Notesale: Turn your study into money

Document Preview

Extracts from the notes are below, to see the PDF you'll receive please use the links above

---

Altered Level of Consciousness
•
•

Comatose – not a neurological problem but a
metabolic
Consciousness – state of self and awareness
// state of awareness on one’s own mental
activity as well as environment

LOC has 3 applications:
1
...
Inner Awareness
3
...
Arousal (RAS) – network; compound of
fibers; state of awakeness
2
...
Reticular Activating System (RAS): a network
of neurons in the brainstem that project
anteriorly to the hypothalamus to mediate
behavior posteriorly to the thalamus; directly to
the cortex for activation of awake,
desynchronized cortical EEG pattern
...
f
...
O
...
Cerebral cortex: gray matter (4-8 mm); gray
colored because it is non-myelinated (no
covering); the brain’s outermost layer of nerve
cell tissue; has a wrinkled appearance from its
folds and grooves; plays a key role in memory,
thinking, learning, reasoning, problem-solving,
emotions, consciousness & functions related to
senses
- Cerebrum: little brain (balance and
coordination)
•

Frontal: decision-making, problem-solving,
conscious thought, attention, emotional and
behavioral control, speech production,
personality, intelligence, body movement

•

•

•

•

Parietal: sensory info(touch, pressure, pain,
position, vibration, temperature) processing,
spatial processing and manipulation – ability
to understand where you are in 3D space,
such as how to navigate around home & town
Temporal: language comprehension, speech
formation, learning, memory, hearing,
nonverbal interpretation, sound-to-visual
image conversion
Occipital: visual processing & interpretation,
visual data collection regarding color, motion
& orientation, object and facial recognition,
depth and distance perception, visual world
mapping
Insula – addiction; center for social emotion

Brainstem: breathing and heart rate
Alexia: inability to comprehend written material
Receptive/Wernicke’s Aphasia: when someone is
able to speak well and use long sentences, but
what they say may not make sense
...

Expressive/Broca Aphasia: where a person may
understand speech but they have difficulty
speaking fluently themselves
...

They often use short phrases and may leave out
small connecting words in sentences
...

 Sensory Areas: receive sensory information
from the senses and environment
- Processing taste and flavor – gustatory cortex
- Assessing touch, temp, position, vibration,
pressure and pain – somatosensory cortex
- Processing hearing info – auditory cortex
- Making sense of visual info & object
recognition – visual cortex
 Motor Areas: involved in voluntary muscle
movement
...
Trapezius Pinch – pinch the trapezius
muscle
2
...
The arms are
bent in toward the body and the wrists and
fingers are bent and held on the chest
...


vertebral arteries then go to the brain stem then
fuse to 1 basilar artery

2 - Decerebrate posture is an abnormal body
posture that involves the arms and legs being
held straight out, the toes being pointed
downward, and the head and neck being arched
backward
...
This type of posturing usually means there
has been severe damage to the brain;
hyperpronation of the hands and plantar flexion

 Akinetic (movement) mutism: with intact LOC
& sensorimotor capacity but with
simultaneous decrease in goal-directed
behavior & emotions; frontal lobe; in wakeful
state of profound apathy, seemingly
indifferent to pain, thirst, or hunger
 Alterations in Arousal
1
...
Vascular causes – Cerebrovascular
accident (CVA) aka stroke
3
...
Trauma – car accidents; increased ICP
5
...
Degenerative – Parkinson’s &
Huntington’s disease
 Metabolic – altered LOC; cerebral
hemisphere: very sensitive; diabetic
ketoacidosis; CHLC
1
...
Electrolyte imbalance (hyponatremia /
hypocalcemia): low sodium (135145mm/L); blood volume expansion
3
...
Drugs: overdose
5
...

Decorticate rigidity occurs when lesions occur in
the cortical white matter, internal capsule,
thalamus, cerebral peduncle, and basal ganglia
...

1 – flaccid (medulla oblongata damaged);
Endotracheal & Tracheostomy Tube
Coma: total absence of awareness (2-4 weeks)
Pseudocoma: the term used for a patient feigning
a comatose state, however it is sometimes also
used for conditions like locked-in syndrome
where patients may involuntarily appear
unconscious but are actually self-aware
...

- 3 & 4 midbrain
- 5, 6,7, 8, & 9 pons (brain stem)
- 5, 9, 10, 11, & 12 medulla oblongata
- Retina of eye CN 2 – sensory for vision
- Opthalmoscope: swelling of the optic disc
(early sign for increased ICP)
- Roving: movement; oculocephalic/doll’s eyesdon’t do if there is cervical fracture; open
eyes, move head upward, eyes go down
...
The three cranial nerves that
affect eye movements are the third, fourth,
and sixth cranial nerve
...

