NEURO

• Controls most of what we do, physically and mentally

• Assessment is most detailed in neuro
• What to look for
o Facial expression
o Grooming
o Mood
o Cognitive status
o Gait, posture , movement with hesitation
o Motor reflexes, movement of arms e.g. Parkinson’s (hands close to their side,
they don’t swing their arms)
o Attention, orientation (name, time, place)
o Judgment – unable to distinguish objects
o Ability to pay attention
o By law when you document that the pt is confused, must have detailed
explanation why the pt is confused
o Long term and short term memory
o Short term: ask what day did you come to the hospital?
o Long term: what year did you graduate from high school?
o Elderly have long term memory
o Assess language skills
o Comprehension: can ask them to use their right hand to touch their left ear
o Memory: give them series of numbers and have them repeat it back
 Level of consciousness
 Alert: responds immediately to visual and verbal stimuli and readily engage in
communication
 Lethargy: drowsy, fall asleep easily, responds to your voice but may need to be
called more than once.
o Lethargy in head trauma pt could be a first sign of a problem, because they
build up ICP
o Increase your assessment on this pt

 Obtundation: need for verbal and tactile stimuli probably more than once. May
fall asleep during conversation – call the doctor at this point
 Stupor: can arouse but only for short period of time, may be a moan response to a
stimuli. Also called semi-comatose
 Coma: neither awake nor aware. Neuro pt is in this. Neurological assessment
every 2hrs. Document.
 When they go from alert to lethargy assess every 15 minutes.

CRANIAL NERVES
• Olfactory (I)- smell, use strong odor like coffee to test for smell
o Smell decreases with age
 o With nose injury they have decrease in olfactory nerve called Anosia
(decrease smell reflex)
• Optic nerve (II)
o Snellen chart 20/20 vision
• Occulomotor (III), Abducens (VI), Trochlear (IV): they work together , control
the pupils and extra ocular movement
• Consensual light reflex
o If the pupils doesn’t constrict there is a problem
o Both pupils should be equal, round and reactive to light
• Trigeminal (V): ophthalmic, maxillary, and mandible
o Have pt bite down on a tongue blade
• Facial nerve (VII)
o Observe during normal conversation
o When pt is smiling
o Ask pt to close the eyebrow
o Wrinkle of the forehead
o Show their teeth
o Responsible for 2/3 of the tongue for taste – sweet, sour, bitter, salt. Seen
in pt affected by stroke
• Acoustic nerve (VIII)
o Put the watch at their ears
o Rhinne or Webber test
o Affected by the side effects of aspirin, antibiotics and lasix
• Glossopharyngeal (IX)
o Gag reflex and swallowing
o Affected when you get your tooth pulled out cause of the use of lidocaine
o Can also be affected in other treatments, like bronchoscopy
o Gag reflex- use tongue blade, or ask them to cough
o Cough is a protective reflex mechanism
• Vagus (X)
o Control of speech , sound and gag reflex
o Look for drooping, inability to speak

• Accessory (XI)
o Control the strength of trapezoid and sternocleidomastoid muscle
o Problem with patient who had stroke
• Hypoglossal (XII)
o Have pt move the tongue
o Psychotropic drugs and raglan affects the tongue
• Acronym
• ON OLD OLYMPIC TINY TOTS A FINN AND GERMAN VIEWS SOME
TOTS
• Motor and sensory acronym
 • SOME SAY MANY MARRY MONEY BUT MY BROTHER SAYS BAD
BUSINESS MARRY MONEY

ANATOMY AND PHYSIOLOGY

• Neuron – basic part of the neurological system
• Contain threadlike projection known as nerve fibers
• Dendrites: conducts impulse to the nerve cell
• Axon: conducts impulses away from nerve cell
CELL BODY
• Nucleus: contain hereditary factors-DNA
• Cytoplasm: fluid made up of chemicals
• Nissil body: aids in metabolism
• Myelin sheath: protects the nerve fibers
o Myasthenia Gravis-myelin sheath is affected
o Sheath insulates and prevent lost of nerve impulse
• Nuerilema: aids in regeneration of nerve fibers, seen in spinal cord injury
• 3 types of neuron
o sensory (afferent): receives impulses of stimuli from the muscle, skin and
joints and transmits message to CNS
o motor (efferent : transmits message from CNS to the body
o causes glands to secrete, sweat gland from pituitary gland
o tells muscle to contract
o central/connecting neuron: transmits impulses from one part of the brain to the
spinal cord
• paresthesia: numbness, indication of neuro problem

