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112 Cards in this Set
- Front
- Back
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What are the two characteristics of traumatic brain injuries?
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1. TBI is a major cause of death and a leading cause of disability among young people
2. Most head injuries are incurred in motor vehicle accidents, falls, and sports accidents |
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How is the severity of TBI classified by the GCS score?
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Mild: GCS score 13-15
Moderate: GCS score 9-12 Severe:GCS score 8 or below - Important to verify the levels |
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What are the 3 characteristics of the Glasgow Coma Scale (GCS)?
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1. One of the parimeters in the assessment (electronic or hard copy chart) know what it is measuring and parementers
2. Standardized tool developed for the purpose of assessing LOC (mentation and sensorium) in acutely brain-injured persons |
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What are the two most powerful predictor of patient outcome?
How does the posturing indicate a poor outcome or injury to the brain? |
1. Decorticate posturing, abnormal flexor response
2. Decerebrate posturing, abnormal extension o Its better if we have to force the pt. to go into the posture o Ischemia is so bad that its causing a motor outcome |
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What is traumatic brain injury (TBI)?
What are the 3 types of TBI? |
- When the brain moves (moves vessels and attachements to brain as well)
1. Focal injury(coup) injury 2. Polar (Coup contracoup) injury 3. Diffuse Axonal Injury (DAI) injury: spreading all over, axonal (the long part of the nerve) --> Worst outcome |
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Where does a dural bleed occur?
What causes a herniation? |
- The 1st layer from the skull (at the dura)
- Can occur from both Epidural and subdural bleeds |
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What is an Epidural bleed, what are its characteristics, and what does it result in?
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1. Artery is the source
2. 1 to 2% of bleeds 3. 90% have skull fx 4. Temporal fossa 5. Middle meningeal artery 6. Can result in uncal herniation 7. Quicker and pressure rises quickly |
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What is a subdural bleed, what are its characteristics, and what does it result in?
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1. Venous is the source
2. 10 to 20% of TBI 3. Acute – 48 hrs a. Never know how bad it is because its so slow 4. Chronic – weeks to months 5. Tearing of the bridging veins 6. Acute can result in herniation |
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What are the 5 treatment goals for TBIs?
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1. Decrease swelling:
2. Control hypertension 3. Control bleeding 4. Control pain and anxiety 5. Maintain tissue perfusion |
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What is the medical treatment for TBIs?
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- No specific drug
- Contradiction: Do not use opiets in a pt. with brain injury, we don’t know if the LOC is conscious or not - Need for a narcotic, we must do a burahole to relieve pressure in the brain |
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What are the two worst things that can happen to a brain?
How can the disruption of vasculature result in an intracranial hemorrhage? |
1. Compression
2. Herniation - Any amount of bleeding inappropriate for the specific area of the brain can cause an intacranial hemrrhage |
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At what rate would an intacrainial hemorrhage expand and how would it increase ICP?
What are the 3 types of hematoma can develope? |
- Can expand slowly or rapidly
- Can increase ICP by progressively compressing the brain 1. Epidural 2. Subdural 3. Subarachnoid |
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What is an epidural hematoma, what does it involve, and its rate of onset?
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- Collection of blood between the dura and the skull
- Involves the arterial injury and therefore has a rapid onset of symptoms - Often involves a fracture of the temporal bone with disruption of the middle meningeal artery |
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What is a primary injury?
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- An intacranial hematoma
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What is a subarachnid hemorrhage, where is it, what does it involve, and how can it be tested?
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- A collection of blood between the arachnoid and the pia mater
- Due to the rupture of bridging veins that pass through the subarachnoid space - Blood spreads through the CSF causing meningeal irritation - Tested by giving a patient a lumbar puncture |
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What is a subdural hematoma, what does it involve, where is it located, and what is its onset?
What is the characteristic of subdural hematomas? |
- Collection of blood between the dura and outer layer of the arachnoid membrane
- Involves the bridging membranes (which pull blood into the sinuses) to make sure there is not a sudden loss of pressure, --> symptoms may be slower - Slower onset 24-48 hours - Chronic subdural hematomas may be prone to rebleeding so in order to slow their bleed, they close themselves off |
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What are the 2 examples of secondary injuries and what do they lead to?
