cushing triad: HTN (widening pulse pressure), decreased resp rate, bradycardia (means increased intracranial pressure)
Neuro exam components
AVPU: awake, response to verbal stimuli, painful stimuli, unresponsive
GCS: 8 or below is comatose
Posturing:
decorticate = arms, legs in
decerebrate = arms, legs out
Electrolyte imbalances in brain injury
Hyponatremia: SIADH and cerebral salt wasting
Hypernatremia: DI (give mannitol)
Management of traumatic brain injury
- Consult neurosurgery
- Limit secondary injury
- Prevent hypotension (syst 90) and hypoxemia (PaO2 60). May give blood to improve tissue perfusion.
- Treat cerebral edema: elevate bed, sedate, paralyse, mannitol, hyperventilation (PaCO2 25-30), during first 24hrs.
- sedation and analgesia: opioids to reduce ICP (Fentanyl) with propofol. Could give Nimbex or Vec. to help oxygenate/ ventilate
- steroids: avoid
- Give mannitol or hypertonic saline for herniation: bolus then gtt. monitor serum osmolality, sodium, and bp.
- Seizure precautions: give phenytoin or keppra
- DVT prophylaxis: stockings, LMWH
- head injury means spine injury until proven otherwise
- hypothermia: can control ICP (89 - 91F)
- decompressive crani: ICP refractory to tx
- brain O2 monitoring (jugular vein O2 sats)
ICP monitoring
For: GCS 3-8 with abnormal CT and comatose pt's with normal CT and older than 40, posturing, hypotension.
Normal value: 5-10 mmHg
Recommend initiating treatment if ICP > 20 mmHG.
Can calculate CPP (CPP = MAP - ICP). Should be 60
Brain death criteria
Must have all:
No spontaneous movement
Absence brain stem reflexes (fixed/ dilated pupils, no corneal reflexes, absent doll's eyes, absent gag, absent vestibular response)
Absence breathing drive/ apnea
can't be declared brain dead when: hypothermia, drug intoxication, severe electrolyte/ acid-base imbalance
EEG, CTA of brain, Cerebral angiography, transcranial doppler
Spinal cord trauma: cause and who
- MVA, falls, acts of violence, sports, wounds
- Rapid acceleration/ deceleration causes hyperextension (fall, rear-end collision)(central cord syndrome), hyperflexion (bilateral facet dislocation), vertical column loading (compression and then shattering from falls/ dive lands on butt, at C1 from diving), whiplash
- Distraction injury: from hanging
- penetrating trauma: from wound
- pathologic fractures (osteoporosis/ cancer)
mainly cervical spine. High mortality.
More common in men
more common in young than old
Fractures and vertebrae
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
- 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
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
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
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
Anterior cord syndrome: weakness/ paralysis with loss of sense of pain and temp
Posterior cord syndrome: can't feel touch and vibration
Central cord syndrome: greater loss in upper extremities than lower
Brown sequard syndrome: one side of spinal cord is damaghed by stab/ gun wound. Ipsilateral motor loss and contralateral loss of pain and temp sense. Extremities that can move have no feeling and that have feeling can not move.
Spinal cord injury: diagnostics
Cervical vertrebrea: lateral xr, then AP (swimmer view)
Thoracic vertebrae: lateral and AP xr, view all 12
Lumbar: lateral and AP, view all 5
CT to check for bony fragments
Films in flexion. extension to check for fractures
Myelogram: detects compression of cord by herniated disks, bone or foreign matter
MRI: cord impingement, hematoma, infarct, contusion, hemorrhage.
Spinal cord management
- Consult neuro
- Airway maintenance (do not hyperextend neck when intubating)
- immobilization (cervical collar/ spine board)
- intravascular fluid (neurogenic shock: warm, dry, brady)
- monitor bp (avoid hypotension: keep MAP 85)
- Foley
- NG
- AB for penetrating injury
- room temp
- good skin care
- fixation of spine
- fusion: attaching injured vertebrae
Key features of dementia
- General decrease in level of cognition - thinking, memory, reasoning
- Behavioral disturbance
- Interference with daily function and independence
Not a disease, but group of symptoms by various diseases
Alzheimer's disease
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
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
- Slow onset
- memory loss and confusion
- problems with language
- impaired abstract reasoning
- aphasia, apraxia, agnosia
- disorientation
- poor judgement
- emotional problems
- sleeplessness
Dementia labs/ diagnostics
- 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
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
- 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
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
Disease with myelin sheath destruction causing disruptions in nerve impulse conduction.
Acquired, immune-mediated.
Relapses/ attacks/ exacerbations and remissions
Etiology of MS
More women than men
Caucasians, more northern European
Early onset, 20-40ies
Measles, Herpes, Chlamydia, Epstein-Barr
Classification of MS
Relapsing - Remitting:
Clear/ defined episodes of relapse and recovery. No progression between episodes and return to baseline. Most often initial presentation.
Secondary progressive:
As Relapsing- Remitting, but then progression between episodes. No return to baseline.
Primary progressive:
Continued disease progression. Minor improvements. Usually after 40yrs.
Progressive relapsing.
Progressive disease with relapses, and progression in between.
Malignant MS:
rapid onset, rapid deterioration
Benign MS: No deterioration after 10 yrs
MS symptoms
Subjective:
- Motor weakness, stiffness
- Numbness, tingling, burning, pain
- double vision, dysarthria, dysphasia, vertigo (brain stem)
- visual deficits
- gait ataxia, tremor, uncoordinated movements (cerebellum)
- cognitive dysfunction: memory, processing
- fatigue (common!)
- sleep disorder
- bladder, bowel dysfunction
- seizures
Objective:
- 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
- neuro exam
- MRI (white matter lesions, lesions spinal cord, T1 and T2 lesions) (diagnostic!)
- CSF analysis: elevated igG and oligoclonal bands in CSF but not serum
MS management
- 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
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
- 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
- consult neuro
- Pharm to relieve symptoms and improve functioning: Carbidopa-levodopa standard treatment.
- Can on/off phenomona with working/ not working of meds. Add catechol-O-methyltransferase
- Adequate nutrition
- Exercise [Show Less]