1
Q
Cranial Nerves
A
On Old Olympus Towering Tops A Fin and German Viewed Some Hops
1 Olfactory -Smell
2 Optic -Vision
3 Oculomotor -EOM, eyelid opening, pupillary constriction
4 Trochlear -Downward and inward eye movement
5 Trigeminal - Mastication, sensation face, mouth, nose
6 Abducens -Lateral eye movement
7 Facial -facial movement, eye/mouth closing, taste, saliva/tear
8 Acoustic -Hearing and equilibrium
9 Glossopharyngeal -phonation, posterior taste, gag, carotid, reflex, swallow
10 Vagus-Talking, swallow, sensation carotid body, carotid reflex
11 Spinal Accessory- (shrug) trapezious/sternocledomastoid
12 Hypoglossal- moves the tongue
2
Q
Sensory/ Motor / Both
A
Some
Say
Marry
Money
But
My
Brother
Says
Big
Bras
Matter
Most
3
Q
WHat is the timeframe for and symptoms of TIA?
A
Periods of cerebral insufficiency with < 24 hours with NO residual effects
TIA indicative of pending stroke (1/3 infarct w/in 5 yrs)
Infarctions more common (80%) than hemmorrhage (20%)
Sx:
- amaurosis fugax (ipsilateral monocular blindness)
- Transient aphasia
- Parathesias of contralateral limbs or face
- Nystagmus, vertigo, dysphagia, sensory deficits
*Same side eye changes, opposite motor changes
4
Q
TIA Classifications
A
Vertebrobasilar: inadequate blood flow vertebral arteries
*neuro like symptoms (vertigo, ataxia, dizziness, VF deficits, weakness, confusion)
Carotid:carotid stenosis (more traditional stroke life symptoms including aphasia, dysarthria, altered LOC, weakness, numbness
5
Q
TIA Dx
A
Dx:
- CT best for distinguishing between ischemia, hemorrhage, tumor
- MRI superior to CT for ischemic infarct
- Echo
- Carotid Doppler/US
- Cerebral Angio
6
Q
TIA Management
A
ASA
Plavix superior choice
Ticlid-needs lab monitoring for agranulocytosis & thrombocytopenia
Assess for HTN *#1 cause heart failure
Carotid endart indicated for >70-80% stenosis in symptomatic pts, decreases risk for stroke/death in recent TIA
7
Q
CVA Definition
A
Rapid onset of neuro defecits > 24 hrs duration
- 4th leading cause of death
- Can be subtle, progressive or sudden onset
8
Q
CVA causes
A
- Atherosclerosis
- Chronic HTN
- Trauma
- Aneurysm
- AV Malformation
- Tumor
9
Q
Hemorrhagic CVA
A
Presents with acute onset of focal neuro defecits
10
Q
Hemorrhagic CVA signs and symptoms
A
Sudden increased ICP including altered mentation, HA, vomiting when extensive
*
11
Q
Hemorrhagic CVA Diagnostics
A
- Head CT
- Cerebral angio
- Lumbar puncture if Grade I or II aneurysm for blood in CSF (do CT first)
12
Q
CVA Management
A
- Surgical evaluation
- Lower systemic BP while avoiding hypotension
- Prevent sudden increased ICP:
- Elevate HOB, Sedation, Oxygen, Analgesic, Laxative
- MAP 110-130 to treat cerebral vasospasm
- Intravascular volume expansion and HTN tx to increase cerebral perfusion (CPP=MAP-ICP)
- Nimodipine (Ca Channel agonist) to counter vasospasm
*Maintain CPP and limit increases in ICP to <20
13
Q
ICP H’s
A
Hypertension
Hypoxia
Hypercapnia
- Tx by hyperventilation, keep CO2<35, O2 high and maintain higher MAP’s 110-130 (increases vital organ perfusion and prevents cerebral vasospasm)
14
Q
Simple Partial Seizures
A
Simple Partial (focal, local)- common with cerebral lesions
- No loss of consciousness
- Rarely lasts >1 min
- Motor sx start with single muscle group and spread to entire side of body
- Paresthesias, flashing lights, vocalizations, hallucinations
15
Q
Complex Partial Seizures
A
Any partial seizure followed by impaired LOC
- May have aura, staring, automatisms such as lip smacking or pulling at clothing
16
Q
Generalized Seizures
A
Absence (petit mal)
- Sudden arrest of motor activity with blank stare
- Common in children/adolescents
- Begin and end suddenly
Tonic-Clonic (Grand mal)
- May have aura
- Begins with repetitive involuntary contraction of muscle (tonic clonic)