What two ways would me monitor a patient with TBI? |
1. Ischemic and hypoxic events
2. Vasogenic/neurogenic edema - Lead to increased ICP and increase LOC - GCS and ICP |
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What are the 4 treatment mechanisms for a patient with TBI?
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1. cardiopulmonary stabilization
2. Radiologic screening to evaluate for emergent surgical management (CT or MRI) 3. Interventions dependent on the severity of TBI and the condition of the patient 4. Maintenance of body temperature or mild hypothermia, normal PaCO2, normal serum glucose level, and normal intravascular volume |
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What does it mean if a patient with TBI is hypothermic?
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- Indicates that the patients brain has been affected in the center which controls the vital signs
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What is a stroke?
What is the most common form of a stroke and can patients recover? |
- a sudden onset of neurologic dysfunction due to cardiovascular disease that results in an area of brain infarction (a event that stopped the blood flow to the area and the whole area that was there has been injured may not recover well but people can recover) stopped the delivery of O2 to the area
- Most common form is ischemic |
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What is a ischemic stroke?
What is a thrombotic stroke? What is an embolic |
- A hypoxic event; a result from a sudden occlusion of cerebral artery secondary to thrombus formation or emboli and may occlude one of the major arteries
- Thrombotic stroke is associated with atherosclerosis and coagulopathies - Embolic strokes are associacted with cardiac dysfunction or dysrhythmias |
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What is the treatment for an ischemic stroke?
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- Salvaging the penumbra is the aim of early thrombotic therapy, although treatment must be instituted w/in 3 hours of symptom onset to be maximally effective (a very short window to recognize symptoms)
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What is a hemorrhagic stroke, where does it occur?
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- A hemorrhage w/in the brain parenchyma
- Usually occurs secondary to severe, chronic, hypertension - Must occur in basal ganglia or thalamus - An injured thalamus can cause an interruption of the communication symptoms of the body |
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Which type of stroke has the highest degree of secondary injury and associated morbidity and mortality?
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- Higher in hemorrhagic stroke than in ischemic stroke
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What are the 3 treatments done for a stroke?
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1. Assessment started with a large bore needle
2. Cardiovascular stabilization 3. Brain CT determines the type and location of stroke |
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What is the treatment for an ischemic stroke?
What is the treatment for a hemorrhagic stroke |
- Treatment aimed at minimizing infarct size and preserving neurologic function
- Blood pressure management, ICP monitoring and management |
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What are the motor and sensory deficits associated with stroke sequelae?
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- Initially motor deficits occur as flaccidity or paralysis; recovery of motor function occurs with onset of spasticity (can lose the motor responses)
- Active/passive range of motion exercises should be started in acute phase of recovery - Intensive rehabilitation commonly required - Sensory disturbances occur in the same location as motor paralysis and may involve neglect or visual impairment |
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What are the 3 language deficits that occur with stroke sequelae?
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1. Aphasia (inability to speak) occurs with brain damage to the dominant cerebral hemisphere and can involve all language modalities
2. Broca (area of the brain) aphasia (verbal motor/expressive) consists of poor articulation and sparse vocabulary 3. Wernicke (area of brain) aphasia (sensory, acoustic, receptive) characterized by impaired auditory comprehension and speech that is fluent but does not make sense |
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What are the 3 cognitive deficits that occur with a stroke sequelae?
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1. Area of the brain affected dictates the presence and severity of cognitive impairments
2. Evidenced as language impairment, impaired spatial relationship skills and short-term memory, and poor judgment 3. May require rehabilitative services |
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What are the characteristics of cardiovascular accidents and how will they affect the health care system in the future?
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-3rd leading cause of death
-Leading cause of disability - Massive impact on the health care system, acutely affected pts will be cared for in the hospitals, others will be cared for in the community |
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What are the 5 types of stokes?
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1. Thrombotic (clot and its fixed)
2. Transient ischemic attacks (comes and it goes, ischemia determines how bad it is) 3. Embolic (traveling) 4. Hemorrhagic 5. Lacunar (looking at a specific disruption of the vascular system) |
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What are the 3 pathophysiologies of strokes?
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1. Loss of perfusion equals cerebral ischemia
2. Either from occlusion or bleed 3. The area of the brain affected most commonly occluded is the middle cerebral artery and its branches |
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What are the 8 clinical manifestations of a stroke?
