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CNS Pathophysiology
NUR 878 Exam III
94
Pathology
Graduate
07/20/2014

Additional Pathology Flashcards

 


 

Cards

Term
Collection of nuclei found on both sides of the thalamus and associated with many functions which include motor control, emotion, cognitive learning.  Subdivisions:  Putnum, caudate nucleus, pallidus, subthalmic nucleaus, substantia nigra.
Definition
Basal Ganglia
Term
Neurodegenerative disease occuring in the substantia nigra resulting in the loss of dopaminergic receptors (inhibitory) and unopposed acetylcholine
Definition
Parkinson's Disease
Term
System of neurons that coordinate motor movement
Definition
Extrapyramidal motor system
Term
With Parkinson's disease, (enhancing/depleting) dopamine results in the extrapyramidal system's excitatory neurotransmitter, acetylcholine being (inhibited/uninhibited)? (choose one)
Definition

Depleting

Uninhibited

Term

True or False:  Age is the MOST important risk factor in Parkinson's? 

 What are some risk factors?

Definition

True

(Mostly effects people between ages of 50-70 years.  Also linked to exposure to chemicals/drugs (MPTP and MPPP) to destroy dopaminergic cells or neurons or is heavily associated with a familial genetic disorder)

Term
What does TRAP stand for?
Definition

Classic "triad" of Parkinson's Disease

  1. Tremors-movements that worsen with REST and improves with voluntary motor movement
  2. Rigidity-proximals muscles of neck first
  3. Akinesia-difficulty initiating and maintaining motion.  Loss of normal arm swing, failure to rotate head,...slowness to execute movement is "bradykinesia"
  4. Postural instability-offten associated with injury (portal to OR)
  5. Emotional disturbances are also common-insomnia, depression, memory loss, dementia, hallucinations
Term
What are the treatment goals for Parkinson's Disease?
Definition
  • Increase amount of dopamine in substantia nigra (consider BBB) or inhibit the acetylcholine
  • ANTIcholinergic drugs
  • Levodopa
  • Symptom management
  • Surgical management-DBS anesthetic implications (ARTICLE)
Term
Parkinson's Disease Drugs
Definition

Increase Dopamine

MAOI

Oral Dopamine

COMT Inhibitors

 

Decrease Acetylcholine

Anticholinergics

Term
What is the normal percentage of Dopamine concentrated in the basal ganglia (caudate nucleus and putamen)?  What percentage with Parkinson's?
Definition
80%; decreases to approx. 10% of normal
Term
True or False: Dopamine readily crosses the BBB?
Definition
False; dopamine does NOT cross the BBB; a precursor to dopamine is levodopa---> Levodopa crosses the BBB and is converted to dopamine
Term
Levodopa crosses the BBB and is converted to dopamine by what enzyme?
Definition
dopa decarboxylase enzyme; restoring the supply of dopamine
Term
Levodopa is usually adminstered with what type of drug in order to maximize the of levodopa entering the brain?
Definition
Peripheral decarboxylase inhibitor; this inhibits the conversion of levodopa to dopamine in the periphery (where dopamine does NOT cross the BBB)
Term
Levodopa-->dopamine circulating outside the brain can produce...?
Definition

HTN and Tachycardia

 (decarboxylase inhibitors reduce these SE)

Term
Levodopa has a (short/extended) 1/2 life? (choose one)
Definition
Short; 1-3 hours and requires FREQUENT dosing orally (i.e. in the OR)
Term
True or False:  Levodopa can be discontinued abruptly?
Definition
False; not advised-rapid exacerbation of symptoms and neuroleptic malignant-like syndrome
Term
What are the EARLY and LATE side effects of levodopa?
Definition

Early:  Nausea and hypotension, salivation

Later:  Involuntary movements, tics, grimacing and rocking of arms/legs/trunk MOST common side effects of chronic therapy (50% of patients within 1-4 mos)

