(BQ) Part 2 book Fast facts about neurocritical care has contents: Myasthenia gravis, isolated seizures, status epilepticus, determination of brain death, organ donation, guillain–barré syndrome,.... and other contents.
IV Neuromuscular Disorders 111 10 Guillain–Barré Syndrome Guillain–Barré syndrome (GBS) is an autoimmune disorder of the peripheral nervous system In GBS, the body’s immune system destroys the myelin sheath and the body’s ability to carry nerve signals, resulting in progressive weakness and possible autonomic dysfunction This can create hemodynamic instability, requiring critical care interventions In this chapter, you will learn how to: ■ ■ ■ Describe symptoms of GBS Diagnose GBS Review treatment strategies for GBS EPIDEMIOLOGY ■ ■ ■ ■ Rare: to in 100,000 per year Slightly more common in men than women (1.25:1) Bimodal incidence ■ Children and young adults ■ Patients over the age of 55 years ❏ Higher rates in older adults Occurs more commonly during winter months 113 113 114 PART IV NEUROMUSCULAR DISORDERS PATHOPHYSIOLOGY The exact pathophysiology of GBS is poorly understood; however, it is typically agreed upon that the immune system is activated by some type of precipitating event/factor that leads to autoantibody production Often, it appears that viral or bacterial infection occurs prior to GBS One theory regarding the disease process is that the infection itself changes nervous system cells in a way that essentially makes them unrecognizable to the immune system, which subsequently treats them as foreign cells Another theory is that the infection makes the immune system hyperactive and attacks the myelin In GBS, the peripheral nervous system is affected, mostly the spinal and cranial nerve roots; however, autonomic nerves can also be affected Once the myelin sheath, which surrounds axons, or even axons themselves are destroyed by the immune system, the nerves cannot transmit signals appropriately Because the nerve pathway between the brain and sensory is damaged, the brain cannot receive signals such as temperature, pain, or even the ability to feel texture In order for recovery to occur, the immune response must be dampened to allow for nerve repair CLASSIFICATIONS ■■ Two main types ■■ Acute inflammatory demyelinating polyneuropathy (AIDP) ❏❏ In AIDP, the myelin sheath and Schwann-cell components are attacked ❏❏ Most common form ■■ Acute motor axonal neuropathy (AMAN) ❏❏ In AMAN, the membranes of the nerve axon are attacked ❏❏ Less common, more severe course of illness with slow recovery CLINICAL COURSE ■■ Stage 1: Immune activation/prodromal (Figure 10.1) ■■ Two-thirds of patients have preceding respiratory or gastrointestinal (GI) infection ■■ Common pathogens are Campylobacter, Mycoplasma, or viruses ■■ Typically prodromal illness occurs about weeks prior to presentation Progression Recovery Figure 10.1 Disease course and stages of GBS GBS, Guillain–Barré syndrome ■ ■ Stage 2: Progression ■ Week to 2: Sensory and/or cranial nerve involvement ■ Peak clinical deficits typically occur at weeks ■ Subacute GBS can progress up to weeks Plateau stage: follows progression Fast Facts Despite initial improvement, 10% of patients deteriorate again and may benefit from another round of treatment ■ Stage 3: Recovery ■ Lasts months to years SIGNS AND SYMPTOMS ■ Weakness ■ Characterized as follows ❏ Progressive ❏ Bilateral ❏ Symmetric ■ Most often starts in legs ■ Commonly ascending Fast Facts Variants to the typical presentation exist Miller Fisher variant often presents as ophthalmoplegia, ataxia, and areflexia, which may then progress to limb weakness Chapter 10 Immune activation Guillain–Barré Syndrome 115 116 ■ PART IV NEUROMUSCULAR DISORDERS ■ ■ ■ Sensory involvement is common ■ Pain ❏ Often described as in the low back or legs ❏ Occurs prior to weakness in one third