Neuro

Question 1

Monro-Kellie hypothesis

Answer 1

Understanding how our patients progress with TBI

3 brain components: brain csf blood
Any increase of one component requires a decrease in another

the total volume of the brain, cerebrospinal fluid (CSF), and blood within the skull is constant. If the volume of one component increases, the volume of another must decrease to maintain equilibrium

Question 2

ICP

Answer 2

Normal 0-15mmHg
Estimate 20 when you don’t know

Question 3

Cerebral Blood Flow

Answer 3

Requires 15-30% of cardiac output to meet metabolic demands
Maintained by cerebral auto regulation, despite changes in cerebral perfusion pressure CPP

Question 4

CPP (cerebral perfusion pressure)

Answer 4

Normal 60-70 optimal CBF, <50 infarction
CPP= MAP - ICP (est 20 when don’t know)
MAP= [(Diastolic BP X 2) + SBP) / 3

Min map 90 in trauma pt, 80 in peds

Question 5

Causes of secondary TBI

Answer 5

3 H’s: hypoxia, hypo hypertension, hypo hypercapnia
Ischemia
Edema
Increased ICP
Vasodilation – maintain ETCO2 35-40

Question 6

Signs Inc ICP

Answer 6

Change in LOC

Sighs of herniation: decirticate decerebrate, blown pupil

** Cushing’s Triad***
Widened pulse pressure (HTN)
Bradycardia
Cheyne Stokes resp

Question 7

CT

Answer 7

Subdural- concave- looks like a banana
Epidural- convex- looks like a lemon

Question 8

Subdural hematoma Tx

Answer 8

Between dura mater and arachnoid membrane
Always venous
Acute: < 4 days, subacute 4 to 21 days, chronic greater than 21 days

Tx: reduce stim, osmotherapy (mannitol 3%), Na+ upper limit of 155, higher serum osmolality (less volume more solute- cell shrinks down), anticonvulsant keppra or Dilantin

Question 9

Epidural hematoma

Answer 9

Always from trauma
Occurs between the cranium and Dura matter often associated with skull fracture
Usually arterial bleeding from the middle meningeal artery, but can be Venus in some case
Causes rapid compression of the brain stem
Classic presentation, LOC, lucid, interval, neurological deterioration 
They initially lose LOC, wake back up, and then the second loss of consciousness is when herniation starts 

Question 10

Subarachnoid hemorrhage

Answer 10

A lot of times caused from AVM but can be caused by trauma or aneurysm occurs mostly in circle of Willis inside brain
Signs: decreased mental status, seizure, sudden onset of severe headache, nausea, vomiting
Tx: SBP<140, Dec ICP
Big thing: don’t allow re-bleading
Give nicardipine for BP

Question 11

Intraventricular hemorrhage

Answer 11

Trauma, aneurysm
Found in frontal and temporal lobe injuries
Treatment maximize CPP greater than 70 maintain SVP less than 160, control ICP
More serious injury, bad outcomes 

Question 12

Diffuse axonal injuries DAI

Answer 12

Occurs when nerve fibers are shown torn or stretched as a result of head impact (frontal-occipital impacts)
MRI preferred for diagnosis
Often diagnosed by ruling out, other injuries, difficult to diagnose bc doesn’t show up on CT
Patients don’t do well
Treatment: prevent secondary injuries, avoid hypotension, hypoxia, cerebral edema, and elevated ICP 

Question 13

Hypoxic ischemic encephalopathy

Answer 13

Inclusion criteria: Neonate’s greater than 35 weeks presenting on the first day of life with evidence of HIE

Exclusion criteria: in infants, less than 35 weeks, encephalopathic infants due to causes other than ischemic encephalopathy

is there any evidence of intrapartum hypoxia. Most often caused from shoulder dystocia