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1. Cortical Motor: Contralateral (opposite side), hemilegia (half the body is paralyzed) or paresis (weakness) of face, arm or leg
2. Cortical Sensory: contralateral loss of sensation 3. Broca dominant or non dominant:anomia (recall the use of everyday objects), aphasia (difficulty speaking), dysarthria(unclear articulation of speech due to the muscles) 4. Vision: Contralateral hemianopsia (half the visual space) or quadranopsia (quarter of the visual space) 5. "time is brain": 6 hour window to treat 6. Drug Therapy: designed to prevent further events; increase blood flow, reperfuse tissues, and protect neurons 7. Control of preexisting risk factor: plaque formation 8. Rehab |
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What is one of the biggest risk factors that can lead to hemmoragic stroke?
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- Hypertension
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What is meningitis?
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- an infection and inflammation of the meninges, which surround brain and spinal cord
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What are the characteristics of bacterial meningitis?
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1. The infection stems from another part of the body
2. One hopes for for a fever but it may not occur 3. More dangerous than viral 4. Meningencoccal vaccine given 5. Bacteria are usually common inhabitants of the nasopharynx |
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What are the two microbes that cause bacterial meningitis?
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1. Neisseria meningitidis
2. Streptococcus pneumonia |
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Which of the 3 TDI's is the worst?
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- Diffuse because it spreads across the axon of the neuron
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Which is the most common artery in a epidural bleed?
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Middle Meningeal bleed
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What is an Uncal herniation?
What is Central tentorial herniation? |
- A type of tentorial herniation that typically occurs with expanding lesions in the temporal lobe.
- Results from expanding lesions in the frontal, parietal, and occipital lobes that force a downward displacement of the hemispheres and basal nuclei with compression of the diencephalon and adjoining mid brain. |
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How is a hemorrhagic stroke treated?
What are the two treatments for ischemic strokes? |
-anti hypertinsive
- Anticoagulants and antithrombolitics |
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Lucunar strokes are related to which to diseases?
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- hypertension and diabetes
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What are the 3 causes of viral meningitis?
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1. Herpes simplex I
2. Adenovirus 3. Coxsaxkievirus 4. Mumps |
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How does bacterial meningitis occur?
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- The presence of infection in bacteria become a toxin and irritate through inflammation in the choroid plexus to enter the CNS and induce the inflammatory response in the meninges, CSF, and the ventricles.
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What is the result of the inflammatory response in bacterial meningitis?
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- Response increases ICP, disrupting blood flow, and potentially producing aseptic thrombus
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What 3 symptoms result in meningeal irritation?
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1. Severe headache
2. Photophobia 3. Nuchal rigidity |
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What are the neurological signs of bacterial meningitis?
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1. Decreased LOC (sensorium or mentation)
2. Cranial nerve pasies 3. Focal deficits |
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What is the difference between meningeal irritation and hemorrhagic stroke?
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The presentation of the patients face, stroke will have a droopy face, meningeal irritation-headache photophobia, nuchal rigidity
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What are the 3 evaluations of a patient with meningitis?
What are the treatments for a patient with meningitis? |
1. physical exam
2. Smears of nasopharyngeal, antigen test 3. Lumbar test 1. Antivirals, and steroids if it is a viral onset 2. Rifampin if its meningococal 3. bacteria are treated with the appropriate antibiotic |
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What is stage 1 in hemostasis?
What is stage 2 in hemostasis? |
- Formation of platelet plug and platelet aggregation
- Coagulation: intrinsic and extrinsic coagulation pathways |
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What is the goal of coagulation?
What is the result of a blood vessel injury? |
- Keeping hemostasis under control, the physiologic removal of clots
- Vasoconstriction |
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What are the 3 major drug classifications for thromboembolic disorders.
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1. Anticoagulants: Stop the clotting cascade (heparin)
2. Antiplatelets: Slow the platelet activity or make them less sticky (asprin) 3. Throbolytics: Interferes with the plasmin/plasminogen formation (TPA: steprokinase) |
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What is the major mechanism of anticoagulants?
What are the two mechanisms of action for anticoagulants (fibrin 10-10a)? |
- To reduce the formation of fibrin
1. Inhibit the synthesis of clotting factors (thrombin III) 2. Inhibit the activity of clotting factors |
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How does Heparin (Unfractionated) act in the body?