of cases ■ Paresthesias ❏ Initial symptom in half of patients, eventually occurs in 70% to 90% ❏ Occur distally first ■ Sensory loss often in patches ■ Fifteen percent of GBS patients have purely motor symptoms Cranial nerve VII ■ Symmetric: Early occurrence, parallel with weakness ■ Asymmetric: Later occurrence, other weakness may be improving Deep tendon reflex (DTR) loss ■ Areflexia occurs early in most patients (70%) but can occur late ■ Initially may be normal or hyperreflexic ■ Ankles most often lost ■ Biceps most often spared ■ If no loss of any DTR during disease course, consider other differential diagnoses Autonomic dysfunction ■ Occurs ~60% of the time ■ More common in severe syndrome Fast Facts Test autonomic function by applying bilateral ocular pressure for 25 seconds If present, this will cause temporary bradycardia ■ ■ ■ Blood pressure ❏ Transient hyper- or hypotension ❏ Orthostatic hypotension ❏ More sensitive to antihypertensives Cardiac arrhythmias ❏ Tachycardia or bradycardia can occur ❏ Dysrhythmias can occur Bladder ❏ Urinary retention ❏ Sphincter symptoms in one tenth of patients 117 Some Widely Accepted Criteria to Admit a Patient with GBS to ICU Vital capacity 50% of the normal ROM) hypersensitivity es: ch side should be tested to between AIS B and C) Root level C5 C = Motor Incomplete Motor function is preserved at the most caudal sacral segments for voluntary anal contraction (VAC) OR the patient meets the criteria for sensory incomplete status (sensory function preserved at the most caudal sacral segments (S4-S5) by LT, PP or DAP), and has some sparing of motor function more than three levels below the ipsilateral motor level on either side of the body (This includes key or non-key muscle functions to determine motor incomplete status.) For AIS C – less than half of key muscle functions below the single NLI have a muscle grade ≥ D = Motor Incomplete Motor incomplete status as defined above, with at least half (half or more) of key muscle functions below the single NLI having a muscle grade ≥ E = Normal If sensation and motor function as tested with C6 C7 humb dicular B = Sensory Incomplete Sensory but not motor function is preserved below the neurological level and includes the sacral segments S4-5 (light touch or pin prick at S4-5 or deep anal pressure) AND no motor function is preserved more than three levels below the motor level on either side of the body C8 the ISNCSCI are graded as normal in all segments, and the patient had prior deficits, then the AIS grade is E Someone without an initial SCI does not receive an AIS grade Using ND: To document the sensory, motor and NLI levels, the ASIA Impairment Scale grade, and/or the zone of partial preservation (ZPP) when they are unable to be determined based on the examination results The following order is recommend individuals with SCI Appendix B A = Complete No sensory or motor function is preserved in the sacral segments S4-5 th gravity eliminated ternal 205 ASIA Impairment Scale (AIS) Determine sensory levels fo The sensory level is the most cauda light touch sensation Determine motor levels for Defined by the lowest key muscle supine testing), providing the key m above that level are judged to be in Note: in regions where there is no presumed to be the same as the s that level is also normal Determine the neurological This refers to the most caudal segm antigravity (3 or more) muscle func (intact) sensory and motor function The NLI is the most cephalad of th steps and Determine whether the inju (i.e absence or presence of sacral If voluntary anal contraction = No AND deep anal pressure = No, the Otherwise, injury is Incomplete Determine ASIA Impairment Is injury Complete? If YES ZPP ( NO on ea Is injury Motor Complete? I NO T1 L2 Are at least half (half or more) neurological level of injury gra L3 NO