*A paresis refers to the incomplete paralysis of a
skeletal muscle, as opposed to a plegia, which
means complete paralysis
...

- use of penlight; atropine sulfate (drug used to
block nerve stimulation of muscles and glands
and relax smooth muscles); if reactive, CN III is
intact (constriction of the pupil)
- DTR: deep tendon reflexes

1+: hyporeflexia - a symptom in which your
skeletal muscles have a decreased or absent
reflex response
...

4+: hyperreflexia with clonus - Clonus is a
rhythmic oscillating stretch reflex that is related
to upper motor neuron lesions
...
Testing for clonus is performed as
part of the neurological exam
...
Airway: maintain patency

-Cranial valve: CSF 10% + Blood 12% + Brain
Tissue 78% = total volume of 1,500 - 1,900 mL
(100%)

-

-

-

Side lying position: drain secretions to
prevent aspiration; tongue won’t obstruct
airway
Oral airway if tongue is obstructing
Prepare ET insertion: if unconscious, there is
already problems in breathing
Suction PRN
Check RR, depth q 1-2h: complications for
the unconscious could be pneumonia, deep
vein thrombosis may lead to pulmonary
embolism; if unconscious, less expansion of
the lungs
Auscultate breath sounds for crackles,
rhonchi: too much water in lungs, meaning
there is less circulation which leads to
pneumonia; suction side, down, and up

B
...
Fluid & Electrolyte Balance/Nutrition
-

-

5

Adequate cardiac output should have
adequate fluids and electrolytes like sodium
Monitor sodium, potassium, magnesium,
and calcium to ensure the patient has
adequate oxygenation to the brain
IVF, NGT feeding as ordered
MIO
Check hydration status skin turgor, mucous
membranes
Mouth care to keep mouth moist, clean &
intact
After 3 days of deep comatose, emergency is
settled, ensure that the patient will eat

*because of this volume, there is intracranial
pressure
-The skull is composed of 8 cranial bones, 14
facial bones, when a person becomes an adult,
there is fusion on both cranial and facial bones
-CSF is also a protection for the brain which
secreted by the choroid plexus in the lateral
ventricles of the brain; this will provide caution in
cases of injury
Factors affecting the balance of pressure
inside/homeostasis of the cranial vault

-

-

-

1
...
Venous Pressure
Any obstruction of the venous flow of blood
back to the heart (example), the volume will
increase and won’t be able to drain thru the
jugular vein

-

-

-

-

-

-

-

-

Venous drainage flow from the brain thru the
jugular vein
If there is tumor in the mediastinum, where
the superior vena cava is located, this can
cause obstruction and will hinder the flow of
venous circulation back to the heart, then the
pressure in the brain will increase
3
...
Temperature
Timeframe to lower temperature in 30
minutes to 1 hour; we will not stop sponge
bath until the temp goes down
If the brain has a high temperature inside, it
could cause vasodilation; and if the blood
vessels will dilate, the volume of blood will
increase inside, so if the volume of blood
increases, this will affect the pressure inside
and the flow of blood is slow: meaning
oxygenation delivery is decreased
Vascular constriction (Vasoconstriction)
causes the pain when we are having
headache when we have fever
5
...
Posture
Normal posture should be standing

-

-

According to the Monro-Kellie Doctrine, the brain
is enclosed to a rigid skull and is compared to a
closed box, there is no more room for expansion
And if there is an increase volume in the 3
components of the brain (CSF, blood, and brain
tissue), the other one will compensate, however
compensation is very limited because the skull is
very rigid
...
Get BP (120/80)
2
...
If MAP is 50, the BP is low – the blood vessels
will start to dilate
4
...
Allowable constriction is only at 150
MAP = DBP (80mmHg) + SBP (120mmHg) – DBP
(80mmHg) ÷ 3 = 93
...
The patient must
breathe in 2 minutes
In 2 minutes without oxygenation to the brain,
metabolism there will stop
...
Elastance – refers to the stiffness of the
brain
2
...

Has lower compliance (less able to expand)
Increasing elastance (there is now increasing
stiffness of the brain
 Stage 3 (severe manifestations stage)
Patient is now in critical condition
Increased elastance (brain is now stiff)
Decreased compliance (less able to expand)
Patient may die
 Stage 4 (very serious stage)
Patient may die
Increase ICP to terminal levels because we
now have the shifting of the brain (brain
herniation)

-

The increase buildup inside the cranial vault,
will move the other structures inside the
brain aka HERNIATION

Cause of ICP Increase
1
...