What are the sources of heparin? |
- Trying to mimic what the naturally occurring heparin does in the body
Sources: 1. Lungs of cattle 2. Intestines of pigs - We worry that it may cause a hypersensitivity reaction - Enhances antithrombin |
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What is the action rate of heparin (Unfractionated)?
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- Rapid acing anticoagulant
- Administered by injection only - IV: Continuous or intermittent - Deep Sub Q |
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What are the 3 adverse effects of Unfractionated Heparin?
What are the 3 contraindications of heparin? |
1. Hemorrhage: heparin may work too well
2. Heparin-induced thrombocytopenia 3. Hypersensitivity reactions Contraindications: 1. Thrombocytopenia (petichea which can lead to throbocytopenia) 2. Uncontrolled bleeding 3. During and immediately after surgery of the eye, brain, or spinal cord |
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What is the antidote for heparin?
What lab is used to monitor heparin? |
1. Protamine Sulfate
- Activated partial thromboplastin time (aPTT) |
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What are the 9 therapeutic uses for heparin Unfractionated?
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1. Preferred anticoagulant during pregnancy and when rapid anticoagulancy is required
2. Pulmonary embolism (PE) 3. Stroke evolving - Very carful because we don’t want to make them bleed 4. Massive deep venous thrombosis (DVT) 5. Open-heart surgery 6. Renal dialysis 7. Low-dose therapy postoperatively - Less movement want to make sure that you don’t develop clots 8. Disseminated intravascular coagulation (DIC) 9. Adjunct to thrombolytic therapy |
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What is low molecular- weight heparin composed of?
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- Composed of molecules that are shorter than those found in unfractionated heparin
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What are the 3 therapeutic uses of heparin?
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1. Prevention of DVT following surgery
2. Treatement of established DVT 3. Prevention of ischemic complications - Patients with unstable angina, non-Q wave MI, and STEMI |
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How is heparin administered and what is the dosage based off of?
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- Administered Sub-Q: absorbed faster than IM, using a shorter needle, and given at a 45 degree angle
- Dosage is based on body weight |
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What are the three difference between unfractionated heparin and low molecular weight heparin?
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- Low molecular weight costs more than unfractionated heparin
- Low molecular weight heparin does not require monitoring and can be given at home - Unfractionated can be given to pregnant women because it has a larger molecular size |
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What are the 3 adverse effects and interactions of unfrctionated heparin?
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1. Bleeding (less than unfractionated heparin)
2. Immune-mediated thrombocytopenia 3. Severe neurologic injury for patients undergoing spinal puncture or spinal epidural anesthesia |
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What lab must be monitored for patients using heparin?
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- Activated partial thromboplastin time (aPTT)
:Signs of blood loss :Platelet count --> Very important to monitor prior to getting on medication - Vital signs - Excretion (for bloody or tarry stools) |
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What are the differences between warfarin and heparin?
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- mechanism
- Time course - indications - management of overdose |
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What is the mechanism of action for Heparin?
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- Activate antithrombin which inactivates two major clotting factors
1. Thrombin 2. Factor Xa - Binding to antithrombin causes a conformational change in antithrombin which greatly increases its ability to interact with factor Xa and thrombin |
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What are the differences in laboratory monitoring between unfractionated heparin and low-molecular weight heparin?
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- Unfractionated heparin requires aPTT monitoring
- With Low-Molecular weight Heparin no aPTT monitoring is required |
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How does the setting for use very between unfractionated heparin and low-molecular weight heparin?
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- Unfractional Heparin: must be done in the hospital setting
- Low molecular weight Heparin can be administered at home or in the hospital |
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How was warfarin created?
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- Originally discovered observing cattle ingesting spoiled clover silage
- Used as rat poison - Failed suicide attempt with large dose brought renewed clinical interest |
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What are the 3 clinical uses of Warfarin?
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1. Oral anticoagulant with delayed onset: wont be destroyed by gastric acids
2. **Vitamin K Antagonist 3. Blocks the biosynthess of factors VII, IX, X and prothrombin by blocking the common pathway |
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What is the onset of warfarin, is it used in emergencies?
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- It takes days to see effects therefore, not used in emergencies
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What are the therapeutic uses of warfarin and what do they do?