L4 L5 S1 (No= more than given side, classificatio INTERNATIONAL STANDARDS FOR NEUROLOGICAL CLASSIFICATION OF SPINAL CORD INJURY AIS=C If sensation and motor function Note: AIS E is used in follow-up tes SCI has recovered normal function individual is neurologically intact; th 206 Steps in Classification Appendix B t Scale (AIS) otor function is preserved in sory but not motor function evel and includes the sacral ick at S4-5 or deep anal preserved more than three r side of the body unction is preserved at the untary anal contraction (VAC) sensory incomplete status ost caudal sacral segments some sparing of motor w the ipsilateral motor level e functions to determine – less than half of key LI have a muscle grade ≥ ncomplete status as defined ) of key muscle functions e grade ≥ or function as tested with n all segments, and the S grade is E Someone e an AIS grade ory, motor and NLI levels, d/or the zone of partial able to be determined S FOR NEUROLOGICAL NAL CORD INJURY The following order is recommended for determining the classification of individuals with SCI Determine sensory levels for right and left sides The sensory level is the most caudal, intact dermatome for both pin prick and light touch sensation Determine motor levels for right and left sides Defined by the lowest key muscle function that has a grade of at least (on supine testing), providing the key muscle functions represented by segments above that level are judged to be intact (graded as a 5) Note: in regions where there is no myotome to test, the motor level is presumed to be the same as the sensory level, if testable motor function above that level is also normal Determine the neurological level of injury (NLI) This refers to the most caudal segment of the cord with intact sensation and antigravity (3 or more) muscle function strength, provided that there is normal (intact) sensory and motor function rostrally respectively The NLI is the most cephalad of the sensory and motor levels determined in steps and Determine whether the injury is Complete or Incomplete (i.e absence or presence of sacral sparing) If voluntary anal contraction = No AND all S4-5 sensory scores = AND deep anal pressure = No, then injury is Complete Otherwise, injury is Incomplete Determine ASIA Impairment Scale (AIS) Grade: Is injury Complete? If YES, AIS=A and can record ZPP (lowest dermatome or myotome NO on each side with some preservation) Is injury Motor Complete? If YES, AIS=B NO (No=voluntary anal contraction OR motor function more than three levels below the motor level on a given side, if the patient has sensory incomplete classification) Are at least half (half or more) of the key muscles below the neurological level of injury graded or better? NO AIS=C YES AIS=D If sensation and motor function is normal in all segments, AIS=E Note: AIS E is used in follow-up testing when an individual with a documented SCI has recovered normal function If at initial testing no deficits are found, the individual is neurologically intact; the ASIA Impairment Scale does not apply Index abducens nerve, 7, 10 Adams Diffuse Axonal Injury Grading, 100 AEDs See antiepileptic drugs Alberta Stroke Program Early CT Score (ASPECTS), 57 aneurysm See also subarachnoid hemorrhage detection and diagnosis, 81 interventions, 83–85 intracranial, 78–79 pseudo-, 79 rupture, 78, 79, 83, 85 types, 79 unsecured, 83 angiography, 67, 95 CT (CTA), 35, 58, 81, 86 digital subtraction (DSA), 81, 86 magnetic resonance (MRA), 86 anhidrosis, 33 anisocoria, 10, 96, 99 anosmia, antibody/antibodies, 117, 118, 123, 128, 171 antiacetylcholine receptor (antiAChR Abs), 124, 126 anti-MuSK, 126 auto-, 114 anticoagulation, reversal of, 65, 72, 73, 96, 99 antiepileptic drugs (AEDs), 73, 80, 102, 146, 147, 151–152 antifibrinolytic agents, 83 antiplatelet therapy/antiplatelets, 62, 73 aphasia, 