- Ususally lasts 2-5 min
- Incontinence possible
- Followed by post-ictal period
17
Q
Status Epilepticus
A
Series of Grand-Mal seizures of >10 minutes duration
- Medical emergency
- May occur when awake or asleep but no regaining of consciousness between attacks
- *most uncommon, but most life-threatening
18
Q
Seizure Diagnostics
A
Assesment
- Presence of aura, onset, spread, type of movement, body parts involoved, pupil changes and reactivity, duration, loss/LOC, incontinence, behavioral and neuro changes after cessation of sz activity
- Note HA, fever, personality changes
EEG *most important test in determining sz classification
CT head for new onset seizures to r/o brain tumor
19
Q
Seizure Management
A
Initial tx is supportive as most sz are self-limiting
- Maintain open airway, nothing in mouth
Parenteral anticonvulsants for rapid cessation of sz
- Benzos- Diazepam 5-10 mg IV (to break & status)
- Lorazepam (ativan) 2-4 mg IV at 1-2 mg/min to break
- Phenytoin (dilantin) loading dose 20mg/kg @ 50mg/min continuous infusion
- Fosphenytoin (cerebyx) Prodrug of dilantin
- Phenobarbitol (Luminol) Used if phenytoin is unresponsive
- Barbituate coma or GA with nueromuscular blockade
20
Q
Subsequent Seizure Prevention
A
Maintenance dosage long-acting anti-convulsants
- Carbemazepine
- Phenytoin
- Phenobarbitol
- Valproic acid
- Primidone
- Clonazepam
Titrate dosage
Never abruptly withdraw, taper
21
Q
Myasthenia Gravis
A
Autoimmune disorder resulting in reduction of acetylcholine receptors at the neuromuscular junction
- Weakness is worse after exercise and better at rest
- Variable course
- Age 20-40 at onset, incidence peaks in 30’s women, 50-60 for men
- Women> men
22
Q
Myasthenia Gravis signs and symptoms
A
- Ptosis
- Diplopia
- Dysarthria
- Dysphagia
- Extremity weakness
- Fatigue
- Respiratory difficulty
- Sensation and DTR WNL
*Visual changes with extremity weakness are characteristic
23
Q
Myasthenia Gravis Diagnostics
A
- Antibodies (AchR-ab) found in >85%
- Edrophonium (Tensilon) test differentiate btwn MG and cholinergic crisis (weakness gets better with Tensilon, worse in a cholinergic crisis)
24
Q
Myasthenia Gravis Management
A
- Neuro referral
- Acetylcholinesterase ihibitor drugs (pyrostigmine bromide=Prostigmin)
- Immunosupressives
- Plasmapheresis
- Ventilator support in a crisis
25
Multiple Sclerosis
Autoimmune disorder characterized by numbness, loss of muscle coordination, vision, speech and bladder control issues
* Attacks myelin sheath which controls transmission of nerve signals
* Variable course
* Onset 20-50 years
* More common Western European descent in temperate zones
26
MS Signs & Symptoms
* Weakness, numbness, tingling or unsteadiness in limb
* Spastic paraparesis
* Diplopia
* Disequilibrium
* Urinary urgency or hesitancy
* Optic atrophy
* Nystagmus (rapid eye movements)
27
MS Diagnostics
* Multifactorial dx, not on labs alone
* Mild lymphocytosis
* CSF: elevated protein, IgG
* MRI of brain
28
MS Management
* Neuro referral
* No tx to prevent progression
* Steroids for relapses
* Anti-spasmodics
* Interferron therapy
* Immunosuppressives
* Plasmapheresis
29
Guillain-Barre
Acute, rapidly progressive form of inflammatory polyneuropahty characterized by demyelinization of peripheral nerves resulting in progressive symmetrical ascending paralysis
* Ususally preceded by suspected viral infection with fever 1-3 weeks prior to onset of BLE muscle weakness
* Flaccid paralysis can occur within 48-72 hours of onset
30
GB Signs & Symptoms
* Rapidly progressive ascending paralysis
* CN impairment AEB difficulties in speech, swallowing, mastication
* Reflexes hypoactive or absent
* Respiratory muscle impariment possible
31
GB Diagnostics and Management
Diagnostics
* CSF protein elevated
* CBC: leukocytosis with left shift
