Neuro Flashcards

Question

management of ICP

Answer 1

1. Eval ABCs and etiology: avoid hypoxia and hypercarbia 2. Increase venous drainage * elevate head 15-20 degrees if hemodynamically * ensure no venous obstruction (esp if C collar in place) 3. diuretics * admin mannitol: (reduces ICP by osmotically shifting fluid from brain to intravascular space, decrease production CSF, induce reflex cerebral vasoconstriction 2/2 decreasing blood viscosity(lasts 6 hr) * risktransient increase intravascular volume can increase BP & decrease ICP (increase transmural pressure): hazard to unrupture aneurysm, AVM, expanding hematoma (mod elevated ICP can serve to tamponade the lesions * elderly: rapid diuresis shrink brain and tear bridging veinssubdural hematoma * increase vascular volume poorly tolerated by HF * cerebal edema if BBB not intact * furosemide * keep in mind that in presence of hypovolemia this an lead to hypotension and worsen cerebral ischemia * hypertonic saline 4. admin barbiturate/propofol (reduced ICP 2/2 cerebral vasoconstriction) and CMR02 * risk of hypotension when admin large doses for cerebral protection 5. hyperventilation to PaC02 25-30 if other methods unsuccessful and ICP elevation was so severe that there was risk of brain stem herniation * too much cerebral vasoconstriction can leadto cerebral injury * effects temporary (6-12 hrs) since Hc02 levels in CSF are adjusted for the change in PaC02 * between Pac02 20-80 CBF changes 1ml/100g per 1mmHg change PaC02 6. If ICP severe requires immediate tx: intraventricular drainremove CSF (no more than 5cc/min). * Too much can cause brainstem herniationHTN/hypotension/bradycardia/tacycardia * if lumbar catheter can cause herniation if obstructive hydrocephalus (obstruction proximal to superior sagittal sinus 7. steroids if brain tumor for vasogenic edema, decrease CSF production? 8. if at risk for seizures implement seizure ppx to avoid increases CMR02

Answer 2

ventricular collapse ruptured cortical veins excessive CSF shunting occurs w brain growth leading to irreverisbly collapsed ventricles (brain grows to fill empty ventricle). **noncompliant venticle** place pt at increased risk for herniation due to i**nability to compensate for changes in intracranial volume** (avoid agents that can cause cerebral edema)

Answer 3

Anesthesia: rhabdo to succ/volatiles, sensitive to resp depressants cards: EKG ab (tachycardia, tall R waves in V1, Q waves in limb leads, inverted T waves), cardiomyopathy, arrthymias, MR resp: ineffective cough/dimished airway refexes (aspiration, infections), macroglossia, GI; delayed gastric emptying

Answer 4

R sternum between 2 and 4th rib

Answer 5

awareness/pain **extubated, dislodgement of lines/surgical equiptment** **air embolism** w vigorious inhalation

Answer 6

- alert surgeon - ensure not change in dept of anesthesia (prop, volatile, relaxant) - correct hypoxia, ensure normocarbia, correct hypovolemia, hypotension, anemia, to optimize oxygen delivery - surgical causes- excessive distration - perform wake up test

Answer 7

* Pathophysiology: destruction nicotinic acetylcholine R at post synaptic memebrane * Sx: * bulbar weakness (diplopia, ptosis, difficulty with speech and swallow, dyspnea), muscle weakness with exertion, thyoma * cardiac:HTN, AV block, a fib, myocarditis, cardiomyopathy, dystolic dysfunction * endocrine: hyperthyroid, RA, pernicious anemia, SLE, thyoma * neonate weakness 2-4 weeks

Answer 8

* Consider avoiding anticholinergic drugs increased weakness * Resistant to succ (2mg/kg), sensitive nondepolarizing agents (reduce by ½ or 1/3) * pridostagmine: may prolong succ, may have unsuccesful reversal of NDMB 2/2 acteylcholestase max inhibited * Increased vagal reflexes * **Emergent cases IVIG, plasma exchange** * Succ and mivacurium may last longer in setting of pyridostigamine * MG exacerbation vs cholinergic crisis (recent dose pyridostigamine or reversal of NDMB * Edrophonium test (tensilon test)- improve strength with MG worsen with cholinergic crisis * Watch for signs cholinergic crisis: AMS, weakness, bradycardia, broncorhea, salivation, N/V/D/urinary freq * Intubate, discontinue anticholinesterase, admin anti muscarinic (atropine)

Answer 9

* Scoring system based on eye opening, motor response, and verbal response that has strong **correlation with severity of head injury and patient outcome.** * Severe 8 or less, mortality 35% * Moderate 9-12, mild 13-15

Answer 10

1. No cervical tenderness/pain 2. No paresthesia or neuro deficit 3. Normal mental status 4. No distracting pain 5. Age \>4 6. If not obtained need lateral C spine, odontoid view, anterior posterior from C1-T1, when stable enough CT cervical spine for ligamentous injury

Answer 11

pain, increasing ICP hypoxia, hypercarbia hypovolemia, anemia

Answer 12

50-70 in head injurty 60-70 ICP \<15

Answer 13

neuro: worsening spinal cord injury, **hypothermic** cards: hypotension-spinal shock vasodilation, knock out cardioaccelerator fibers pulm: respiratory inpairment 2/2 **diaphagmatic** impairemrnt, aspiration risk (impaired airway reflexes), **difficult airway** w manual in line heme: DVT, PE (venous stasis)

Answer 14

1. Vasospasm: TCD or angiography (more specific and shows extent and severity of vasospasm) 2. Rebleed- monitor BP 3. Hydrocephalus- ventric drain 4. Seizure-anti seizure meds 5. Increasing cererbral edema 6. CSW, SIADH

Answer 15

flaccid paralysis, loss sensation, spinal reflexes, sympathetic vasomotor tone, temp regulation below level of injury, paralytic ileus,

Answer 16

* AMS H/A,, visual changes, papillaedema, ataxia, focal deficits, cushing triad (HTN, bradycardia, change resp pattern), N/V * CT/MRI: small/slit like ventricles/\>0.5mm midline shift * If ICP monitor measure it directly (intraventricular catheter is gold standard)- ICP measurement, CSF drainage but risks damage to brain, bleeding/infection.

Answer 17

* Utility HUNT HESS Score: correlates with **M&M** * 0 unrupttured * 1-5 ruptured * 1: slight H/A and nunchal rigidity * 2: severe H/A nuchal rigidity + neuro deficits limited to **cranial nerve palsy** * 3: drowsy/confused, **mild focal deficits** * 4: stupor, **hemiparesis** * 5: coma, decrerebrate rigidity

Answer 18

* Hypervolemia, HTN, hemodilution-improve delivery of blood to ischemia areas with impaired autoregulation by increase perfusion pressure and decreasing viscosity * Risks: cerebral edema, increase ICP, pulm edema,

Answer 19

pressure measurements less reliable posterior fossa tumor at increased risk of noncommuncating hydrocephalus (obstruction of CSF outflow)

Neuro Flashcards

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