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AHN 572 Neuro 1 Questions With
Complete Solutions
Coup - Correct answer Bruising at direct impact
Countercoup - Correct answer Cranial Contents shift, temporal or posterior
region
Mechanism of Injury : Acceleraiton-Deceleration - Correct answer Coup-
countercoup, where rapid acceleration of head hits directly, then crainial contents stop and shift then decelerate (diffuse injury)
blunt trauma - Correct answer Direct impact
Penetrating Trauma - Correct answer Penetrates into the brain tissue
High velocity trauma example - Correct answer Gun shot wound
Low velocity trauma example - Correct answer Swinging hammer
Coup-Countercoup trauma example - Correct answer Head hitting dashboard
in MVC
3 types of primary head injury - Correct answer 1. Scalp lac
- Skull Fracture
- Brain Injury
Scalp Lac assessment - Correct answer Most common injury,
Get good HPI, Ask about timing of last tetanus shot
Scalp Lac PE findings - Correct answer Profuse bleeding, Apply direct pressure
if no underlying skull fracture,
Monitor what for scalp lac - Correct answer s/s of hypotension & shock:
tachycardia, decreased Urinary Output, AMS
Scalp Lac treatment - Correct answer examine Thoroughly, clean before
suturing. Sutures for face Staples for scalp
5 types of skull fractures - Correct answer 1. simple
- depressed
- compound
- penetrating
- basilar
Simple Skull Fracture - Correct answer No displacement of bone, requires no
specific treatment
Depressed Skull Fracture - Correct answer Fragment depressed into skull
S/S depressed skull fracture - Correct answer asymptomatic : possibly altered
LOC
Treatment of Depressed Skull Fracture - Correct answer Prophylactic antibiotic,
tetanus if needed, seizure precaution and consult neurosurgery
Compound Bone Skull Fracture - Correct answer Bone depressed and in part
is sticking out through the skin
Penetrating skull fracture - Correct answer Object penetrating into the skull and
possibly brain tissue
Basilar Skull Fracture - Correct answer Fracture in the floor of the skull
Treatment for Basilar skull fracture - Correct answer Prescribe prophylactic
antibiotics
Identifying features of Basilar Skull Fracture - Correct answer 1. Raccoon eyes
- Battle's Sign - Mastoid Ecchymosis
- CSF leakage - rhinorrhea, or otorrhea
Testing for CSF lead - Correct answer CSF is high in glucose and sodium, test
for glucose on Accu Chek will be positive.
Subdural hematoma definition - Correct answer Most common type of
intercranial bleed Highest mortality rate Venous bleed and nature caused by injury between the Dura mater in the brain tissue
Definition of acute subdural bleed - Correct answer Develops in minutes to
hours, less than 48
Definition of subacute subdural bleed - Correct answer Bleed developing
between 48 hours and two weeks Need to obtain CT scan and neurosurgery consult
Definition of chronic subdural bleed - Correct answer Developing over the
course of greater than two weeks Need to obtain CT scan and Neurosurgery consult Be careful not to miss diagnosed as dementia
Definition of epidural hematoma - Correct answer Injury resulting in an arterial
bleed between the epidural space and the skull does not cross suture line
Exam findings for subdural bleed - Correct answer Drowsiness, agitation,
confusion, headache, unilateral or bilateral pupil dilation, late hemiparesis
Subdural bleed often mimics what? - Correct answer Stroke
Elderly patients present with subdural bleed in this manner - Correct
answer Headache, memory loss, personality change, incontinence, ataxia
Subdural bleed is Venous or arterial? - Correct answer Venous
Epidural bleed signs and symptoms - Correct answer Loss of consciousness,
lucid interval that progresses into rapid deterioration where patient becomes: Obtunded progressing to coma
Physical exam findings for epidural bleed - Correct answer 1. Ipsilateral pupil