* LP, MRI, CT sometimes used in dx
Treatment
* Supportive while myelin regenerates
* Sx recede w/in 2 weeks, resolve w/in 2 years
* Neuro consult
32
Meningitis
* Should be considered in any patient with fever and neurologic symptoms, especially if history of other infection (PNA) or head trauma
* Acute, bacterial meningitis is a medical emergency
Causes
* Strep pneumoniae, H. Influenze, N. Meningitidis in 80-90% of cases
* Most common in the hospital is Staph Epidermis
33
Meningitis Signs & Symptoms
* Fever (101-103)
* Severe HA
* N/V
* Nuchal rigidity
* Positive Kernig's Sign (pain and spasm of hamstring muscles)
* Positive Brudzinski's Sign (legs flex at hips and knees in response to flexion of the head and neck to the chest)
* Photophobia
* Seizures
34
Meningitis Diagnostics & Management
Diagnostics
* Lumbar Puncture - Bacterial presentation: CSF cloudy or xanthocrhomic (yellow) with elevated pressure, protein, decreased glucose (bugs eat sugar) and presence of WBC's
* Viral Presentation-normal to elevated opening pressure, normal protein and glucose, some WBC
* CT head is indicated
Management
* Control S&S, maintain electrolyte balance
* High dose parenteral ATB therapy ASAP for suspected bacterial cases
* Aqueous PCN G, vanc with a third gen cephalosporin until C&S is available, or fluoroquinolones
35
Head Trauma
* Men\< 35 years, accidents leading cause of death
* Over 70% accidents involve head injury
* Leading cause of death in all trauma cases
Monroe-Kellie Doctrine: when 1 content of brain goes up (blood, CSF, Brain tissue), another goes down
S&S:
* Assess: time and place of injury, how it occured, LOC, occurence of a lucid interval (suggests bleed \*Epidural hematoma), sz activity, amnesia (indicates severity of blow)
Decompensating pts may show Cushing's Triad:
* Widening pulse pressure (SBP increases in attempt to maintain CPP (CPP=MAP-ICP))
* Decreased RR
* Decreased HR
Battle's sign -bruising at mastoid
Raccoon eyes
Otorrhea or Rhinorrhea
36
Head Trauma Diagnostics/Management
Diagnostics:
* C Spine films all pts
* Skull films and Head CT
Management:
* ABC's assessed in any significant head trauma or altered LOC
* Stabilization of VS and ongoing Neuro eval
* Neurosurgery consult
37
Spinal Cord Trauma
* 1/2 of all spinal cord injuries occur above T1
* More common in young males
Four P's:
* Paralysis
* Paresthesias
* Pain
* Position
38
Levels of Vertebral Damage
* C4 or above- Quad, may need vent
* C4-C5: Quad, control of head/neck, shoulders, trapezius, elbox flexion
* C5-C6: Quad, some extension of wrist, index finger/ thumb
* C6-C7: Elbow extension, capable of feeding and dressing
* C7-T1: Hand movement
* T1-T2: Para, upper extremity control, no trunk control
* T3-T8: Some trunk control
* T9-T10: Bowel and bladder reflex, moves trunk and upper thigh
* T11-L1: Most leg and foot, ambulation possible
* L1-L2: Lower legs, feet, perineum, bowel, bladder and sexual function if S2-4 nerves involved
* \*C=arms and hands, T=trunk
39
Strength Grades
5/5 normal
4/5 Full ROM against moderate resistance and gravity
3/5 Full ROM against gravity, not against resistance
2/5 Can move but not against gravity (roll, not lift)
1/5 Muscle contracts, no movement of extremity
0/5 Flaccid
40
Spinal Cord Injury Diagnostics/Management
Diagnostics:
* Spinal XR series
* CT scan, MRI, myelography
Management
* Methylprednisone 30 mg/kg IV bolus followed by infusion of 5.4 mg/kg/hr 23 hours improves neurologic recovery when administered w/in 8 hrs of injury
* Neuro consult
41
Spinal Cord Injury 2 major complication types by Level
C4 or above- resp compromise
T4-T6 - autonomic dysreflexia, emergency condition (seen in full bladder or annoying type problem like a wrinkled sheet)
* exagerated autonomic response to stimulus