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1. Long term prophylaxis and thrombosis
a. Prevention of venous thrombosis and associated pulmonary embolism b. Prevention of thrombosis during atrial fibrillation c. Prevention of thromboembolism (in patients with prosthetic heart valves) |
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How is Warfarin treatment monitored?
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1. Prothrombin time (PT lab)
- Use the INR to standardize the warfarin level |
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What are the 4 adverse effects of warfarin?
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1. Hemorrhage (Vitamin K to stop bleeding)
2. Fetal hemorrhage and teratogenesis (the body doesn't form well) from warfarin use during pregnancy 3. Use during lactation can cross to the baby 4. Other adverse effect |
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What are the drug interactions for warfarin?
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1. Drugs that increase anticoagulant effects
2. Drugs that promote bleeding 3. Drugs that decrease anticoagulant effects 4. Heparin 5. Aspirin 6. Acetaminophen |
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What 3 drugs require monitoring with a PT if taken with warfarin?
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1. Heparin
2. Aspirin 3. Acetaminophen |
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What is the Cyclooxygenase inhibitor drug?
What is its MOA? How is it administered? |
- Aspirin
- Irreversibly inhibits cyclooxygenase, and thereby blocks synthesis of TXAs. - Given PO |
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What is the adenosine diphosphate receptor blocker?
What is its mechanism of action? How is it administered? |
- Plavix
- Irreversibly blocks receptors for ADP - PO |
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What are the glycoprotein IIb/IIa receptor blockers?
What is its mechanism of action? How is it administered? |
- Aggrastat
- Reversibly blocks receptors for GP IIb/IIa - IV infusion |
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What are the therapeutic uses of aspirin?
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1. Ischemic stroke
2. TIA: transient ischemic attack 3. Chronic stable angina 4. Unstable angina 5. Coronary stenting 6. Acute IM 7. Previous IM 8. Primary prevention of IM |
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What are the 2 therapeutic uses of plavix?
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1. Prevents blockage of coronary artery stents
2. Reduces thrombotic events in patients with acute coronary syndromes - IM, ischemic stroke, and vascular death - Worry that A fib may occur in patients |
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What are the 3 characteristics of aspirin?
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- Inhibits coagulation by blocking ADP from attaching to its receptor
- Similar adverse effects to those of aspirin - Use with causton in combination with other drugs that may promote bleeding |
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What are the 3 characteristics of Glycoprotein (GP) IIb/IIIa?
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1. Most effective antiplatelet drugs
2. "super aspirin": super way of keepin the platelets from coming together 3. Reversible blockade of platelet GP IIb/IIIa receptors |
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What is the mechanism of action for Streptokinase and tPA?
What are drugs used to break a clot in the central line? |
- Promote conversion of plasminogen to plasmin, an degrades the fibrin matrix of thrombi.
- tPA and streptokinase |
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Which drug is more effective and more expensive?
Which drug is given on an accelerated schedule |
- tPA
- tPA |
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What are the two Thrombolytic Drugs?
What is the major adverse effects of these drugs? |
1. Streptokinase
2. tPA - Bleeding |
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What are the 2 nursing interventions for thrombolytic drugs?
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1. Anticoagulants increase risk for hemorrhage
2. Blood replacement may need to be considered |
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What is the MOA and 3 therapeutic uses of Streptokinase?
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- Binds to plasminogen to form activator complex, which causes conversion of plasminogen to plasmin
Therapeutic uses: 1. Acute coronary thrombosis (acute MI) 2. DVT 3. Massive pulmonary emboli |
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What are the 4 adverse effects of Streptokinase?
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1. Bleeding
2. Antibody production 3. Hypotension 4. Fever - Always watch VS and watch for bleeding and recall which side the bleeding occurs in |
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What drug is used to stop the fibrinolysis caused by streptokinase?
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- Aminocaproic acid (Amicar) administered IV
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What If the middle cerebral artery is occluded will it cause damage to lateral or contralateral hemisphere?
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Lateral hemisphere
- All others affect the contralateral hemisphere |
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What are the 3 therapeutic uses of
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1. Myocardial infarction
2. Ischemic stroke 3. Massive pulmonary emboli |
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What are the 5 thrombotic drugs ?
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1. Tenecteplase
2. Reteplase 3. Urokinase 4. TPA 5. Streptokinase |
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Which pathway is more effective but what does it need to be initiated?