Therapeutic hypothermia: 33-34C, EEG and supportive care

Question 14

Seizure

Answer 14

75% of pediatrics will have first seizure activity as status seizures

Causes: hyperthermia, hypoglycemia, hyperglycemia, electrolyte, imbalances

Management: airway, intubation, mechanical ventilation,
First line: Ativan .1mg/kg, Valium .15-.2mg/kg
Second line: phenytoin 20mg/kg, valproic acid 20-40mg/kg phenobarbital 15-20mg/kg

Question 15

Anterior cord syndrome

Answer 15

Iatrogenic, not common in trauma
Anterior spinal artery embolus
Aortic dissection
Hyperflexion injury of the cervical spine

Signs: injury below T10, urinary incontinence, spastic, paralysis, loss of pain, pressure, temp, crude touch

Question 16

Brown-Sequard Syndrome
***TQ

Answer 16

Results from an injury to 1/2 of the spinal column

Causes: penetrating trauma, like stabbing or GSW, spinal cord tumor

Signs: ipsilateral loss of fine touch, ipsilateral UMN lesion, contralateral loss of pain/temp

Question 17

Central cord syndrome

Answer 17

Causes: hyper extension, injury, parentheses MVA, diving), syringomyelia (chiari malformation)

These are cervical – thoracic injuries, upper motor neuron, upper extremities affected more than lower*TQ**

Question 18

Sciwora

Answer 18

Neurological symptoms of a spinal cord injury despite normal imaging. Often associated as swelling of the spinal cord

Spin
Cord
Injury
Without
Radiograph
Abnormality

Question 19

2 assessment findings that are important in spinal cord injury patient

Answer 19

1) Are they hot or cold? True spinal cord injuries will say they are hot.
2) can they lift their legs?

Question 20

Spinal shock versus neurogenic shock 

Answer 20

Spinal shock is acute spinal cord injury, loss of voluntary reflexes below level of injury, last days two months

Neurogenic shock is an acute spinal cord injury C1 to T5, loss of vasomotor and sympathetic, nervous system tone below level of injury, hypotension, bradycardia, temperature regulation, last up to six weeks. Norepi first line med when they start to diurese

Spinal shock is a temporary neurological state of depressed reflexes that resolves, neurogenic shock is a persistent circulatory problem from loss of sympathetic tone

Question 21

Autonomic dysreflexia

Answer 21

Side effects of spinal cord injury. Lesions t6 and above. Any pain stimuli induced this- spiked BP
Ex: kinked foley cath, too small shoes. Pt can’t register pain but body responds w spike in BP

Question 22

What can increase mortality by 50% in spinal cord injuries?

Answer 22

One episode of hypoxia or hypotension 

Question 23

What happens with hypocarbia?

Answer 23

Leads to decrease cerebral blood flow and possible cerebral ischemia

Question 24

A patient suffering from brown Sequard syndrome presents how?

Greater weakness and upper extremities and lower extremities
Ipsilateral motors, contralateral pain loss
Complete motor pain and temperature loss below the level of the injury
Complete flaccidity below the level of the injury 

Answer 24

Ipsilateral motor loss, contralateral pain loss 

Question 25

Your patient has an intracranial pressure of 28, with a BP of 100/60. Calculate the cerebral perfusion pressure CPP.

Answer 25

45

Question 26

How does a patient with an epidural hematoma present? Rapid onset of unconsciousness, posture, seizure activity Slow loss of consciousness, ipsilateral posturing, contralateral pupil changes Unconsciousness, followed by a brief period of lucidity, and a period of rapid decrease in the level of consciousness Slow loss of consciousness, pupil changes, and seizure activity

Answer 26

Unconsciousness followed by a brief. A lucidity, in a period of rapid decrease in the level of consciousness. Epidural hematoma’s occur when blood buildup between the derma and the skull. Epidural bleeding is rapid because it is usually from an artery, most often in the middle menial artery 20 to 30% of all epidural bleeds are a result of impact to the temporal area called the Pterion region.