dilation
- Contralateral hemiparesis in hemiplegia
- Looks like an eyeball on CT scan
Epidural bleed is Venous or arterieral - Correct answer Arterial
Develops RAPIDLY
Cushings Triad - Correct answer 1. Widened Pulse Pressure
- Decreased RR
- Decreased HR
Cerebral Perfusion Pressure - Correct answer CPP = MAP - ICP - Normal CPP
is 60- ICP will be given, know how to calculate MAP
Calculate MAP - Correct answer MAP= [SBP + (2xDPB)]/
CO2 goal if ventilated - Correct answer 30-40, do not hyperventilate anymore,
Remember CO2 is a vasodilator - careful with hypercapnia
Identification of epidural bleed (5) - Correct answer 1. arterial, develops rapidly
- Does Not cross suture line
- Loss of consciousness, then lucid with rapid deterioration
- Ipsilateral pupil dilation
- Looks like eyeball on CT scann
Identification of subdural bleed (5) - Correct answer 1. Venous, slower to
develop
- Cross suture line
- Drowsiness, Agitation, or confusion
- Unilateral or bilateral pupil dilation
- Crescent shaped on CT scan
Cerebral edema - Correct answer Buildup of fluid around the brain causing
increased intercranial pressure
Normal ICP - Correct answer 5-
Signs of decompensation with increased ICP - Correct answer Cushing's triad,
altered LOC, amnesia of events, headache, nausea, vomiting, dizziness, posturing
Two types of posturing - Correct answer 1. Decerebrate
- Decorticate
Treatment for patients with increased ICP (7) - Correct answer 1. Consult
neurosurgery
- ICP target 20-
- keep cpp near 60
Signs of Brain trauma patient deteroriating - Correct answer 1. Cushings Triad
- Early Exam Findings -Headache, nausea, Vomiting, EMS, increased respiratory effort, involuntary movements, motor changes, pupilary changes
- Late Exam Findings -Decreased GCS, decreased respirations, irregular breathing pattern, bradycardia, increased SBP
AVPU findings - Correct answer A- Alert
V- Responds to verbal P- Responds to pain U- Unresponsive
GCS (3-15) - Correct answer 15 - normal
12-14 - mild 8-11 - moderate <8 - comatose, poor prognosis
Importance of pupils in increased ICP - Correct answer 1. Very sensitive to
changes in pressure inside the skull
- Dilated, unresponsive pupil usually indicates significant head injury
Importance of vitals in increased ICP - Correct answer 1. Unusual And
unexpected vital signs occur commonly
- Low heart rate and high blood pressure common
- Hypotension usually due to bleeding elsewhere
Exam findings in increased ICP - Correct answer 1. Altered LOC, amnesia of
events
- Headache, nausea, vomiting, dizziness
- Posturing indicate brain stem involvement
Hyponatremia in brain trauma - Correct answer Most common electrolyte
abnormality in brain trauma
Causes of hyponatremia - Correct answer 1. SIADH
- Cerebral salt wasting
Treatment of SIADH - Correct answer 1. Restrict Fluid
Use of 3%NS - Correct answer Mobilizes fluid across blood brain barrier
may worsen edema in patients with cardiac and pulmonary issue
Causes of hypernatremia - Correct answer 1. Diabetes Insipidus
- Use of Osmotic (mannitol) & Thiazide diuretics
Mannitol - Correct answer Drug of choice for brain herniation
-creates osmotic gradient that pulls water from CNS
- Monitor Serum osmolarity (goal < 320) -Monitor BP - hypotension -Volume replacement may be necessary to keep euvoliemia
TBI Patients at risk for? - Correct answer DI d/t damage to the pituitary
-monitor labs for high serum NA and high serum osmol (elevated = dry) -Urine will have low specific gravity & Osmol
Treatment of TBI patients - Correct answer 1. Keep good BP and Volume
- Airway -GCS < 8 intubate -Keep Sats > 92% -PaCO2 35-
- Avoid Steroids
- DVT prophylaxis when cleared by neurosurgery
- Seizure treatment- dilantin if < 7 days post trauma
- Early nutrition
Treatment of ICP - Correct answer 1. Maintain ICP 20-
- CSF drainage with ventriculostomy
- Head of Bed > 30 degrees
- Hyperventilate in acute phase, not long term solution
