brain injuries and symptoms

• hypoxia
• ischemia

• focal 
• global

• ischemia from heart attach, cardiac arrest
• head trauma - concussions, hematoma 
• infection - encephalitis [infection of the brain]
• brain tumor
• stoke, brain attack, or CVA
• hypoxia from drug use, rsp arrest
• seizures

• oxygen and perfusion
• cooling to dec. metabolic needs
• blood sugar control

• exitatory amino acids and calcium cascade - these are changes once the crisis has passed and the brain tissue is trying to get bac kto normal
• brain swelling - vasogenic and cytotoxic

• stepwise, it goes from rostral to caudal
• first - LOC
• pupillary changes - tells us which side is affected
• oculomotor response - the way your eyes move around in your head
• motor response - hand grip test
• patterns of breathing, circulation

LOC

• alert
• confusion and disorientation 
• delirium
• obstundation - pt. is really sleepy but your able to wake them up
• stupor - barely waking up
• coma

indicated the presence and level of brain stem dysfunction

• eye movement 
• nystagmus - uncontrolled side to side rapid movement of the eyes
• doll's eyes - eyes are fixed, and moves away from the direction your're turning their head in

• can tell you the level of brain dysfunction 
• determines most severely damaged side

sign of Brain injury, a lot of pressure on the brainstem. Their in a coma and will spontaneously develop this flexed position where their arms and hands are pulled in, their feet is fanned out and knees turned inward

lower level injury within the brain. Hyperextension where the arms and hands are turned out, feet are flexed downward. Can happen before the person is going to die

Rate, rhythm, pattern

Sighing & yawning

Cheyne-Stokes - More rapid deep breathing then slower more shallow breathing

Gasping breath - A neurological reflex before they stop breathing all together

Hyperventilation- Can happen with damage to the lower brain centers

Very irregular - Periods of apnea, etc.

• inc. blood volume
• inc. cerebral spinal fluid
• inc. brain tissue

• obstructs cerebral blood flow
• destroys brain cells
• herniation - where parts of the brain that are normally positioned in certain areas in our head begin to move into compartments it would not normally be

• late signs of increased intracranial pressure
• high BP
• slow pulse
• wide pulse pressure

• LOC: restless, disorientation
• headache: maybe, usually
• VS: HR, BP, RR stable
• Pupils: dilated ipsilaterally [side of injury]
• visual changes: blurring, dec. visual acuity

• LOC: coma
• Headache: increasing pain
• VS: cushings triad: inc. BP, slow pulse and wide pulse
• Pupils: dilated bilaterally and fixed
• Visual changes: can't be assessed

• also known as brain attack
• ischemic stroke
• hemorrhagic stroke

• transient ischemic attack [TIA]
• thrombotic stroke [large vessel]
• Lacunar infarct [small vessel stroke]
• embolic stroke [moving clot]

• focal ischemic cerebral neurological deficits - lack O2 for a short period of time
• usually lasts 1-2 hours
• temporary disturbances in cerebral blood flow - reverses before infarction occur 
• can be a warning sign for something more serious 
• no damage occurs

left side of heart

• Presence of earlier TIAs?: frequent
• Onset: acute, hours to days
• Associated headache: occasional, not severe
• Stiff neck: rare
• Loss of consciousness: occasional, not at onset
• Blood in CSF?: rare

• Presence of earlier TIAs?: occasional 
• Onset: acute
• Associated headache?: often mod., severe 
• Stiff neck: rare
• Loss of consciousness: occasional, brief 
• Blood in CSF: rare

• Presence of TIAs: infrequent 
• Onset: acute, progressing
• Associated headache: frequent, severe
• Stiff neck: frequent
• Loss of conspicuousness: frequent 
• Blood in CSF: frequent

• sudden in onset, not LOC
• usually one-sided
• most common - weakness of face and arm
• other - unilateral numbness, vision loss, aphasia, dysarthria, and sudden, unexplained imbalance or ataxia

