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Neurology

Neurology. The Skull. The brain’s protector. The Skull. Made of 8 irregularly fused bones. Smooth on the outside, folds and ridges on the inner surface. The Cranial Vault. Foramen magnum. The Brain (80%). Increased Brain Volume. Mass. Cerebral Swelling.

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Neurology

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  1. Neurology

  2. The Skull The brain’s protector

  3. The Skull Made of 8 irregularly fused bones Smooth on the outside, folds and ridges on the inner surface

  4. The Cranial Vault

  5. Foramen magnum

  6. The Brain (80%)

  7. Increased Brain Volume • Mass • Cerebral Swelling

  8. Normally about 750cc of circulating volume 20% of the Cardiac Output Blood (10%)

  9. Increased Blood Volume • Hemorrhage • Vasodilatation

  10. Cerebrospinal Fluid (10%)

  11. Increased CSF Volume • Hydrocephalus

  12. Intracranial Pressure (ICP) • The pressure exerted by the brain tissue, intracranial blood, & CSF

  13. Normal ICP0-15 mm Hg

  14. Dura Mater Tough Mother

  15. Double layered Inelastic, fibrous membrane Holds the brain in place Dura Mater

  16. Epidural Space • Space that is directly above the Dura • Middle Meningeal Artery is present here

  17. Epidural Hematoma

  18. Subdural Space

  19. Cerebral lobes

  20. Frontal lobe Impulses Movement

  21. Frontal lobe Personality Spoken Language

  22. Parietal lobe Touch Understanding Sight Understanding

  23. Parietal lobe Distance and Position to Objects

  24. Temporal lobe Hearing Written Words Memory

  25. Controls Balance

  26. Damage Causes Ipsilateral Movement

  27. Brainstem Pons Mid Brain Medulla Oblongata

  28. Neuro Assessment

  29. Down and Dirty • ABC’s First • Quick History • LOC • Vital Signs • Pupils • Early or Late? • Early: restlessness, disorientation, lethargy • Late: Increase BP, pupillary changes, seizures

  30. Assessment • GLASGOW COMA SCALE • Best Eye Opening • Best Verbal Response • Best Motor Response

  31. Best Eye Opening • Spontaneously-4 • To Verbal Command-3 • To Pain-2 • No Response-1

  32. Best Verbal Response • Oriented, Converses-5 • Disoriented, Converses-4 • Inappropriate words-3 • Incomprehensible sounds-2 • No Response-1

  33. Best Motor Response • Obeys Commands-6 • To Pain • Localizes Pain-5 • Flexion Withdrawal-4 • Abnormal Flexion-3 • Abnormal Extension-2 • No Response-1

  34. Glasgow Coma Scale Pediatrics • Verbal (2 to 5 years) • Appropriate words or -5 • Inappropriate words-4 • Persistent cries and/or screams-3

  35. Glasgow Coma Scale Pediatrics • Verbal (0 to 23 months) • Smiles or coos appropriately-5 • Cries and consolable-4 • Persistent inappropriate crying and / or screaming-3

  36. Severity of Injury • Mild • GCS Score 14-15 • Moderate • GSC Score 9-13 • Severe • GCS Score 3-8

  37. A desk scores a “3”

  38. Loss of Consciousness“A,E,I,O,U TIPS” • A • Alcohol • E • Epilepsy • I • Insulin (too much, too little) • O • Oxygen (too much, too little) • U • Uremia or other metabolic issues • T • Trauma, toxicity, tumors, thermoregulation • I • Infections, ischemia • P • Psychiatric, poisonings • S • Stroke, syncope or other neurologic / cardiovascular causes

  39. Babinski’s Reflex • Present when stroking of Planter surface of foot causes • Flexing of great toe • Fanning of other toes • Normally present in children <2yo • Presence in >2yo indicates problem in corticospinal tract (nerve path spine to brain)

  40. Abnormal posturing is a late sign of increasing ICP Decorticate Abnormal flexion Decerebrate Abnormal extension

  41. Meningeal Signs • Nuchal rigidity • Stiff neck, pain on flexion • Photophobia • Positive Brudzinski’s • Involuntary flexion of knees/hips when neck flexed • Positive Kernig’s • Unable to straighten leg when hip fully flexed in supine patient

  42. Increased Intracranial Pressure

  43. Intracranial Pressure • Intracranial pressure reflects • Brain • Cerebrospinal fluid • Blood • As intracranial pressure increases, cerebral perfusion pressure decreases • Leads to cerebral ischemia and hypoxia • In a hypotensive patient, even a marginally elevated ICP can be harmful • Adequacy of cerebral perfusion pressure is most important

  44. Increased Intracranial Pressure • Initially -intracranial volume increases-ICP remains stable. • System becomes less compliant, or less able to tolerate increases in volume • Later, intracranial volume cont’s to increase, less compliance will be unable to buffer the increases and ICP will rise

  45. Increased Intracranial Pressure Assessment • Early picture of increased intracranial pressure (IICP) • LOC • Loss of insight • Loss of recent memory • Restless, irritable, uncooperative behavior • Requires more stimulation to get same response • Speech less distinct • Sudden quietness in a very restless patient

  46. Increased Intracranial Pressure Early Increasing ICP Motor function • Usually contralateral to lesion • Pronator drift • Loss of one or more grades on the strength scale • Increased tone

  47. Increased Intracranial Pressure • Early Increasing ICP • Pupils • Sluggish to light response • Usually unilateral • Ipsilateral to lesion • Papilledema or bulging of optic discs • Blurred vision

  48. Increased Intracranial Pressure • Early Increasing ICP • Vital signs • Occasionally tachycardic • Occasional hypertensive swings

  49. Increased Intracranial Pressure • Late Increasing ICP • LOC • Arousable only with deep pain • Unarousable • Motor function • Dense hemiparesis • Abnormal flexion • Abnormal extension • No response (flaccidity preliminary to death)

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