23, 61, 69, 171 expressive, 55, 56 global, 56 receptive, 55, 56 aphasic patients best language assessment, 23 dysarthria scoring, 24 extinction/inattention scoring, 25 LOC scoring, 19 sensory assessment, 23 apnea and brain death, 176, 177–179 and coma, 29, 31, 32 and ICP, 44 and respiratory failure, 129 and seizures, 137 arrhythmias, 140, 148 bradycardia, 29, 42, 94, 109, 116 tachycardia, 62, 116, 129, 138 arteriovenous malformation (AVM), 60, 66, 67 ASPECTS See Alberta Stroke Program Early CT Score asymmetry, 10, 11, 32 207 Index 208 atherosclerosis, 52, 54 AVM See arteriovenous malformation barbiturates, 150, 177, 181 Bell’s phenomenon, 34 bilevel positive airway pressure (BIPAP), 119, 130 BIPAP See bilevel positive airway pressure blindness, 20, 55 blood pressure (BP), 116 control/management, 61, 71, 83, 96, 99, 109 diastolic (DBP), 60 systolic (SBP), 60, 71, 83, 109, 177, 180, 186 BP See blood pressure brain death, 175–181, 183, 184, 185 ancillary tests, 179–181 apnea exam, 176, 177–179 brainstem reflexes and responses, 178 components of, 176 confounding factors in diagnosis of, 176, 177 definition, 175 examination, 176–181 pronunciation of, 176 brain herniation, 37, 41–42 brain injury, 6, 12, 14, 38, 83, 147, 150 See also traumatic brain injury brainstem, 27, 70, 100, 175 cranial nerves’ origin, 6, encephalitis, 171 lesions, 10, 11, 13 reflexes, 31–32, 34, 178 burr hole, 96, 99 CAA See cerebral amyloid angiopathy CBF See cerebral blood flow cerebellum, 15, 68, 70 cerebral amyloid angiopathy (CAA), 66, 67 cerebral angiogram, 180 cerebral artery/arteries, 53, 54, 81 anterior (ACA), 50, 55, 63 middle (MCA), 50, 55, 57, 63 posterior (PCA), 41, 55 cerebral blood flow (CBF), 38, 43, 45, 58 cerebral perfusion pressure (CPP), 38, 42, 45, 96, 99, 101 cerebrospinal fluid (CSF) elevated protein levels, 117, 147 interpretation in disease conditions, 157, 159–161, 165–168 in intracranial hypertension, 37–40 in SAH, 84, 160–161 cerebrum, 6, cerebral cortex, 13, 27, 43, 100 Cheyne–Stokes respirations, 29, 31 circle of Willis, 49, 50 CNs See cranial nerves coagulopathy, 70 rebound, 72 reverse, 72, 73 See also anticoagulation, reversal of COATPEGS, 29–30 “cold calorics,” 34 collateral circulation, 53, 54 coma, 98, 102, 176 See also comatose patients deep, 28 definition of, 4, 27 etiology of, 28, 35 evaluation of, 28–36 hysterical, 36 investigations/tests for, 35–36 light, 28 metabolic, 29–30, 32 mimics, 36 structural, 32 comatose patients corneal reflex, 34 emergency treatment for, 28 eye movements, 33–34 dysarthria scoring, 24 facial palsy scoring, 21 DAI See diffuse axonal injury diabetes, 53, 60, 87 diffuse axonal injury (DAI), 91, 99–102 classification, 100 concussion/mild, 100 diagnosis, 100–101 epidemiology, 99 management, 101–102 pathophysiology, 100 prognosis, 102 severity, 100 symptoms, 100 digital subtraction angiography (DSA), 81, 86 diplopia, 125, 171 “doll’s eyes,” 34 DSA See digital subtraction angiography dysarthria, 12, 18, 55, 56–57, 125, 171 scoring, 19, 24, 25 dysphagia, 12, 55, 125, 171 dysphasia, 56–57 edema, 30, 37, 46, 57, 100, 104, 186 angio-, 61 cerebral, 38–39, 53, 63 cytotoxic, 38–39 papill-, 6, 158, 159 periorbital, 30 pulmonary, 147 vasogenic, 38–39 EDH See epidural hematoma EEG See electroencephalography electroencephalography (EEG), 6, 73, 141, 143, 145, 148–149, 169, 179 electromyography (EMG), 126–127 EMG See electromyography encephalitis, 139, 141, 165–172 acute disseminated (ADEM), 169–170 CSF interpretation in, 165–168 diagnosis, 166 herpes simplex, 167–169 investigations, 166–167 paraneoplastic, 170–172 presentation, 165 Index 209 full outline of unresponsiveness (FOUR) score, 30–32 gag reflex, 34 GCS score, 4, 30 LOC, 30 mental status, 32 motor exam, 32 neurological examination, 29–34 physical examination, 28–29 pupil exam, 32–33 respiratory patterns in, 29 