- Opiods for pain
- Paralytics if needed
- Mannitol 0.25-1g/kg, do not give if SBP<
Brain death definition - Correct answer Patient has sustained irreversible
cessation of all functions of the entire brain, including the brain stem. Brain death equals death
Exclusions to Brain death - Correct answer 1. Hypothermia < 32°C
- Drug intoxication or poisoning
- Severe electrolyte, acid base, or endocrine disturbance
- Medical/Surgical complications
- Pedestrian accident
Types of Spinal Cord Injuries - Correct answer 1. Rapid
Acceleration/Deceleration 2.Distraction injuries: results from hanging
- Penetrating Trauma
- Hematoma
- Pathologic Fracture
Types of acceleration/deceleration SCI (4) - Correct answer 1. Hyperextension
- Hyperflexion
- Compression
- Whiplash
Hyperextension SCI - Correct answer Usually a fall on face, forehead, or chin
- Rear end collision resulting in rupture of antherior longitudinal ligament
- may cause cord to stretch, resulting in central cord syndrome
Hyperflexion SCI - Correct answer Greatest stress occurs C5-C6, causing
bilateral facet dislocation
Compression SCI - Correct answer Occurs in driving accidents, usually C1, or
falls where patient lands on feet or buttocks -vertebral body is shattered resulting in a "burst" fracture
Whiplash SCI - Correct answer sudden hyperextension of the spine that
stretches ligaments
Assessment of SCI patient - Correct answer Get a good history
-mechanism of injury -patient complaints -Motor/Sensory Response -Prehospital treatment
Physical Exam - Correct answer Complete within 2-5 minutes
-75% SCI are from secondary injury
ABCDE Trauma Assesment - Correct answer A-Airway
-Blockage, C-spine injury B-Breathing
-tension pneumo, pulmonary edema, bronchospasm C-Circulation -shock D-Disability -Seizure, hypoglycemia, meningitis, intracrainal bleed E-Exposure -hypo/hyperthermia, critical skin condition
Early SCI deaths are because of - Correct answer Respiratory complications
-respiratory paralysis
Motor Assessment for SCI - Correct answer 1. Motor level = last level with 3/
function against gravity
- Grade and assess bilaterally
- inability to perform a function means lesion is above that level
Deep Tendon Reflexs - Correct answer Arm - bicep C
Leg - Paterllar L Achilles - S
Pathologic Reflexes - Correct answer 1. Babinski - upper motor neuron lesion
- Hoffman - upper motor neuron lesion at or above the cervical spinal cord
- Clonus - long standing UMN lesion
Types of lesions - Correct answer 1. Complete - lacks sensory function,
proprioception, and voluntary motor function below level of damage
- Incomplete - parts of cord at site of lesion are intact, perform rectal exam and notice voluntary contractions around finger
Sensory Assessment for SCI - Correct answer -Sensory Level = last level with
preserved sensation -Begin at area of no feeling and proceed up to area of feeling -Injury at area of unfelt pain
- Assess back with log roll -Observe for entry/exit wounds
Respiratory Assessment for SCI - Correct answer 1. Chest Excursion
- Use of intercostal muscles or diaphragm
- Cord injury above C3 will result in respiratory arrest
- Above C4 breath no more
Determine Motor Level - Correct answer Motor Level = last level with 3/
function
Injury at level for - Correct answer Sensory
Injury above level for - Correct answer motor
Dermatome C4 - Correct answer Shoulders
Dermatome C6 - Correct answer Thumb
Dermatome C7 - Correct answer Middle Finger
Dermatome C8 - Correct answer Little Finger
Dermatome T4 - Correct answer Nipples
Dermatome T6 - Correct answer Xiphoid
Dermatome T10 - Correct answer Umbilicus
Dermatome L3 - Correct answer Just above patella
Dermatome L4 - Correct answer medial malleolus
Dermatome L5 - Correct answer Great Toe
Dermatome S1 - Correct answer Lateral Malleolus
Dermatome S4-5 - Correct answer Peri-anal
Findings for C2-C3 Lesion - Correct answer Respiratory paralysis