REFLEXES
• Achilles reflex: may be diminished or absent in the elderly
• Quadriceps reflex: check in OB mothers receiving mag-sulfate (PIH), if reflex is
decreased notify doctor
• Reflex responses: 0 – absent 1-hypoactive 2-normal 3- hyperactive 4 hyperactive
with clonus ( a continued rhythmic contraction of the muscle with continuous
application of stimulus)
• Babinski : normal response should have toes go inward
• Dolls eyes: checks for brain death
o Normal: eyes move from side to side when head is turned
o Abnormal: Remains in fixed position when head is turned
• Caloric test: use cool water in syringe in the ear (test)
o When cold water is instilled eyes move from side to side , away from the cold
water and then slowly back
o If warm water is used eyes moves towards the warm water and then back
o Abnormal : eyes will remain fixed
• Kerning’s sign: meningitis
o When one knee is lifted the pain is felt in other leg and attempts to lift it
 • Brudzinski’s sign
o When head is lifted the knee automatically come up
• Decerberate- arms are flexed, brain dead, poor prognosis
• Decorticate: not as bad
• Brain stem injury is usually incompatible with life
• C4 injury don’t do dolls eyes on cervical injury
• C-spine precaution
o Keep head of bed flat, don’t raise head up until ruled out
o Use cervical collar
o Don’t take cervical collar off until confirmation from x-ray
o Have to be careful , can cause paralysis

CEREBRAL BLOOD FLOW

• Arises from internal carotid artery and posterior carotid artery.
• Circle of Willis : arises form basilar artery and internal carotid artery
• Blood Brain Barrier: barrier between the blood capillary and brain tissue
o Prevents some substances from entering the brain tissue
o Lipids can’t enter
• CBF: amount of blood passing through the brain tissue in 1min
• Brain use about 20% of body oxygen and 25% of glucose
• Brain has the ability to regulate its own blood flow called autoregulation
• Autoregualtion: cerebral blood flow vessels will try to maintain a constant blood
flow by change in pressure
• Makes sure the brain gets its metabolic needs
• It’s the dilation and constriction
• It fails to regulate when MAP is less than 50 :
• there is cerebral ischemia – syncope, blurred vision
• MAP > 150 : there is a lot of vasoconstriction, cerebral blood flow is affected
• Pt that have that had stroke and have BP around 250/130 the doctor will say hold
their MAP at 140, don’t hold BP meds unless MAP is 140 or less because you
don’t want the pt to RE-Infarct/ or stroke to return
• Antihypertensive should be given based on MAP
• CPP: pressure needed to ensure blood flow to the brain
• CPP = MAP – ICP
• Normal is 70-100mm/Hg
• 50 to 60 is needed for adequate perfusion
• ICP 0-15mmHg, >15 is abnormal
• Coughing, head trauma, sneezing, suctioning etc causes increased ICP
• Give codeine to suppress the cough
• Projectile vomiting – there is a brain tumor
• Child can tolerate ICP better because the have more room cause the bone is not
calcified like adults
 • Papillar edema or chocked disc: mean BP in increased, and pressure is on the
optic nerve
• CSF: accounts of 150ml circulating at any given time
o Cushions and support the brain and spinal cord
o Excretes toxic waste in CNS
• Concern: don’t flex neck, don’t tie the endotracheal tube
o Head injury increase ICP, put sandbag on the sides of the head (test)
• Monro Kellie hypothesis: cranial bulb is rigid and fixed and made up of three
compartments
o The brain, blood volume, CSF
o Maintain normal ICP
o If the brain swell one if the two must change
o Give mannitol- osmotic diuretic- pulls water out of the cerebral bulb
o Burr holes is done in the head to allow space
o Brain tumors - ICP

BRAIN HERNIATION
• Shifting of the brain, poor prognosis
• Lateral shift: singulated herniation
o Pupil will dilate on the side that is affected
• Midbrain: both pupils are fixed
• Pons: pinpoint movement, non reactant, herniation pushing on the pons, bad sign
• Diabetics: small reactive metabolic
• Get pressure off the brain

BRAIN INJURY
• Coup-counter-coup: hit-move-hit
• When there is a hit on the right side check the left pupil
• Penetrating head injury: refer to copy
• Anytime there is a he ad injury in the ER ask them to describe what happen at the
site of injury to check to see if they had loss of LOC, or vomited which is a bad
sign
• Skull is full nice blood vessel
• Scalp laceration: clean it up, give antibiotics