sensory scoring, 23 with status epilepticus, 146, 148, 149 confusion, 4, 5, 42, 93, 137, 148, 150, 169 corneal reflex, 7, 31, 34 CPP See cerebral perfusion pressure cranial nerves (CNs), 6–13 I (olfactory nerve), 6, II (optic nerve), 6, 7, 8–9, 44 III (oculomotor nerve), 7, 9–10 IV (trochlear nerve), 7, 10–11 V (trigeminal), 7, 11, 34 VI (abducens), 7, 10 VII (facial), 7, 11, 34 VIII (vestibulocochlear), 7, 11 IX (glossopharyngeal), 7, 12 X (vagus), 7, 12 XI (spinal), 7, 12 XII (hypoglossal), 7, 12 craniotomy, 74, 84, 96, 99 CSF See cerebrospinal fluid CT angiography (CTA), 35, 58, 81, 86 CT perfusion (CTP), 35, 58–59, 86 CT scan, 35–36, 40, 42, 67, 96, 98, 99, 101, 108, 127, 166 See also CT angiography; CT perfusion; noncontrast CT scan CTA See CT angiography CTP See CT perfusion Cushing’s triad, 42, 94 Index 210 EOMs See extraocular eye movements epidural hematoma (EDH), 91, 93–97, 146 definition, 93 diagnostic evaluation, 95 epidemiology, 93 management, 96 pathophysiology, 93–94 prognosis, 97 symptoms, 94 epilepsy, 36, 135, 142, 169 euvolemia, 86, 109, 177 EVD See external ventricular drain extension, 5, 16, 31, 106, 129 external ventricular drain (EVD), 41, 42–43, 46, 84 extinction, 13, 18, 24–25, 55, 61 See also inattention; visual extinction extraocular eye movements (EOMs), 10–11 facial nerve, 7, 11, 34 FLAIR See fluid-attenuated inversion recovery flexion, 5, 16, 31, 176 fluid-attenuated inversion recovery (FLAIR), 81, 101, 168, 169 forced vital capacity (FVC), 119, 129 FOUR score See full outline of unresponsiveness score full outline of unresponsiveness (FOUR) score brainstem reflexes, 31–32 eye response, 30–31 motor response, 31 respirations, 31, 32 funduscopic examination, FVC See forced vital capacity gag reflex, 7, 12, 34 gaze palsy, 10, 20 gaze paresis, 20 GBS See Guillain–Barré syndrome GCS See Glasgow Coma Scale GCSE See generalized convulsive status epilepticus generalized convulsive status epilepticus (GCSE), 145, 148, 152 Glasgow Coma Scale (GCS), 3, 17, 184 comatose patients’ score, 4, 30 eye response, 4, ICH classification, 70, 75 limitations of, 30 motor response, TBI classification, 92, 97, 100 verbal response, 4–5 glossopharyngeal nerve, 7, 12 graphesthesia, 13 grimace/grimacing, 4, 21, 23 Guillain–Barré syndrome (GBS), 36, 113–121, 161 acute inflammatory demyelinating polyneuropathy (AIDP), 114, 118 acute management, 118–120 acute motor axonal neuropathy (AMAN), 114, 118 admission to ICU, 117 clinical course, 114–115 CSF interpretation in, 160–161 diagnosis, 117–118 epidemiology, 113 Miller Fisher variant, 115, 117 pathophysiology, 114 prognosis, 120–121 signs and symptoms, 115–117 treatment, 120 head trauma, 6, 60, 97 headache in aSAH, 80, 86 in encephalitis, 168, 169 in intracranial hypertension, 40, 42 in meningitis, 157–158 migraine, 80, 138 in stroke, 54, 67, 69 in TBI, 93, 94, 100 hypertension (HTN) See also intracranial hypertension and herniation syndrome, 29 and ICH, 66, 71 and ICP, 42 as SAH risk factor, 78, 79, 86 and seizures, 137, 148 as stroke risk factor, 53, 61 and TBI, 94, 96, 99 hyperthermia, 45, 63, 109, 147, 148 hyperventilation, 29, 45, 101 hypoglossal nerve, 7, 12 hypoglycemia, 28, 29, 32, 63, 140, 147, 148 hyposmia, hypotension, 83, 86, 96, 99, 101, 109, 116, 119, 148, 152, 177 hypoxia, 28, 101, 129, 147 ICH See intracerebral hemorrhage ICP See intracranial pressure inattention, 18, 24–25, 55 See also extinction incontinence, urinary, 55, 105, 110 infarction, 18, 36, 52–53, 58, 104 cerebral, 85 middle cerebral artery (MCA), 57 myocardial, 60 INR See international normalized ratio instability autonomic, 108, 119 hemodynamic, 113, 119, 130, 178 international normalized ratio (INR), 60, 63, 70, 72, 73, 83, 95, 98 intracerebral hemorrhage (ICH) blood pressure control, 71 causes, 66–67 classification, 70 clinical manifestations, 67–69 diagnostic