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What is cranial nerve I, and its major function?
Olfactory, its major function is smell
What is the cranial nerve II and its major function?
Optic, its major function is vision
What is cranial nerve III and its function?
Oculomotor, its major function is eye movement
What is cranial nerve IV and its major function?
Trochlear, its major function is eye movement
What is cranial nerve V and its major function?
Trigeminal, its major function is chewing, face, mouth, teeth scalp sensation
What is cranial nerve VI and its function?
Abducens and it turns eyes outward
What is cranial nerve VII and its major function?
Facial and it controls most facial expressions and taste sensation, tears, mucus and saliva production
What is cranial nerve VIII and its major function?
Vestibulocochlear (Acoustic) and its major function is hearing and equilibrium
What is cranial nerve IX and its major function?
Glossopharyngeal and its major function is the sensations of throat, taste, swallowing movements, secretion of saliva normal voice (contraction of the pharynx)
What is cranial nerve X and its major function?
Sensory and motor to larynx, (-) HR, contraction of the eliminatory tube, (+) digestive secretions, sensory of cardiac, resp. + BP reflexes
What is cranial nerve XI, and its major function?
Accessory (spinal accessory) and its major function is controlling the trapezius & sternocleidomastoid muscles
What is cranial nerve XII and its major function?
Hypoglossal and its major function is controlling tongue movement
Divisions of the Cerebrum?
Left Hemisphere and the Right Hemisphere
The Left Hemisphere is responsible for what characteristics?
- -Problem solving
- -Logical reasoning
The Right Hemisphere is responsible for what characteristics?
- -Artistic abilities
- -Spatial relations
- -Emotional/Behavioral characteristics
What are the Lobes of the Cerebrum?
- -Frontal Lobe
- -Parietal Lobe
- -Temporal Lobe
- -Occipital Lobe
What does the Frontal lobe do?
- -Voluntary Movements
- -Intellectual function
- -This is where the Broca's area is located
What does the Parietal lobe do?
- -Sensation (touch and pain)
- -This is where the Wernickies area is located
What is the 3 parts of a Neuron?
How do we test cranial nerve I?
How do we test cranial nerve II?
How do we test cranial nerve III?
Check pupil size, shape, reactivity to light - Cardinal Gaze
How do we test cranial nerve IV?
Turn eye laterally, up+down
How do we test cranial nerve V?
- Sensory: Use something thats sharp/dull and put on pt�s face, cheek, chin and ask pt to distinguish
- Motor: Ask pt to clinch teeth while you palpate the temporal, massetar muscle
How do we test cranial nerve VI?
How do we test cranial nerve VII?
- Motor: Smile, frown, raise eye brow
- Sensory: Taste something
- Parasympathetic: Mucus membranes are pink and wet
How do we test cranial nerve VIII?
Rombergs/Snapping hearing test
How do we test cranial nerve IX?
- Sensory: Taste/gag reflex
- Motor: Ask patient to swallow and listen for normal voice sounds Parasympathetic: Secretion of saliva
How do we test cranial nerve X?
- Sensory: Assess patient ability to swallow and produce saliva, rub tummy
- Motor: Produce normal voice sounds
- Parasympathetic: Valsalva maneuver
How do we test cranial nerve XI?
Ask patient to shrug shoulders and look left and right
How do we test cranial nerve XII?
Ask patient to stick out their tongue and move it around
- A period of prolonged inspiratory hold
- People do this on a regular basis (A deep breath)
What is Normal Breathing called?
What are Cheyne-Stokes?
- A regular irregular breathing pattern
- Usually associated with a Neurological problem, however sow people do normally
- Pattern with periods of apnea
- Looks like torsades de pointes
What is Central Neurogenic Hyperventilation?
Fast, Deep and regular ventilations
What is the Pronators Drift test?
- This is where you ask the patient to put their arms up in front of them with there palms facing up, if one of the arms fall and turns downward then it is a positive drift pronators drift test, if the arm falls but the hands remain supinated the test is positive arm drift
- Test coordination
What is the Eye Opening of the GCS?
- 4 - Spontaneous
- 3 - Open to Voice
- 2 - Open to Pain
- 1 - No eye opening
What is the Verbal section of the GCS?
- 5 - Oriented
- 4 - Confused speech
- 3 - Inappropriate words
- 2 - Incomprehensible words
- 1 - No Verbal response
What is the Motor response section of the GCS?