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- Extrinsic factors are more effective but the intrinsic factors are needed to initiate
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What are the tests and differences of intrinsic and extrinsic factors?
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Extrinsic:
- PT - Tissue Intrinsic: - aPTT - Blood vessels |
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What other type of drugs are given to a patient other than heparin?
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Thromboic drugs
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Where does the switch over occur in the optic nerve?
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- The optic chasm
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What is the medication used for seizures?
What type of medication is it and what is it effective against? |
Phenytoin
- Broad spectrum, effective against all seizures except absent |
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How does phenytoin work and what is its MOA?
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- Can suppressing seizures w/o suppressing respiration
MOA: Selectively inhibits the Na+ channel re-entry back into the neuron and prevents the spread of seizures from hyperactive focus --> depresses the action potential |
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How is phenytoin administered and in what form?
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PO
1. Tablets 2. Solution 3. ER capsules |
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What are the 5 pharmacokinetics of phenytoin?
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1. Wide patient to patient variation in absorption and metabolism
2. Has a very narrow index 3.** Can become toxic with a small increase and sub-therapeutic with a small deacrease 4. Absorption varies between different oral formulations 5. Half-life has a range of 8-60 hours |
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What are the 4 characteristics of how phenytoin is metabolized?
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1. **Liver has a limited capacity to metabolize
2. **Makes the dosage/plasma level vary difficult to manage 3. Therapeutic dosage is only slightly smaller than what is needed to saturate the hepatic enzymes 4. A small change in dose gives a huge change in plasma levels |
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What are the 5 types of adverse effects of phenytoin?
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1. CNS: Nystagmus,sedation, ataxia, diplopia, and cognitive impairment
2. **Gingival hyperplasia 3. Skin Rash: morbilliform, rare occurrence of stevens-johnson 4. **Pregnancy: Teratogen- mot or mental deficiency, microcephaly 5. Decrease synthesis of Vit K and Vit D |
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2How do neuro dysfunction and seizures correlate?
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- Any disorder that alters the nerutonal envionment and may cause seizure activity
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What are the 4 etiologies of seizures?
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1. Cerebral lesions: Tumor, blood clot, and infections
2. Biochemical disorders: Fluid and electrolyte imbalances, hypoxia, pyrixonia, nutritional disorders, and acute w/d from alcohol 3. Cerebral trauma 4. Epilepsy |
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What are the 2 types of seizures?
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1. Partial seizure: Simple, complex, partial, evolving to general
2. Gererlized: Involves the whole brain (thalamus and reticular activating system) and impaires consciousness 3. Specialized epileptic syndrome: Febrile, hysterical, reflex, myoclonus |
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What distinguishes the partial seizures?
What are the 3 types of parital seizures? |
- Activity is restricted to 1 brain hemisphere
1. Simple: Individual does not have a change in LOC (motor, sensory, autonomic systems) 2. Complex: May have many different combinations of cognitive affective and psychomotor symptoms, either loss or alteration of consciousness 3. Partial evolving to general: Starts in one hemisphere of the brain and spreads to both |
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What are the 5 generalized types of seizures?
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1. Absent (petite mal): in children (2-10 sec)
2. Atypical absent: lip smacking and staring 3. Myoclionic: muscle jerks and extremely brief 4. Atonic: "Drop attacks", we worry about the fall 5. Tonic-clonic (gran mal): stiffening and repetitive jerking of muscle groups |
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How is the tonic phase characterized?
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- Muscle rigidity, lasts 10-15 seconds followed by clonic activity, include open eyes and mouth, extension of the legs and adduction of the arms, respiration is restricted
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How is the clonic phase characterized?
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Violent rhymic muscle contraction; eyes roll, face grimaces, and pulse accelerates; lasts 1-2 minutes
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What are the body movement of the tonic and clonic phase of seizures?
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What are the 4 areas to monitor during a seizure and why?
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1. Drug evaluation-effectiveness: Control of seizures, adjustment of dosage
2. Plasma drug levels: all have established therapeutic levels - Effective in monitoring compliance and toxicity 3. Promoting compliance: Educate about the chronicity of the process -Promote compliance b involving family and patient taking responsibility for control 4. Withdrawing Anteipileptic drugs (AED): done slowly, over 6 weeks to several months - Failure to gradually reduce can cause se |