studies for, 67, 70 epidemiology, 65 management, 71–74 mortality, 74 neurosurgical interventions for, 74 Index 211 hearing loss, 11, 171 hematoma, 67, 85, 92, 110 epidural (EDH), 91, 93–97, 146 evacuation, 46, 74, 96, 97, 99 groin, 81 subdural (SDH), 40, 91, 97–99, 146 volume estimation, 71 hemianopia bilateral, 20 bipolar, complete, 20, 61 contralateral, 69 homonymous, 8, 55, 69 ipsilateral, 55 partial, 20 hemianopsia See hemianopia hemicraniectomy, decompressive, 63, 74 hemineglect, hemiparesis, 11, 14, 55, 68, 82, 94, 105 hemiplegia, 14 hemorrhage, 36, 37, 53, 57, 74, 92 See also intracerebral hemorrhage; subarachnoid hemorrhage hemorrhagic conversion, 18, 63–64 hemorrhagic stroke See intracerebral hemorrhage herniation, 9, 10, 30, 37, 38, 162 anterior disc, 105 brain, 37, 41–42 herniation syndrome, 28, 29, 37, 42, 84, 99 hippus, 9, 33 Horner’s syndrome, 33 HTN See hypertension Hunt–Hess score, 82 hydrocephalus, 35, 41, 46, 67, 72 communicating, 39 ex-vacuo, 39 noncommunicating/obstructive, 39, 84 normal pressure, 39–40 hygroma, 40 hyperglycemia, 75, 148 hyperosmia, Index 212 intracerebral hemorrhage (ICH) (cont.) pathophysiology, 66 prognosis, 74–75 reverse coagulopathy, 72, 73 risk factors for, 66–67 score, 70, 74 “spot sign,” 67 intracranial hypertension, 38–41, 147 See also intracranial pressure intracranial pressure (ICP) diagnosis, 42–44 increased, 42–44, 53, 94, 99, 101, 102 and intracranial hypertension, 38, 39, 40 medical interventions, 45–46 neurosurgical interventions, 46 normal range values, 38, 43 nursing interventions, 44 intravenous immunoglobulin (IVIG), 120, 128, 130, 170, 172 ischemia, 45, 52, 54, 57, 58, 84 cord, 109 delayed cerebral (DCI), 85–86 ischemic stroke, 85 care of patients with, 63 complications, 63–64 diagnostic studies, 57–59 embolic, 54 management, 59–63 medications, 59–62 neurosurgical interventions, 63 thrombotic, 52–53 transient ischemic attack (TIA), 51–52, 62, 138 types, 51–54 IVIG See intravenous immunoglobulin jolt accentuation test, 158 Lazarus movements, 176 lesions, 9–13, 30, 32, 105, 108 level of consciousness (LOC), 3, 17 alert, 4, 19 in comatose patients, 4, 30 lethargic, measurement, 4, See also Glasgow Coma Scale obtunded, 4, 23 in stroke patients, 18–19 stupor, limb ataxia, 18, 22, 25, 68, 115 LOC See level of consciousness locked-in syndrome, 30, 31, 36 LP See lumbar puncture lumbar puncture (LP) coma, 35 encephalitis, 166, 168, 170, 171 meningitis, 159, 162 SAH, 81, 84 seizures, 141, 149–150 magnetic resonance angiography (MRA), 86 magnetic resonance imaging (MRI) aneurysm, 81 coma, 35 edema, 39 encephalitis, 166, 168, 169–170, 171 GBS, 118 ICH, 67 ischemic stroke, 57–58 MG, 127 SCI, 108, 110 seizures, 139, 140 TBI, 95, 98, 101 MAP See mean arterial pressure Marshall classification, 92 Mayo Classification System, 92–93 mean arterial pressure (MAP), 38, 109, 162 meningismus, 69, 157, 158 meningitis, 6, 9, 139, 157–164 antibiotics for, 162, 163 CSF interpretation in, 159–161 diagnosis, 159–162 presentation, 157–158 treatment, 162–164 types, 162–164 nail bed pressure, 4, 5, 32 National Institute of Health Stroke Scale (NIHSS) booklet, 23, 24 limitations of, 25 stroke severity, 17–18, 54, 60, 63, 64 National Institute of Neurological Disorders and Stroke (NINDS), 59, 60 NCSE See nonconvulsive status epilepticus negative inspiratory force (NIF), 117, 119, 127, 129 neglect, 9, 25, 55, 69 See also extinction; inattention neuro checks, components of, 3–16 cranial nerve (CN) examination, 6–13 Glasgow Coma Scale (GCS), 3, 4–5 level of consciousness (LOC), 3, motor exam, 13–14 orientation, 3, 5–6 pronator drift assessment, 14 reflexes, 15–16 sensation, 13 speech/language, 3, neurological examination of comatose patients, 29–34 goal of, 3, 17 of stroke patients, 17–25 NIF See negative inspiratory force NIHSS See National Institute of