- 6 - Obeys commands
- 5 - Localizes Pain
- 4 - Withdraws from pain
- 3 - Flexion (Decorticate)
- 2 - Extension (Decerebrate)
- 1 - No Motor response
What is the mnemonic we use for comas/unconsciousness?
What is noncommunicating hydrocephalus?
CSF reabsorption is blocked, usually at an acqueduct; generally a genetic malformation
What is communicating hydrocephalus?
Problem with the arachnoid villi; absorption is not occurring at the rate it is supposed to; much more common type
What are some modifiable risk factors for strokes?
- Birth control
What are some non-modifiable risk factors for strokes?
- Previous stroke
- A Fib
- Clotting disorders
What is a TIA?
Transient ischemic attack; all SXS resolve within 24 hours with no permanent neurological deficit
What are some signs (observable by us) of a stroke?
- Facial Drooping
How do we manage a stroke in the prehospital setting?
- Rapid recognition and transport
- Establish timeline for fibrinolytics (3 hours from onset of symptoms)
- Specific assessment
- Positioning- 15% elevation of head
- IV and BGL check- start with 12.5g of dextrose if indicated
- Note HTN but DO NOT TREAT IT
- EKG monitor
- Management of temperature
- Protection of paralyzed extremities
- Manage seizures if present - very bad sign; stop immediately (benzos)
What is delirium?
Abrupt disorientation, usually with delusions and hallucinations
What is dementia?
Slow progressive loss with the inability to learn new things, difficulty remembering recent events, and personality and behavioral changes
What are the three main causes of dementia and which is most common?
- Alzheimer's - most common at 50%
- Creutzfeldt-Jakob disease - 1:1 million
What is Alzheimer's Disease (AD)?
- Progressive congenital disease involving 4 genes (3 are inherited)
- Brain cells in cerebral cortex die and brain substance shrinks
- Abnormal clumps and tangled bundles of fibers are formed
What kinds of things does Alzheimer's disease affect?
What is Huntington's disease (HD)?
- Familial disease passed from parent to child through a mutation in the normal gene
- Results from genetically programmed degeneration neurons
- Causes a severe degeneration of basal ganglia and frontal lobe
- Doesn't show up until midlife
What kinds of things does Huntington's disease affect?
- Uncontrolled movements
- Loss of intellectual and thought processes
What is Creutzfeldt-Jakob disease?
- Rare, fatal neurogenerative CNS disease
- Belongs to the family Transmissible spongiform encephalopathies
- In animals is known as Mad Cow disease
- Caused by an infectious protein; characterized by rapid onset and very short life span from onset of symptoms
What kinds of things does Creutzfeldt-Jakob disease cause?
- Confusion and forgetfulness
- Rapidly progresses to dementia
- Myoclonus and ataxia
What is Meniere's disease?
Idiopathetic disorder of the inner ear
What are some SXS of Meniere's disease?
- Fullness in the ears
- Hearing loss
What is a seizure?
Spontaneous excessive discharge of nerons in the brain; cause brief alteration in consciousness or behavior
How do we manage a patient with seizures in the prehospital setting?
- Protection from injury
- Airway management with adequate ventilation
- IV and BGL- give dextrose if indicated
- EKG monitor
What is a tension headache?
Muscle contractions in the head and shoulders; usually from stress
What is a cluster headache?
Involves a release of histamine; will usually have edema, runny nose, watery eyes accompanying
What is a migarine headache?
Comes from the constriction and dilation of blood vessels
What drugs are sometimes prescribed to help manage migraines?
Calcium channel blockers or beta blockers
What are some symptoms of a migraine headache?
- Blurry vision
- Numbness and tingling
What is a sinus headache?
Associated with allergies or inflammation due to infection
How do we manage a patient with a HA in the prehospital setting?
- obtain OPQRSTU history
- Position the patient for comfort
- IV access if indicated
- BGL and ECG monitor
- Consider medication (anti-emetics or analgesics)
- Reassure the patient and transport
What is meningitis?
- Inflammation of the meninges
- Bacterial type is more widespread and worse
- Viral AKA aseptic type is limited to the meninges
- Fungal type is very rare
- 10-15% of the population are carriers
What are the SXS of meningitis?
- Severe HA
- Nuchal rigidity
- Kernig's sign
- Brudzinski's sign
- Lethary or stupor
- Possible petekial rash (late sign)
- Decreased mentation
What is Wernicke's Encephalopathy?