* diaphoresis and flushing above level of injury
* chills and vasoconstriction below injury
* HTN
* Bradycardia
* HA-severe
* Nausea
* Tx -antihypertensives and removal of stimulus
T6 or above: Neurogenic shock
* During transmission of sympathetic impulses, unoppsed parasympathetic stimulation leading to loss of vasomotor tone inducing vasodilation
* Hypovolemia, decreased venous return, decreased cardiac output
* Sympathomimetic vasopressors
42
Cause of Parkinson's Dz
Degenerative disorder resulting from insufficient dopamine in the body
* Onset 45-65, idiopathic, equal gender distribution, all ethnic groups
43
Parkinson's Signs/Symptoms
Most common are top three:
* Tremor, enhanced by stress
* Rigidity
* Bradykinesia (slow movement)
Additional sx:
* Wooden facies
* Dysphagia
* Drooling, decreased blinking
* Myerson's sign (tapping over bridge of nose produces sustained blink response)
44
Parkinson's Diagnostics/Management
Diagnostics:
* None
Lung problems/infection usually is cause of death
Management
Increase dopamine (If difficulty moving, like feet sticking to flr)
* Carbidopa-Levodopa (Sinemet), Amatadine (Symmetryl), Tolcapone (Tasmar), Pramipexole (Mirapex), Ropinirole (Requip)- all are used in combination, not alone
Anticholinergics (for worsening tremor)
* Benzoropine (Cogentin), Trihexyphenydyl (Artane)
Selegiline (Edepryl) or Depranyl
45
Drug Abuse/ Alcoholism Pneumonic
C- need to **C**ut down?
A- people **A**nnoyed you by criticizing your drinking?
G- felt **G**uilty?
E- need for **E**ye-opener drink in the morning?
Managment:
* Consult regarding tx and detox
* Therapuetic communication "I'm concerned about alcoholism", not you have a drinking problem
* Treatable dz
* AA referral, Al-Anon (family) /Ala-Teen
46
Confusion- Delerium vs Dementia
Delerium: sudden, transient onset of clouded sensorium, occurs at any age, associated with physical stressor
Causes:
* Toxins, alcohol/drugs, trauma, Fecal impaction, poor nutrition, electrolye imbalance, anesthesia
Dementia: Gradual memory loss, not recoverable with decreased intellectual functioning, \>60 years of age
Causes:
* Atherosclerosis, neurotransmitter defecits, cortical atrophy, ventricular dilation, loss brain cells, viral, Alzheimer's
47
Alzheimer's
Development of multiple cognitive defects characterized by both memory impairment and:
## Footnote
Aphasia (difficult speech)
Apraxia (Inability to perform previously learned task)
Agnosia (Inability to recognize object)
Inability to plan, organize, sequence and abstract thought
Other findings: limb rigidity, flexion posture, gait disturbance
\*Most common cause of dementia
\*acetylcholine deficiency
Diagnostics:
Draw labs to r/o other diseases
CT/MRI r/o tumor
Management:
Meds to increase ACTH (acetylcholinesterase inhibitors)
Donazepril (Aricept), Galantamine (Razadyne), Rivastigmine (Exelon)
Referral for counseling
48
Gerontology Considerations
Increased risk of sleep disorders, delerium, **neurodegenerative diseases,** falls, loss of independence with ADL's
Physiologic changes: decreased neurons and neurotransmitters, decreased thermoregulation, peripheral nervous changes, decreased dopamine receptors, increased alpha responses
Impaired muscle strength, sense of touch, increased pain tolerance, slowed motor skills, diminshed balance, temp sensitivity, blunted temp response, slowed cognitive response but not intelligence
49
Dysarthria
Not able to articulate
50
Apraxia
Inability to perform a previously known task
51
Amaurosis Fugax
Ipisilateral, monocular blindness
52
Time limit for TPA/thrombolytics
3 hours
53
Want CO2 low in the head?
It causes vasoconstriction to cerebral vessels
CO2 Level should be 35
54
Cerebral perfusion pressure equation
CPP= MAP-ICP
Keep MAP high 110-130
55
CCB used to prevent vasospasm in head bleed?