• paralyzed LEFT side
• behavior: quick, impulsive
• spacial and perceptual deficits

• paralyzed RIGHT side
• behavior: slow, cautious
• speech and language deficits
• depression

• must be immediate [within three hours]- usually early identification, special medical teams
• differentiate the type of stroke b/ each one is treated differently
• Tx with new medications and procedures
• better recovery if area surrounding ischemic areas has circulation restored fast

thrombolytics - tPA, tissue plasminogen activator

hemorrhagic stoke

• seizure = sudden, disorderly discharge of a group of cerebral neurons within the brain. sometimes this activates a part of the brain that controls motor function
• convulsion - motor seizures
• not a disease but symptoms
• common is children esp. related to fevers, elders
• epilepsy - seizure disorder without identifiable cause

• congenital defects: fam his.=more susceptible 
• tumors
• vascular lesions
• metabolic abromalities - changes in ph, etc.
• head injury
• fever - related to children
• drug and alcohol use/withdrawal - decreases seizure threshold 
• infections
• medications

• +/- bizarre muscle movements
• +/- unsual sensation. perceptions [tactile, odors, sounds, visual]
• +/- loss of consciousness 
• exact manifestations depends on the LOCATION of focus and SPREAD in the brain

A change in sensation that the person notices shortly before their going to have a seizure. Usually a sensory change, it might be a smell, sound, or feeling

Sensations that people get even a longer period of time before they actually have a seizure and it can even be hours or days leading up to the seizure and kind of more subtle changes

• after seizure
• esp. for seizure that caused loss of consciousness, it's a global change in the entire brain
• pt. can be confused, combative, very sleepy and hard to focus
• time where we as the nurse can intervene and care for the pt.

starts in one lobe, so no loss of consciousness if simple, or, if complex spreads to both lobes, leading to impaired consciousness

• wide spread
• spread widely and fast to both lobes, so loss of consciousness

• often confused with simple partial 
• NOT just a blank stare
• motion [automatisms, eyelid movement]
• lasts a few seconds 
• cease in adulthool or evolve into motor seizures 
• the medications phenobarbitol and phenytoin worsen seizures

• "drop attacks" - sudden loss of muscle tone for a few minutes 
• can be familial 
• rule out syncope

• tonic phase
• clonic phase

• simple partial seizure is prodrome
• loss of consciousness 
• sharp tonic muscle contractions
• incontinence [bladder]

• brain fights back, alternating contraction and relaxation, slowing
• postictal: altered LOC, sleepy

up to 40%

other treatments include: brain surgery, ketogenic diet, vagal nerve stimulator

underutilized as a cure for seizures

high fat and protein w/ no carbs

product that a pt. can control. it shuts down and increase the potentiation threshold for the neurons in the brain so that they don't lead to seizures

• lack of adherence is the major reason for poor control due to bad SE
• balance of seizure control and adverse effects of the AEDs
• important to diagnose type of seizure, as it affects choice of AEDs
• may need to adjust doses and add meds
• adjust dosages using plasma drug levels

• seizures may be infrequent, making it hard to monitor effectiveness
• non-compliance may be an issue
• with multiple drugs, hard to know which is causing effect

• block sodium channels so that neurons depolarize more slowly and stops rapid firing 
• block calcium channels, same
• block glutamate [excitatory neurotransmitter] receptors 
• increase GABA [inhibatory neurotransmitter] - by increasing GABA your going to reduce the number of seizures

• rapid withdrawl can lead to sever aeizures
• most AEDs cause CNS depression, ESP. with other CNS depressants like alcohol
• many AEDs are metabolized by the live, induce liver enzymes, and change metabolism of other meds, including other AEDs
• enzymes induction leads to inactivation of normal dose - oral contraception and warfarin
• most AEDs can have negative effects on the fetus, but seizures have worse effects on the fetus

• traditional 
• newer

well known, cheaper, more adverse SE

phenytoin (Dilantin)

carbamazepine

valproic acid

phenobarbitol

ethosuximide

not as tested, more expensive, but fewer adverse SE

• gabapentin
• lamotrigine
• topiramate

Normalizes sodium flux in neuron

Raises seizure threshold

For partial and tonic clonic seizures, but NOT absence seizures

CNS: dizziness, sluggishness, confusion (Avoid alcohol, other CNS depressants)

GI: nausea, constipation

If the pt. developed  Rash – They must stop he medication!