Health Stroke Scale nimodipine, 86 NINDS See National Institute of Neurological Disorders and Stroke noncontrast CT scan, 57, 67, 81, 95, 98, 148, 159 nonconvulsive status epilepticus (NCSE), 138, 145, 148, 169 normothermia, 63, 109 nuclear medicine scan, 180 nystagmus, 10–11, 34, 36, 55, 146 ocular bobbing, 11 oculocephalics, 20, 34, 178 oculomotor nerve, 7, 9–10 oculovestibular testing, 34, 36, 178 olfactory nerve, 6, OPO See organ procurement organization optic nerve, 6, 7, 8–9, 44 organ donation, 183–187 See also organ donors consent process, 184–185 donor management, 185–186 organ evaluation and management, 186 organ recovery process, 186–187 Index 213 MG See myasthenia gravis miosis, 33 modified Fisher scale, 82, 83 Monro–Kellie doctrine, 37–38 MRA See magnetic resonance angiography MRI See magnetic resonance imaging multiple sclerosis (MS), 107, 160–161, 170 muscle/muscles bulk, 13 strength, 14, 126, 127 tone, 13, 32, 56, 107, 126, 136 myasthenia gravis (MG), 36, 123– 130 See also myasthenic crisis admission to ICU, 127 diagnosis, 125–127 epidemiology, 123–124 pathophysiology, 124 signs and symptoms, 125 treatment, 127–128 myasthenic crisis, 123, 125, 128–130 management, 129–130 mortality, 130 respiratory failure, 129–130 signs and symptoms, 129 triggers, 128 Index 214 organ donors exclusion criteria for potential, 184 referral of potential, 184 types, 183–184 organ procurement organization (OPO), 183, 184, 185 palsy, 10, 20–21 papilledema, 6, 158, 159 paresthesias, 13, 116 partial thromboplastin time (PTT), 63, 70, 95, 98 PCC See prothrombin complex concentrate penumbra, 58–59 peripheral vision, 8, 20 pinprick stimulation, 22–23, 106 plasma exchange (PLEX), 120, 127, 130 plasmapheresis, 128, 170, 171 PLEX See plasma exchange pneumocephalus, 40–41 pons, 7, 11, 29, 33, 34, 36, 68, 70 posturing, 28, 32, 82 prothrombin complex concentrate (PCC), 72, 73 prothrombin time (PT), 60, 63, 70, 95, 98 PT See prothrombin time ptosis, 69, 125, 126 PTT See partial thromboplastin time pupils, examination of, 9–10, 31 light reflex dysfunction, 33 metabolic coma, 32 unilateral hypothalamic damage, 33 reflexes ankle, 15 biceps, 15 brachioradialis, 15 brainstem, 31–32, 34, 178 Clonus (pathologic), 15, 16 corneal, 7, 31, 34 cough, 32 deep tendon, 15, 116, 165 gag, 7, 12, 34 Hoffman response (pathologic), 16 jaw jerk, 11 knee jerk, 15 oculocephalic, 20, 34, 178 oculovestibular, 34, 36, 178 papillary, 31 pendular, 15 plantar (pathologic), 16 spinal cord, 176 triceps, 15 quadrantanopia, 8, 20 SAH See subarachnoid hemorrhage SCI See spinal cord injury SDH See subdural hematoma seizure/seizures, 9, 35, 36, 42, 45, 73, 80, 94, 135–143 See also epilepsy; status epilepticus conditions mistaken as, 140 differentials for evaluation of, 139 epidemiology, 136 focal, 136–137 generalized, 137, 139, 140 investigations, 138–141 medications to be avoided, 149, 152 nursing interventions for acute, 142 prognosis, 142 provoked, 136, 142, 143 psychogenic nonepileptic, 139, 140 recurrence, 143, 145 symptomatic, 135–136 symptoms, 138 treatment, 141–142 types, 136–138 unprovoked, 135, 136, 142 selective serotonin-reuptake inhibitors (SSRIs), 62 facial grimace to, 21, 178 motor response to, 5, 31, 178 withdrawal to, 5, 23 stroke See also stroke patients brainstem, 53 clinical manifestations, 54–57 hemorrhagic See intracerebral hemorrhage ischemic See ischemic stroke malignant hemispheric, 63 pathophysiology, 49–51 risk factors for, 49, 51 secondary, 62 posteriorcirculation, 25 stroke patients, 17–25 arm motor assessment, 21 best gaze, 19–20 best language, 23–24 dysarthria, 24 extinction/inattention, 24–25 facial palsy, 11, 20–21 leg motor function, 22 limb ataxia, 22 LOC, 18–19 sensory assessment, 22–23 visual field testing, 20 subarachnoid hemorrhage (SAH), 6, 35, 39 aneurysmal (aSAH), 78, 80 See also aneurysm complications, 