Nimodipine/Nimotop
56
What is difference between a simple partial and complex partial sz?
Loss of or impaired consciousness
57
How to differentiate tonic-clonic from complex partial?
Tonic clonic- blue, loss of bladder control, change in LOC but will be POST-ICTAL
58
Name two out-pt anti-sz drugs
Tegretol and dilantin
59
Wihch hemisphere presents with left hemiparesis, right visual field changes, spatial disorientation (can't determine true body postition)
Right hemishpere hemorrhagic stroke
60
brudzinski sign
head to chest and they curl up knees and hips (like a baby)
61
Kernig's sign
Pain and spasms of the hamstring muscles
62
With fast onset, suspect viral or bacterial meningitis?
Bacterial
63
Brown sequard syndrome
ipsilateral symptoms, contralateral pain
64
Raccoon eyes
Basilar skull fx
65
Lucid interval
Epidural hematoma
| (arteries are outside, arterial bleed)
66
Slow onset, bonk on head, weird behavior, on blood thinner
Subdural hematoma
67
Cushings triad
1) widening pulse pressure (BP up)
2) decreased HR (vagal stimulation)
3) respiratory rate decreased, irregular
Herniation of brainstem
68
c 4
breathe no more
On the vent
69
Quad
Cervical spine
70
Lumbar
Lower legs
71
spinal
sexual function
72
2/5
zero against gravity
73
are steroids used in spinal cord injury?
yes if within 8 hrs of injury
Methylprednisone 30 mg IV bolus
74
Which hemisphere hemorrhagic stroke presents with right hemiparesis, aphasia, dysarthria, difficulty reading/writing
Left (dominant) hemisphere
75
Thromobolytic criteria for ischemic CVA
fibrinoltyic therapy if \<3 hrs onset
76
Goal for ICP with CVA?
Maintain CPP and limit increases in ICP to \<20
77
How to prevent cerebral vasospasm?
Nimodipine (Ca Channel agonist) to counter vasospasm
MAP 110-130 to treat cerebral vasospasm
78
Which type of seizure is common with cerebral lesions?
Simple partial
79
Autonomic dysreflexia
Bladder or rectal stim causing HTN or other syndromes
80
In which disease are steroids contrindicated?
guiliian-barre
81
Central Cord Syndrome
Hyper extension injury with discord between upper and lower symptoms
Can walk across the room but can't shake hands
82
Mini-Mental status exam pneumonic
O rientation to place and time
R egocnition (3 objects)
A ttention (7's backward)
R ecall (recall the 3 objects 5 min later)
Language
2 identify 2 names of objects
3 Follow 3 step command
R eading a statment and doing it without saying it aloud
W riting a sentence
D rawing a design (copy)
83
MMMS exam scoring
Max 30
No impairment 24-30
Delerium/Dementia or both: 18-23 mild, 0-7 severe
84
Hemianopia
1/2 visual field loss
85
CPP= MAP-ICP
86
Drug of choice to prevent/counteract vasospasm in CVA?
Nimodipine (CCB)
87
Eventual capabilities in SCI by level
C4 breathe no more
C1-T1: Quadraplegia, may have use of arms
T1-L1: Paraplegia
T9-L1: May eventually ambulate
L1-L2: bowel and bladder
If S2-S4 involvement, may have sexual dysfunction
88
Myerson's sign
Parkinson's -
tapping over bridge of nose produces sustained blink response
89
Dementia Pneumonic
D- Drug reaxn
E- Emotional disorder
M- Metabolic/endocrine
E- Eye/ear disorder
N- Nutritional problem
T- Tumors
I- Infxn
A- Atherosclerosis
90
91
\*Most common cause of dementia
\*acetylcholine deficiency
ACNP Certification
flashcards
Decks in class (17)
# Cards
-
Heme-onc45
-
Neuro91
-
Cardiovascular68
-
Pulmonary110
-
GI59
-
Immunology/ Misc34
-
GU/Renal/STD's80
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Antibiotics25
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Shock states/Hemodynamics59
-
Risk Assessment61
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Herbal agents20
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Issues, Trends & Health Policy118
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Endocrine102
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Cultural considerations22
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Common Problems43
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Gero considerations14
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Test questions61