It's a life-threatening condition that causes
fluid to develop in the brain; no more grooves
2
...

3
...
Infarcts (death cell): if there is a clot, there is
blockage, the portion perfused by the medial
cerebral artery is not oxygenated and
therefore can cause death of the cell; spaceoccupying lesion (ischemic type of stroke) and
so stroke can likewise cause an increase ICP
a
...
Subdural Hematoma / Hemorrhagic / rupture
of the blood vessel
- Both hemorrhagic and ischemic type of stroke
may cause increase in ICP
- Case of a ruptured blood vessel which
occurred at the subdural meningeal layer of
the brain
- Protection of the brain:
o Skull (8 cranial & 14 facial bones)
o Cerebrospinal Fluid (CSF)
o Blood Brain Barrier (BBB)
o 3 MENINGES / MENINGAL LAYER:
▪ Dura Mater
▪ Arachnoid
▪ Pia Mater
- Bridging veins may rupture
- Acceleration of the brain (it moved forward)
so the impact will blow back the brain and
there is deceleration of the brain

-

-

With these movements inside, it may cause
the rupture of the bridging veins that is going
thru the dura mater and it can snap
And this will cause the formation of subdural
hematoma
Slow formation of the subdural hematoma
because it is venous in origin
Hematoma is also considered as a spaceoccupying lesion
Subdural Hematoma is divided into 3:
o Subacute subdural hematoma - a
hematoma that evolves from an acute
SDH within 4 to 21 days of head injury
o Acute subdural hematoma - acute
subdural hematomas are less than 72
hours old and are hyperdense
compared with the brain on computed
tomography scans
...


*space-occupying lesions: infarcts, hematoma
6
...
Hydrocephalus: cause the obstruction of the
flow of cerebral fluid through the ventricles of
the brain
- There is a buildup of CSF in the hollow spaces
inside the brain
- The flow is continuous of CSF from the
ventricles of the brain into the subarachnoid
space and will be absorbed by the venous
circulation
- How much of the CSF is reduced every day?
o 500mL but some are reabsorbed
o Net is 125mL – 150mL
- It is a clear fluid
- The one that is secreting CSF is the choroid
plexus in the lateral ventricles of the brain;
CSF flows from the lateral to the third
ventricle via the interventricular foramina
8
...
Gamma Knife: directly to the tumor cells
to kill these cells
- While killing the tumor cells, it will also
manipulate the brain tissue just like
intracerebral surgery

9

-

Watch for signs of increased ICP because
there might a rebound cerebral edema

PATHOPHYSIOLOGY

COMPLICATIONS
-

1
...
Brain Herniation:
Cingulate/Subfalcine herniation: you can see
this in CT scans; herniation occurs below the
falx cerebri
o Structures in the middle is part of the
diencephalon like basal ganglia,
internal capsule, thalamus
o The movement is going down because
there is a hole at the foramen
magnum at the base of the brain
o Movement at the cingulate gyrus to
the other side of the cerebral
hemisphere
Transtentorial/Central: if these structures will
move down, traversing the tentorium
cerebelli this is called Transtentorial
herniation
o Movement coming from the center,
then downward traversing the
tentorium cerebelli
o DOWNWARD, CENTRAL
Uncal/Lateral: movement at the structure at
the side
o LATERAL

-

Tonsillar Herniation: at the tonsils
Thick layer of dura mater:
o Falx Cerebri: divide and holds down
the cerebral hemisphere;
o Tentorium cerebelli: it forms the roof
of the cerebellum; protects the
cerebellum from the weight of the
cerebrum (biggest part of the brain)
- Subdural hematoma pushes the other
structures into the other side of the brain
especially at the level of the cingulate gyrus
A
...
Change in LOC
o Related to impaired cerebral blood
flow (CBF) affecting cerebral cortex &
RAS
o Falling score GCS <7
▪ 1-1-1 (GCS of 3) = Deep Coma
▪ GCS of 8/7 = Light Coma
o Early behavioral changes:
▪ Restlessness (initial sign),
irritability, drowsiness,
confusion, apathy
o Difficulty/Inability to follow
commands
o Change in response to painful stimuli
o Difficulty/Inability in verbalization or
responding to auditory stimuli
2
...

