What is the best continuous sedative drip for intubated neuro patients
Propofol ( diprivan)
What part of the neuro exam is the best indicator of neurological deterioration
Changes in LOC
What are late signs of deteriorating neurological status
Fixed and dilated pupils
Decerebrate posturing
Cranial nerve 3
Oculomotor
EOM pupil constriction
Raises lowers eyelid
Cranial nerve 4
Trochlear
EOM
Down and in
Cranial nerve 6
Abducens
EOM
Lateral gazes
Cranial nerve V
Trigeminal
Sensory of face and mastication and corneals
Cranial nerve 9
Glossopharangeal
Posterior taste buds and innervates pharyngeal sensation
Cranial nerve 12
Hypoglossal
Tongue movements
What is the cerebellar responsible for
Gait and posture
What does the cerebellar exam consist of
Gait and posture
Heel to shin ( drag heel of one foot down the shin of opposite leg looking for uninterrupted contact)
Ataxia ( staggering, unsteady wide gait)
Dysmetria ( inability to control the range of movement in muscle action { past pointing}
Where is c4
At the clavicle
Innervates the diaphragm
Where is t4
At the nipple
Where is t10
At the umbilicus
Brain death testing
Dolls eyes
+ dolls eye is a good sign ( the eyes moves in the opposite direction the head was turned)
If the reflex is negative severe brain stem damage is indicated
Oculovestibular reflex
Infusion of ice cold water into the ear canal of a comatose patient
A intact brain stem will turn the eyes outward and downward from affected ear
A GCS 8 or less indicates what
Comatose
A GCS of 3 indicates what
Unresponsive
Central pain
Tells examiner what level the brain is functioning
Peripheral pain
Tells the examiner what level the cord is functioning
What’s normal ICP
0-15
What is ICP
Pressure within the cranial volt
What is CCP
Cerebral perfusion pressure
What is normal CCP
60-80
How do u calculate CCP
MAP-ICP=CCP
What drain can calculate ICP
EVD
What is Cushing triad
HTN
Bradycardia
Widened pulse pressure
What is criteria for brain death
- Pupils nonreactive ( usually dilated)
- No protective reflexes ( cough, gag, corneals)
- No respirations above what the vent provides
- Core temp 36 degrees Celsius or above
- PACO2 greater than 60
- No movement of any kind to central pain
- On no sedatives, paralytics, or barbiturates
Brain facts
Brain is totally dependent on oxygen and glucose for its metabolism
Receives 750 ml/min blood
Recieves 15-20% of resting cardiac output
Brain is supplied by 2 major arteries
What is a ischemic stroke
Occlusion of a blood vessel
What is a hemmorhagic stroke
Rupture of a blood vessel
What is penumbra
Zone of hypoperfused neuronal cells that are unable to function but remain viable
Located around the injury
What’s a embolic stroke
Clots form elsewhere and travels to brain
Accounts for 15-20% of all ischemic strokes
Where’s the origin of a embolic stroke
Cardiac origin
A fib, decreased heart valves, infectious endocarditis, cardiomyopathy
What’s a thrombotic stroke
Atherosclerosis vessels narrow, the plaque may dislodge
TIAs may precede
What’s the origin of a thrombotic stroke
HTN
Smoking
Diabetes
How do you diagnose a stroke
A CT to rule out hemmorhage is the gold standard ( should be done within 25 min)
CTA to identify acute vascular occlusion
Perfusion CT shows areas of perfusion and penumbra
What’s the gold standard on examining cerebral circulation
Angiography
What may patients with a intercerebral hemmorhagic present with
Lateralized weakness, sensory symptoms, aphasia, visual field cuts
Headaches, vomiting,
Elevated systolic pressure
Coma and / or decreases in LOC
What is care of the intercerebral hemmorhage
Medical priorities to prevent hematoma expansion
Reverse anti coagulants ( vit k, FFP, Factor VIIa
BP management
Maintain CCP above 60 if monitoring ICP
What’s a subarachnoid hemmorhage
Presentation of classic severe headache May have loss of consciousness Unchallenged rigidity or stiff neck Photophobic, photophonic N/V Focal neurologic deficits
How do you diagnose SAH
Cerebral angiography do the gold standard Non contrast CT lumbar puncture MRA CTA to detect aneurysm
What are complications of SAH
Cerebral vasospasm
Hydrocephalus
What med is riven q4 hr to every SAH patient
PO CCB
What are strategies for ICP management
Bed 30 degrees Suctioning 3% NS OR 1.5% NSS if peripheral line Osmotic diuretic Paralytic, sedation Temp control, seizure control hypothermia