- Sudden onset of ataxia, nystagmus, disturbances in speech
- Can be caused by IV glucose in a malnourished patient
- This is why we administer thiamine before glucose (thiamine is needed to process glucose)
What is Korsakoff's Psychosis?
- Found with Wernicke's encephalopathy in chronic alcoholics
- Usually considered irreversible because cell damage has occurred
- Causes apathy, poor memory, retrograde amnesia, confabulation, and dementia
What is the most common type of skull fracture?
Linear fracture (80%)
How do we manage a linear skull fracture?
- Keep area clean
- C-spine precautions
- Bleeding control
What are four signs of a basilar skull fracture?
- Raccoon eyes
- Battle's sign
- CSF leakage
What is a depressed skull fracture?
The bone is being pushed into the brain itself; it is often associated with scalp lacerations, could involve a hematoma or cerebral contusion
What is an open vault fracture?
An opening between the scalp and the brain; it is associated with multi-system trauma
How do we manage an open vault fracture?
- Spinal immobilization
- Ventilatory support with O2
- Contamination control
- Rapid transport
- IV and ECG monitor
What are the four classifications of brain injuries?
- Mild diffuse
- Moderate diffuse
- Diffuse axonal injury
- Focal injury
What is a mild diffuse brain injury?
AKA concussion; defined by less than 5 mins LOC; mentation continues to improve; no structural damage
What are the SXS of a mild diffuse brain injury?
- Temporary LOC
- Rapid return to normal behavior
- Amnesia retrograde or antegrade
What is a moderate diffuse brain injury?
A bruising of the brain tissue; it is actual structural damage
What are the SXS of a moderate diffuse brain injury?
- Definite LOC
- Persistent confusion, disorientation, and amnesia of event
- They have no specific timeline
What is a diffuse axonal injury?
Shearing, stretching or tearing of the nerve fibers or cells- axons; breaks nerve cells and tears them apart so that the cells die
What are the SXS of a diffuse axonal injury?
- Possible posturing
- MOre amnesia
- Decreased LOC from pressure on RAS
- Pupillary response problems
What is a focal injury?
An injury to a specific area; specific grossly observable brain lesions
What are some causes of focal injuries?
- Skull fractures
- Cerebral contusions
What is the formula for CPP?
CPP= MAP - ICP
What is the formula for MAP?
MAP= diastolic pressure + 1/3 pulse pressure
What is the formula for pulse pressure?
systolic pressure - diastolic pressure
What is normal ICP?
What is normal MAP?
What is normal CPP?
What are the SXS of ICP?
- Cushing's Triad
- First HTN (systolic)
- Second Bradycardia
- Third Irregular respirations
What are the SXS of hypovolemia/shock?
What are the types of brain hemmorhage?
- Subarachnoid Hematoma
- Intracerebral Hematoma
What are the SXS of an epidural brain hemorrhage?
- Rapidly developing
- Linear or depressed skull fracture MOI
- Transient LOC - lucid interval
Where is an epidural brain hemorrhage located and why is it more severe?
Below the skull and above the dura mater; involves arterial bleeding
What are the characteristics of a subdural hemorrhage?
- Between the dura mater and the arachnoid mater
- Often caused by blunt trauma
- Involves venous bleeding
- Can develop symptoms within 24 hours or up to a few days
- Can be acute, subacute, or chronic
What is a subarachnoid hematoma?
Intracranial bleed into the CSF below the arachnoid mater above pia mater
What are the SXS of subarachnoid hematoma?
- Sudden and severe HA
- Meningitis SXS (i.e. stiff neck) because it irritates CSF
What is an intracerebral hematoma?
A brain bleed; AKA cerebral contusion; more than 5cc somewhere within the brain- BAD
What are the types of spinal trauma?
- Axial loading
- lateral bending
What is axial loading?
- Drives the weight of the body against the head; having an object fall onto the head or upward force to pts feet
- AKA vertical compression
What is a flexion injury?
Bending forward or backwards past normal range of motion
What is a hyperextension injury?
Jointed parts are pulled away from each other by movement outside normal range of motion
What is a hyperrotation injury?
Movement about the axis of the body past the normal range of motion
What is a subluxation injury?
Incomplete or partial dislocation of a joint; vertebra are pushed into the spinal canal
What is a lateral bending injury?
The head and neck are bent to the side past normal range of motion causing injury to the Cspine
What is a distraction injury?
Pulling apart of the spine; accidental or intentional hangings are examples of this
What are the classifications of spinal injuries?