Flaccid paralysis Areflexia Loss of sensation below the mandible
Findings for C5-C6 Lesion - Correct answer Diaphragmatic breathing
Paralysis intercostal and abdominal muscle
Quadriplegia Anesthesia below the clavicle Areflexia - except bicep reflex Fecal and Urinary Retention Priapasm
Findings for T2-L1 Lesion - Correct answer Paraplegia
Anesthesia in the legs
Findings for L1-L5 Lesion - Correct answer Flaccid paralysis to partial flaccid
paralysis Abdominal & Cremasteric reflexes present Ankle & Plantar reflexes absent
C1-C4 Lesion effects which other organs - Correct answer -Eyes, Neck,
Diaphragm -Inability to breathe, headaches, stiff neck, sinus problems, sore throat, vision problems, hypo/hypertension, bradycardia -Respiratory paralysis, neurogenic shock -Needs ventilator support, fluid resuscitation, vasopressors, and inotropes
C5-C8 lesion effects which other organs - Correct answer -Esophagus, heart,
lungs, chest -Weak respiratory/diaphragmatice breathing, intercostal/abdominal muscle paralysis, hypertension, bradycardia -neurogenic shock -Needs hemodynamic stabilization, fluid resuscitation, vasopressors and inotropes
T1-T4 lesion effects which other organs - Correct answer -Esophagus, heart,
lungs, Chest, larynx, trachea -Difficulty breathing, heart condition, hypertension, bronchitis, pneumonia -May require a ventilator support, not necessarily vent dependent
T5-T10 lesion effects which other organs - Correct answer -Gallbladder, liver,
diaphragm, stomach, pancreas, spleen, kidneys, small intestine, appendix, adrenals, stomach -Call bladder conditions, liver conditions, jaundice, stomach issues - ulcers gastritis, kidney problems -Injury above T6 - Autonomic hyperreflexia: Involuntary nervous system overreacts to external or bodily stimuli -Illuminate stimuli triggering the reaction, empty the bladder and bowels, change temperature -Treat blood pressure and heart rate, PPI for ulcer
-Loss of motor but sensory preservation on ipsilateral side -Preservation of motor but sensory loss on contralateral side
Initial treatment for SCI - Correct answer -immobilize
-Prevent hypotension, dopamine, NOT Neosynephrine -Fluid Resuscitation -Maintain O2, Do not move neck if intubation is needed - Jaw thrust
Hospital management for SCI - Correct answer -NGT to LWS
-Foley -Methylprednisolone (Start within 8 hours of injury or not at all) -Ct Scan - do not give contrast in trauma pt -MRI -Cervical spine clearance -Cervical traction -Surgical decompression and/or fusion
Contraindications for Methylprednisolone in SCI - Correct answer -Cauda
equina syndrome -GSW -Pregnancy -Age < 13 -PAtient on Maintenance steroids
Cervical Spine Clearance - Correct answer -Cleared by ER, neurosurgery, or
orthopedic physician -Criteria include: -Patient awake and oriented -Has no distracting injuries -Has no drugs on board -Is neurologically intact -CT/MRI required if patient is comatose, or has neck pain
Subluxation of C-spine > 3.5 - Correct answer Typically unstable
Cervical Traction - Correct answer -Gardner Wells tongs
-Contraindicated in unstable hyperextension injuries -Start with 3 pounds, do not exceed 10 pounds -C-collar can be removed while patient is in traction
Pin Care for Cervical traction - Correct answer -Clean Q shift with appropriate
solution then apply Betadine ointment -Take x-rays at regular intervals and after every move from bed
Indications for Surgical decompression - Correct answer -Compression of the
Spinal cord/nerves -Stabilizers boney elements
Emergent Surgical Decompression - Correct answer -Incomplete lesions with
progressing neuro deficit
Elective Surgical Decompression - Correct answer -Complete lesion, central
cord syndrome
Long term care for SCI - Correct answer -Rehab for motor function
-Bladder/bowel training -Psychological and social support
Three types of distributive shock - Correct answer 1. Neurogenic shock
- Septic shock