SKULL FRACTURES
TYPES
• Linear: use a CT scan to diagnose, not life threatening, clean it up, put on
antibiotics
• Give head chart:
• for discharge, have someone wake them up q2hrs, if they can’t arouse the person,
call 911
• basilar skull fracture: dangerous, occurs at the base of the skull
 o cause battle’s (ecchymosis behind the ear) sign, raccoon eyes, halo sign
o don’t insert an NG tube with basal skull fracture, because it can further the
brain injury (Test)
MANAGEMENT
o Frequent neurological assessment
o Caution when administering medication.
o They can get Tylenol with codeine, antibiotics
o Rationale: you can’t do a good assessment if pt is medication
o Unless we have cerebral spinal cord injury, slight elevation of the head
o When you sleep flat without a pillow you have a stretch on the cranial
artery
o If they having a headache at night ask them how many pillow they sleep
on

HEMATOMA
• Epidural hematoma: bleeding between the skull and the brain dura
• They can herniated if something is not done relieve the pressure
• Brief loss of consciousness
• May be alert and oriented in the ER, but can loose consciousness again
• Fixed and dilated pupils on same side of injury
• Arterial injury
• Usually caused injury to artery, bleed freely
• Burr hole, mannitol, surgery
• Look for any sudden changes in LOC
• If there is a change is LOC, is a medical emergency
• Usually sent to ICU
• CT scan of the head

SUBDURAL HEMATOMA
• Accumulation of blood between dura and arachnoid
• Venous injury
• Slow with symptoms
o Acute- 48hrs
o Subacute- 48hrs to 2wks
o Chronic – 2wks >
• Assess: drowsiness(first symptom), lethargic, headache, agitation (expansion of
the hematoma)
• Monro Kellie hypothesis is eliminated
• Pt with a headache come to ER should be ask if they fell and hit head in the last
month
• Stiff neck, seizure activity – there is problem
• Treatment – surgery

INTRACEREBRAL
 • Bleeding within the tissue
• Causes: uncontrolled HTN, ruptured aneurysm, trauma
• Symptoms: headache, quick decrease of LOC, dilation of one pupil, hemiplegia,
• Use catheter for drainage, and measure ICP, done at bedside
• CT scan
• Mannitol: watch urine output, don’t want the CVP too low, check CVP because a
lot fluid is pulled out

CONCUSSION
• Shaken baby syndrome
• Temporary loss of neurological function with no apparent structural damage
• Frontal lobe:
o Personality changes/ aggressive behavior
o Irrational behavior
• Treatment: observe
o may stay in the hospital overnight or sent home with a head chart
HEAD CHART
• Should tell the family in any difficulty in
o Waking pt up
o Speech
o Confusion
o Severe headache
o Vomiting
o Weakness on one side of the body
• Look for closely for elderly, cause they are misdiagnosed and confused

CONTUSION
• Most severe than concussion
• Bruise in the brain
• Hemorrhage
• May be unconscious much longer period
• Ask the pt if they urinate or have a stool
• With contusion they have loss of bowel and bladder control
• Able to wake up but slip right back to unconsciousness
• Vitals: same as for shock
• Problem with eye movement
RECOVERY
• Go into cerebral irritability
• Hyperactive
• Residual findings:
o Usually impaired mental function, headache, vertigo
• Treatment: anticonvulsive medication
CUSHING’S TRIAD (TEST)
o Bradycardia
 o Widened pulse pressure (SBP-DBP)
o Irregular respiration
• Call doctor with cushings triad
• Monitor BP
• Usually a sign of impending death
• Loosing neurological function
• Fixed and dilated pupils
• Absent of cough and gag reflex
• Don’t run dextrose because it increases ICP and fluid volume
• Give NS

BRAIN DEATH
• Irreversible function of the brain
• Brain stem function has stop
• May occur suddenly
• No function for up to 24hrs, temperature may be normal
• Give them Levophed (vasoconstrictor) and leave them dead
• They give Levophed to get BP, last resort meds after dopamine
• Diagnosis
o Absent of brain stem reflex
o Apneic – can’t breathe off ventilator
o Apneic test:
 Take pt off the ventilator, draw a blood gas, let the Pa CO2 rise, if
PaCO2 is 60 mm above it should stimulate respiration
 If high PaCO2 and no respiration then pt is brain dead
o Caloric stimulator: check ocular movement, use of the cold water
o EEG:
 demonstrate: absent of brain activity
 isoelectric line is flat
 done on three different days
o Angiogram CBF:
 Have an IV running, use of contrast media, have X-ray of the head
to visualize vessels, and if they don’t see none of the contrast
media you brain dead.
o Two doctors have to OK before pulling pt off the vent