- Sprains and strains
- Fractures and dislocations
- Sacral and coccygeal fractures
- Cord injuries - primary and secondary
- Cord lesions
What is a hyperflexion sprain?
A posterior ligament in the spinal cord tears at least partially
What is a hyperextension sprain?
What are wedge-shaped fractures?
Hyperflexion from compression forces applied to the front of the vertebrae; seen in industrial falls
What are teardrop fractures?
- Unstable fractures caused by a combination of severe hyperflexion and compression forces; the vertebrae fracture and dislocates into the spinal column
- Often seen in MVAs
What is a sacral fracture and what does it cause?
Fracture of S1 and S2; loss of perianal sensory motor function and damage to bladder and bladder sphincters
What is a coccygeal fracture?
"broken tailbone"; caused by direct blow or fall; causes pt moderate pain
What is a primary cord injury?
Injury that occurs at the time of impact
What is a secondary cord injury?
- Injury that occurs after the initial insult
- movement of bone fragments
What is a complete cord lesion?
- Spinal fracture or dislocation; causes a total absence of pain, pressure, and joint sensation below the level of injury
- Can cause motor paralysis below level of injury
- May be associated with ANS dysfunction below level of injury
What is an incomplete cord lesion?
- Associated with three main syndromes
- Central cord syndrome
- Anterior cord syndrome
- Brown-Sequard syndrome
What is Central cord syndrome?
- Usually a cervical lesion caused by hyperextension or flexion
- Classified by a greater motor dysfunction in upper extremities than lower extremities
- Paralysis of the arms and sacral sparing are common with this syndrome
What is Anterior cord syndrome?
- Usually associated with flexion injuries
- Causes a variable loss of motor function, pain, and/or temperature sensation below the level of injury
What is Brown-Sequard syndrome?
- Usually associated with hemitransection of the cord; common MOIs are knife or missile injuries
- Causes weakness in upper and lower extremities on the same side as the injury with loss of pain and temperature sensation on the opposite side from the injury
What is spinal shock?
Temporary loss of spinal cord function distal to the injury
How do we manage spinal shock?
Oxygen, spinal immobilization, fluids
What is neurogenic shock?
- AKA neurogenic hypotension
- Hypotension following spinal shock
- Autonomic dysfunction; relative bradycardia, hypothermia, vasodilation of peripiheral vessels
How do we manage neurogenic shock?
- Control oxygenation, perfusion, and pH as best as possible
- Consider dopamine 2-10mcg/kg/min
What is autonomic hyperreflexia?
- AKA autonomic dysreflexia
- Associated with chronic SCI in patient with injuries at T6 or above
- Its a cardiovascular response stimulated by the sympathetic nervous system
- Caused by distended bladder or rectum
- Emptying of the bladder or bowel often relieves symptoms
What are the SXS of autonomic hyperreflexia?
- Severe HTN (systolic above 300)
- Blurred vision
- Sweating above level of injury
- Flushing of skin
What are the four major classifications of cerebral palsy?
- Spastic paralysis
What is spastic paralysis cerebral palsy?
- most common form
- scissored legs
- increased muscle tone
- damage is in motor cortex itself
- can be para, quad, or diplic
What is dyskinetic cerebral palsy?
- 2nd most common form
- basal ganglia and extrapyramidal system are affected
- fine motor is mostly affected
What is ataxic cerebral palsy?
- cerebellum is affected
- balance issues
- least common form
What is mixed cerebral palsy?
combinations of the other types
What is Bell's palsy?
sudden temporary facial paralysis due to inflammation to CN VIII (Facial)
What are the SXS of Bell's palsy?
- mild weakness to total paralysis
- facial drooping
- NO PAIN
What is trigeminal neuralgia?
damage to CN V causes pain limited to the face but there is no motor involvement
What is glossopharyngeal neuralgia?
- compression of CN IX due to inflammation causes severe pain in the tongue, throat, ear, and tonsils
- difficulty swallowing can occur
- can be life threatening if pressure starts to compress the brain stem
What is acoustic neuroma?
a benign neoplasm compresses cranial nerve VIII and causes symptoms (can involve VII and V also)
What are the SXS of acoustic neuroma?
- unilateral hearing loss (differentiating from Meniere's)
- balance disturbances
- fullness in the ear
- trigeminal neuralgia
What is Parkinson's disease?
progressive neurologic disease that affects the basal ganglia (and therefore fine motor control) due to an imbalance between low dopamine and normal ACH
What are the SXS of Parkinson's disease?