Gingival hyperplasia [overgrowth of the gums hich can cause bleeding, loss of teeth, etc] (use folate rinse)

Teratogenic (palate, lip, heart)

Folate supplementation REDUCES RISK

• - INDUCES [increases] hepatic metabolism of
• vitamin
• - B12, folate, vitamin D, vitamin K
• - This causes a lot of the SE
• - DISPLACES folate from plasma proteins
• - Phenytoin metabolism USES UP folate

• - highly bound to plasma proteins
• note free, unbound phenytoin levels
• narrow therapeutic range
• liver has limited ability to metabolize - keep 10 - 20 mcg/ml therapeutic range

• sedation
• nystagmus
• ataxia - not being able to walk correctly and losing your balance 
• diplopia - double vision
• cognitive impairment

• - Many drug incompatibilities
• - (Do NOT mix C/ other parenteral Rxs)
• - INDUCES hepatic p-450 enzymes
• - DISPLACES other drugs, nutrients from plasma proteins
• - BINDS to proteins in enteral feedings

• - Similar to phenytoin, but fewer side effects
• - Can cause leukopenia, anemia, thrombocytopenia, even fatal aplastic anemia (bone marrow shut down) - rarely
• - Can cause bad bone marrow suppression that can even be fatal by cutting off production of blood cells

• can be used for simple partial 
• also used [infreq] for complex-partial, tonic-clonic and febrile seizures 
• similar adverse effects as phenytoin but NO EFFECT ON FOLATE, NO GINGIVAL HYPERPLASIA [over growth of gums]
• ling time to stabalize - Stakes
• a while to stabilize in the blood, it has a long half life so you have to add to it gradually and allow it to level out over a couple of weeks

• - inc. Acts on increasing Gamma aminobutyric acid (GABA), an inhibitory neurotransmitter
• - For ALL generalized seizures
• - 75% of partial seizures controlled also
• - Also used for bipolar disorder

• - Teratogenic (neural tube defects) - avoid in pregnancy
• - Hepatotoxicity, pancreatitis (avoid infants, elderly)
• - CNS depression (avoid alcohol, etc.)
• - Inhibits platelet aggregation
• - NO BEHAVIORAL EFFECTS

• - Diazepine receptors potentiate GABA
• - Used for rapid cessation of seizures
• - MONITOR for respiratory depression

In a person who has uncontrolled seizures, people have used benzodiazepine to stop the seizure activity completely right away

A benzodiazepine for maintenance therapy of absence, akinetic seizures

• - For seizures caused by hypomagnesemia (eclampsia, hypothyroidism, alcohol withdrawal)
• - Side effects from hypocalcemia (CNS depression, hypotension, hypothermia, circulatory collapse)
• - Monitor serum magnesium levels
• - Treat magnesium sulfate toxicity with IV calcium gluconate
• - An antisizure medication that is a smooth muscle relaxant that works in situations where hypomagnesaemia are causing the problem

respiratory rate and count RR freq

• - Continuous tonic-clonic seizures that last for over 20 min., unconscious
• - The longer the seizure activity, the more resistant to stopping the seizure, start treatment within 5 min.
• - Seizures using up oxygen and glucose, cause acidosis, brain damage, even death

Goals:  maintain ventilation, treat hypoglycemia, stop seizures

• Start IV, draw labs [looking at electrolytes], give benzodiazepine
• - Lorazepam (Ativan), long acting (72 hr), preferred - Will quickly stop the seizure
• - Diazepam (Valium), short acting, need repeat