- Anaphylactic shock
Definition of distributive shock - Correct answer Distribution of intravascular
volume is abnormal due to decreased systemic vascular resistance, characterized by decreased capillary integrity and vasodilation
Characteristics of neurogenic shock - Correct answer -Seen in patients with
traumatic quadriplegia, high spinal anesthesia -Hypotensive, bradycardia, hypothermic, decreased CVP, decreased PCWP, decreased cardiac output and cardiac index,Decreased SVR, decreased urinary output
Characteristics of septic shock - Correct answer -Systemic inflammatory
response to the introduction of infection in the bloodstream that alters vascular tone resulting in a relative hypovolemia -Hypertensive, tachycardia, tachypnea, decreased CVP, decreased PCWP, cardiac output an index initially increased, then decreased, SVR decreased, urinary output decreased - late sign
Characteristics of anaphylactic shock - Correct answer -Systemic IgE mediated
reaction that occurs after allergen exposure -Hypotensive, tachycardic, MAP decreased, CVP decreased, PCWP decreased, cardiac output/index decreased, SVR decreased, urinary output decreased
Causes of obstructive shock - Correct answer Cardiac Tampanode, PE,
tension pneumothorax, valvular disease
Characteristics of obstructive shock - Correct answer Hypotensive, tachycardic,
CVP increased, PCWP normal, cardiac output/index decrease, SVR increase, urinary output decreased
Assessment findings of hypovolemic shock - Correct answer -Pale, cool,
clammy -Low SVP, postural hypotension, tachycardia -Poor turgor, flat neck veins -Oliguria -Change in LOC -Macy signs and symptoms of electrolyte in balance, increased glucose
Assessment findings of cardiogenic shock - Correct answer -Cool, clammy
-Hypotensive, tachycardic, may have bradycardia -Oliguria -JVD -Hepatomegaly -Dysrhythmias -Rales
Assessment findings of anaphylactic shock - Correct answer -"I think I'm going
to die", Impending doom -Dyspnea, tachycardic, hypotensive -Pruritis, erythema, angioedema -G.I. complaints, back pain
Assessment findings of neurogenic shock - Correct answer -Same as other
distributive shock, pronounced Neuro deficits -History taking is crucial -Extremities may be warm and dry -BRADYCARDIA -Hypothermia
Assessment findings of septic shock - Correct answer -Warm in early stage
-Warm, flushed, febrile, altered LOC, increased residuals -Cold in late stage -Oliguria, acidotic, edema
Assessment findings and obstructive shock - Correct answer -Consistent with
decreased cardiac output -Rapid progression, initial presentation may be cardiac/respiratory arrest
Management of hemorrhagic shock - Correct answer -Control bleeding or
source of volume loss -Fluid resuscitation start with crystalloids, consider blood products and colloids -PRBC -Insulin and or DDAVP for DI, along with fluids
Management of cardiogenic shock - Correct answer -Stabilize initially
-Supplemental oxygen -Crystalloid if no pulmonary edema -PA catheter, arterial line, Foley -Dobutamine max 40 mcg/kg/min -Dopamine 5-10 mcg/kg/min
Management of obstructive shock - Correct answer -Treat underline cause,
ABCs, fluids, vasopressors, possible emergency surgical intervention
Management of anaphylactic shock - Correct answer -AIRWAY
-Remove antigen -Epi SubQ (.5-1 mL of 1:1000) -Antihistamine, Benadryl, Pepcid -Fluids, pressors as needed
Management of neurogenic shock - Correct answer -Secure airway and spine
-Fluids, pressors, treat bradycardia, treat hypothermia
Management of septic shock - Correct answer -Airway
-Fluids, pressors -Broad-spectrum antibiotics, follow labs -Treat hyper/hypo thermia, nutrition
Shock Stage I - Correct answer No real signs early, high index of suspicion,
need to follow trends
Shock Stage II - Correct answer -Compensatory
-Fight or flight hormonal, volume and energy -Chemical V/Q changes -Blood pressure normal, but MAP decreased -Tachycardic