85–88 CSF interpretation in, 160–161 diagnosis, 80–81, 86 epidemiology, 77–78 medical interventions, 83, 86 neurosurgical interventions, 84–85, 88 pathophysiology, 78–79 risk factors for, 78 severity, 82–83 signs and symptoms, 80 urine abnormalities in, 86, 87 subdural hematoma (SDH), 40, 91, 97–99, 146 classification, 98 definition, 97 diagnostic evaluation, 98 epidemiology, 97 Index 215 somatosensory evoke potentials (SSEPs), 180–181 spasticity, 13, 32, 56 spinal accessory nerve, 7, 12 spinal anatomy, 104–105 spinal cord injury (SCI) clinical presentation, 105–106 diagnostic tests, 107–108 epidemiology, 103–104 location, 104 management, 108–110 muscle groups affected by, 106 pathophysiology, 104 physical assessment, 106–107 prognosis, 110 spinal cord syndromes, 105 SSEPs See somatosensory evoke potentials SSRIs See selective serotoninreuptake inhibitors Statin therapy, 62 status epilepticus, 143, 145–152, 169 antiepileptic therapy, 142, 146, 147 See also antiepileptic drugs causes, 146–147 convulsive, 138 See also generalized convulsive status epilepticus epidemiology, 146 investigations, 148–150 medications that trigger, 149, 152 mortality, 152 nonconvulsive See nonconvulsive status epilepticus pathophysiologic effects, 147–148 prognosis, 152 refractory, 146, 151 symptoms, 146, 148 treatment, 150–152 stereognosis, 13 stimuli, noxious comatose patients’ response to, 31, 32 eye opening to, 4, Index 216 subdural hematoma (SDH) (cont.) management, 99 pathophysiology, 97–98 prognosis, 99 symptoms, 98 classification, 92–93 epidemiology, 91 severity, 92–93 trigeminal nerve, 7, 11, 34 trochlear nerve, 7, 10–11 TBI See traumatic brain injury TCD See transcranial Doppler TEG See thromboelastogram tensilon test, 126 thrombectomy, 63 thromboelastogram (TEG), 70 thymectomy, 128 TIA See transient ischemic attack tissue plasminogen activator (tPA), 18, 59–64 administration, 61, 63 blood pressure control, 61–62 exclusion criteria, 60 hemorrhagic conversion, 63–64 inclusion criteria, 60 intra-arterial, 63 reversal agent for, 73 Todd’s paralysis, 32, 137, 138, 143 toxic metabolic encephalopathy, 28 tPA See tissue plasminogen activator transcranial Doppler (TCD), 43, 86, 179–180 transient ischemic attack (TIA), 51–52, 62, 138, 140 traumatic brain injury (TBI), 39, 146 See also diffuse axonal injury; epidural hematoma; subdural hematoma Uniform Determination of Death Act (1981), 175 vagus nerve, 7, 12 valsalva, 41 vasopressors, 45, 109, 119, 120, 162 vasospasm, 82–86 vestibulocochlear nerve, 7, 11 visual acuity, 7, visual extinction, 9, 61 visual fields, 7, 8, 17, 20, 55 vitamin K, 72–73 weakness, 11, 12, 14, 19, 21, 22, 61, 105, 108, 115–116, 119, 125, 170 See also hemiparesis WFNS scale See World Federation of Neurosurgical Societies scale World Federation of Neurosurgical Societies (WFNS) scale, 82 xanthochromia, 81, 160, 168 Fast F FAST FACTS FOR YOUR NURSING CAREER Choose from Over 40 Titles! These must-have reference books are packed with timely, useful, and accessible information presented in a clear, precise format Pocket-sized and affordable, the series provides quick access to information you need to know and use daily springerpub.com/FastFacts Fast Facts BOB Grayscale Book.indd 8/21/18 3:58 PM ... from mother with MG 123 123 124 Temporary Symptoms abate to months after birth Bimodal incidence ■ Women peak during their 20 s and 30s ■ Men peak during their 70s and 80s ❏ PART IV NEUROMUSCULAR... Penn, A S., & Sanders, D B (20 00) Myasthenia gravis: Recommendations for clinical research standards Neurology, 55, 16 23 doi:10. 121 2/WNL.55.1.16 V Seizures 133 12 Isolated Seizures Seizures... Z., Sultan, B., & Katirji, B (20 08) Guillain–Barré syndrome: Incidence and mortality rates in US hospitals Neurology, 70, 1608–1613 doi:10. 121 2/01.wnl.0000310983.38 724 .d4 Hughes, R.A.C., Brassington,