Cushing's triad consists of bradycardia (also
known as a low heart rate), irregular
respirations, and a widened pulse pressure
...
Cheyne-Stokes respiration
- Retention of CO2
- Diencephalon to midbrain
- Hyperventilation with Apnea
2
...
Apneustic breathing
- Very long inspiratory, long expiratory
- Already at pons
4
...
Ataxic
- Very irregular breathing
- At medulla oblongata
3
...
Metabolic – reactive to light; no damage
to CN III
2
...
Tectum – (midbrain) rhythmic constriction
and dilation of the pupil when you
examine the eye; large; “fixed at the
middle” hippus
4
...
Midbrain – fixed at the middle; fixation of
the two pupils in the middle; large
(midbrain compression) CN III
involvement
6
...
Medulla Oblongata – marked dilated,
fixed, patient is almost dead – full blown
pupil
4
...
Extension posturing (decerebrate rigidity)
- Compromised oxygenation at the level of the
midbrain and the pons while the corticospinal
tract is passing through brain stem
B
...
Other changes
- Headache early in the morning: patient after
a head injury, we observe after 24-48 hours
and assess for ICP increase, including the
question, “Sir, gasakit imo ulo?”
- Projectile vomiting: no precedence of nausea;
vomiting center of the brain: medulla
oblongata
- Corticospinal Babinski: upper motor neuron;
abnormal reflexes may be present like:
grasping, chewing, sucking especially if
patient is delirious (2nd stage of ICP increase)
- Seizure: tonic and clonic phase; seizure
threshold describes the minimum intensity of
a stimulus required to induce a seizure
...
Establish and Maintain airway, breathing
and CPR cardiopulmonary resuscitation
(ABC)
o Assist with ET or tracheostomy- for
adequate ventilation
o Maintain on mechanical ventilator
o Monitor ABG – guides O2 therapy
o Pulse oximetry – O2 sat – 100%
• Assist with hyperventilation with
volume respirator (PaCO2 <25 mmHg)
– constriction of cerebral blood
vessels, reducing CBF → decrease ICP
• Avoid hypoxia
▪ Maintain PaO2 100 mmHg
▪ < PaO2 < 60 → vasodilation →
increase ICP
• Elevate head by 30°
▪ Reduce sagittal sinus pressure
& jugular venous pressure

12

▪

-

Aids in decreasing cerebral
edema
▪ Enhances respiratory exchange
• Prevent abdominal distention
(interfere with respiratory function)
Assist with NGT insertion
• Avoid activities or positions that may
increase ICP
▪ Keep head in alignment with
torso
▪ Avoid hyperflexion or
hyperextension of the neck
▪ Minimize suctioning or other
stimuli that may increase ICP
(e
...
coughing, sneezing,
Valsalva maneuver, rectal
exam)
 5-10 seconds of suction
 Straining defecation –
soften stools
 Increase intrathoracic
pressure impedes
venous return →
increase ICP
2
...
8 as a simpler formula
Normal values: 275 – 295 mOsm/kg (275-295
mmol/kg)
o Monitor complications:
▪ Diabetes insipidus (pituitary
gland produces insufficient
ADH, hence the kidneys make
a lot of urine – severe
dehydration



-

-

-

-

13

Rx – vasopressin,
desmopressin, acetate
 SIADH (Syndrome of
inappropriate
antidiuretic hormone
secretion is a condition
in which the body
makes too much
antidiuretic hormone
(ADH)) – dilutional
hyponatremia →
cerebral edema →
changes in LOC →
seizures → coma
 200 cc per hour –
polyuria in two
consecutive hours
o Many retention of fluids
▪ Dilutional hyponatremia
▪ Osmotic diuretics (mannitol)
3
...
Protection from injury
Use restraints judiciously
Seizure precaution; minimize environmental
stimuli
5
...
Treat fever aggressively – increased CBF
and cerebral blood volume → increase ICP
7
...
will sleep
Osmotic diuretics – draw fluids towards
plasma
o Mannitol (Osmitrol), glycerol & urea

▪

-

-

-

Crystalize at room temp;
hulom in warm water – given
at soluset
▪ 100 mL every 6 hours – given
by IV – attached to a flow
meter
▪ Increase plasma osmolality
▪ Enhanced flow of water from
tissues including the brain and
CSF
▪ Into interstitial fluid & plasma
* watch for urine output
▪ Decrease cerebral edema,
elevated ICP, and CSF volume
& pressure
Loop diuretic: single does; check BP
o furosemide (Lasix)
Anticonvulsant: long term therapy seizure
(Lipakote)
o phenytoin Na (Dilantin) – good oral
hygiene (can cause gingival
hyperplasia
Antiulcerants
o Proton pump inhibitors
(PPI)/histamine H2 receptor
blockers/antacids – omeprazole,
ranitidine
Neuroprotectant
o Citicholine
Stool softeners
o senna

UBD 2023



---