- Tremors that occur at rest
How is Parkinson's treated?
What is Amyotrophic Lateral Sclerosis?
- ALS or Lou Gherig's disease; caused by the neurons in the mortor cortex and spinal cord wasting and hardening and becoming non-functional
- Affects voluntary skeletal muscle
- Rapidly progressing
- Does not affect intellect
- Starts in a specific isolated area and then progresses throughout body, causing paraplegia and eventually death (paralysis of diaphragm)
What is muscular dystrophy?
refers to a group of motor neuron genetic diseases characterized by progressive weakness and degeneration of skeletal muscles
What is the most common form of MD?
- Duchenne's; affects males primarily
- involves the deficit of dystrophin protein that starts killing muscle and replacing it w/ connective tissue; usually can't walk by age 12
What is multiple sclerosis?
- thought to be an autoimmune disease that affects the central nervous system
- involves destruction of CNS myelin (demyelination) of the white matter of the brain
- most common acquired disease of the nervous system in young adults, more women than men
- does not affect intellect
What are the SXS of multiple sclerosis?
- unsteady gait
- slurred speech
- blurred or double vision
- facial numbness or pain
What is Guillian-Barre syndrome (GBS)?
- autoimmune inflammatory disorder of the peripheral nerves and sometimes cranial nerves
- exact cause is unknown but could be viral infections or immunizations
- causes damage to myelin sheaths
What are the SXS of Guillian-Barre syndrome?
- progressive muscle weakness
- can affect ANS-swallowing and respiration
What is myasenthia gravis?
- chronic autoimmune disorder that destroys ACH receptor sites at neuromuscular junctions
- prevents nerve impulses from reaching the muscles
- weakness and rapid fatigue occurs in affected muscles
When does myasenthia gravis usually affect females?
When does myasenthia gravis usually affect males?
What are some SXS of myasenthia gravis?
- drooping eyelids
- difficulty speaking
- difficulty swallowing and chewing
- weakened respiratory muscles
- difficulty with extremity movements
What is a myasthenic crisis?
- Severe muscle weakness involving respiratory insufficiency
- Problem here is respiratory arrest
What is a cholinergic crisis?
- associated with myasenthia gravis
- anticholinergic drug toxicity causes SLUDGE symptoms along with symptoms of myasthenic crisis
- the muscles stop responding to ACH and can lead to paralysis of respiratory muscles
What is the adult dose for Diazepam?
What is the adult dose for Lorazepam?
What is the adult dose for Midazolam?
What is the dosage for our calcium preparations?
5-10mL q 5-10
What is the adult dosage for Dextrose?
What the adult dose for Dopamine for neurogenic shock?
2-20mcg/kg/min; upper level for neuro shock is 10mcg/kg/min; good starting point is 5
What is the adult dose for glucagon?
- 0.5-1.0mg for hypoglycemia
- 3-10mg for Beta Blocker OD
What is the indication for Mannitol?
acute cerebral edema not responsive to other modalities; transport only
What is the adult dose for Narcan?
0.4-2.0mg titrated to respiratory effect
What is the adult dose for Pralidoxime?
What is the adult dose for Promethazine?
12.5-25mg q 4 hrs
What is the adult dose for Sodium Bicarbonate?
1 mEq/kg only with MCEP
What is the adult dose for Thiamine?
What is the adult dose for Atropine used as an anticholinergic?
What are the major neurotransmitters?
Serotonin Dopamine GABA Norepinephrine Epinephrine ACH
Describe nerve transmission in the ANS.
- Impulse is transmitted through the preganglionic neuron and across the synaptic junction to the postganglionic neuron
- The preganglionic neurotransmitter in both the sympathetic and parasympathetic systems is ACH
- ACH is contained in vesicles on the synaptic knob on the end of the presynaptic neuron
- These vesicles break open and release ACH so that it travels across and hits the receptor sites on the plasma membrane of the postsynaptic neuron
- The postganglionic neuron then transmits the impulse to the affected organ
- In the sympathetic nervous system the postganglionic neurotransmitter is norepinephrine
- In the parasympathetic nervous system the postganglionic neurotransmitter is ACH
- At the organ, the vesicles once again break open and release whichever neurotransmitter they are carrying
- The receptor sites are stimulated at the affected organ
- Any leftover neurotransmitter after stimulation can be reabsorbed or destroyed by enzymes specific to the neurotransmitter