Term
True or False:  Antidopaminergics are used to treat Parkinson's Disease?
Definition
False; can antagonize levodopa and worsen disease
Term
List Antidopaminergics
Definition
Butyrophenones=haldol,droperidol
Phenothiazines=compazine, phenergan
Prokinetics=reglan
Term
MAOI (exaggerate/blunt) levodopa? (choose one)
Definition
EXAGGERATE
Term
Anticholinergics (improve/worsen) the symptoms of involuntary movements due to dopamine? (choose one)
Definition
Improve
Term
COMT
(peripheral decarboxylase inhibitor)
Definition
Catechol-O-methyl transferase
Term
Blocking the COMT enzyme will PREVENT breakdown of levodopa and increase the plasma concentration by what percent?
Definition
10-15%
Term
Explain how anticholinergics work for the treatment of Parkinson's Disease
Definition
Blunt the effect of the excitatory neurotransmitter acetylcholine; correcting the imbalance between dopamine and acetylcholine (MUST CROSS BBB)
Term
Glycopyrolate-Cross the BBB?
Definition
NO
Term
Atropine-Cross the BBB?
Definition
Yes
Term
Occurs particularly in the elderly when given anticholinergic; CNS dysfunction: Confusion, hallucinations, memory disturbances, sedation and the mydriasis can produce blurred vision
Definition
Anticholinergic Syndrome
Term
Thought to decrease the reuptake of dopamine or promote dopamine release at the nerve terminals (Tx:Antiviral...Parkinson's)
Definition
Amantidine
Term
What drug can be used to increase availability of acetylcholine in the treatment of anticholinergic syndrome?
Definition
Neostigmine-blocks the breakdown of acetylcholine by inhibiting acetylcholinesterase
Term
Anesthetic Management of Parkson's
Definition
1. Medications should be continued up to the day of surgery (NO abrupt withdrawal); consider dosing during OR
2. AVOID antidopaminergics (phenergan, compazine, haldol...etc.). Zofran CAN be used as well as Benadryl
3. Premedication and nausea control. Anticholinergics (atropine) and benadryl may be useful for exacerbation of symptoms, PLUS Benadryl is VERY useful sedative/antiemetic for these pt.'s
4. Induction agents for pt.'s on Levodopa may lead to hypo- or hypertension
5. Hypotension should be treated with DIRECT acting agent (Epinephrine, norepinephrine). Ephedrine has IN-Direct effects.
6. Autonomic instability-consider A-LINE
7. Small incidence of hyperkalemia with SUCCS.
Term
Autosomal dominant disease where the caudate nucleus of the basal ganglia is destroyed or dysfunctional that leads to not enough acetylcholine and too much dopamine
Definition
Huntington's Chorea
Term
Dopamine is moderated in the caudate nucleus by...?
Definition
GABA; inhibits dopamine; reduced in Huntington's Chorea
Term
True or False: Huntington's Chorea is diagnosed primarily in the elderly?
Definition
False; this is a 'young person's disease' most people presenting in 30-40's
Term
Symptoms seen with Hungtington's Chorea?
Definition
Jerking, uncontrolled random movements (Chorea); BEFORE the movement begins the pt. often exhibits mood changes/depression/RAGE ISSUES...ETOH, compulsive behaviors, pharyngeal muscle control loss (ASPIRATION) and death 12-20 yrs. after dx.
Term
True or False: Using Succs in a Huntington's Chorea pt. may cause prolonged paralysis?
Definition
True; correlation between a reduction in plasma cholinesterase (Succs has similar structure to ACTH and is broken down by cholinesterase)
Term
What type of medication is used to control movements and emotional disturbances in Huntington's Chorea?
Definition
Antidopaminergics (like Haldol...with butyrophenone or phenothiazines)
Term
True or False: Huntington's Chorea pts are NOT sensitive to NDMRs?
Definition
False
Term
General category of conditions in which sustained muscle contractions cause twisting and repetitive movements or abnormal postures
Definition
Dystonia; Thought to be a defect in the production or release of GABA; causes can be hereditary, trauma induced, psychiatric or drug induced (antidopaminergic drugs).
Term
Dystonia that involves intense contractions of the neck and facial muscles
Definition
Spasmotic Torticollis
Term
GABA
Definition
Gamma Aminobutyric Acid
Term
Anesthetic implications for dystonias (spasmotic torticollis)
Definition
Change in vertebral structures and anatomy, may require awake fiberoptic intubation; Positioning issues; induction allergic responses, rhizotomy cautions
Term
If a dystonic reaction occurs on induction...?
Definition
NDMRs will relax the muscle structures
Term
If a dystonic reaction occurs due to medication administration...?
Definition
Considered an ALLERGY and Benadryl 25-50mg IV is choice drug to reverse torticollis
Term
With a rhizotomy at C1-C3, there is a potential for loss of?
Definition
Hemidiaphragm
Term
Neurodegeneration and progressive loss (increases with age; patients >70 yo) of gray matter. Progressive impairment of memory, judgment, decision making, and emotional lability
Definition
Alzheimer Disease
Term
Alzheimer disease accounts for what percentage of all dementia in the U.S.?
Definition
40-80%
Term
Treatment of Alzheimer disease targets what?
Definition
Slowing of the disease; NO treatment has been found
Term
Some challenges with Alzheimer patients...
Definition
1. Consent issues-only if they are able to demonstrate a cognitive understanding of the procedure and its implications. It is important to reassure pt. and allow as much involvement as possible
2. Uncooperative-Regional anesthetics requires pt. cooperation. GENERAL anesthesia is often used.
3. Central acting drugs (most of what we use to induce general anesthesia) can produce PROLONGED and UNPREDICTABLE effects in the Alzheimer pt. Premedicate w/ small doses "use less and give more". Delerium can be associated with anticholinergics that cross BBB (atropine, scopolamine), so AVOID. Use glycopyrolate (does NOT cross BBB)
Term
Reversible demyelination at random sites in the brain and spinal cord. Chronic inflammation produces scarring and permanent effects. (?autoimmune that is initiated by a viral infection). Effects primarily females (2:1) between the ages of 20-40 yrs. Unpredictable with periods of 'attacks' and 'remissions' (until remissions become infrequent). Symptoms depend on group of neurons effected (sensory, visual, motor)
Definition
Multiple Sclerosis
Term
True or False: Keeping a pt. with MS warm is priority in the OR?
Definition
False; Temperature is an important factor in conduction across the demyelinated neurons. Increases in body temperature EXACERBATE the symptoms (decreasing transmission).
Term
True or False: If an MS pt. has a relapse, elective surgeries can proceed?
Definition
False; elective surgeries should be avoided if an MS pt. has relapsed
Term
When having a pt. with MS consent...the consent should reflect what?
Definition
That the anesthetic and surgery may WORSEN the disease and symptoms
Term
True or False: Spinal anesthesia is the preferred method with MS pt.'s?
Definition
False; spinals have been shown to exacerbate the disease whereas, regional techniques and epidural blocks do NOT
Term
The MS pt.'s cardiovascular system may be _______ due to autonomic dysfunction?
Definition
Labile
Term
Succinylcholine should be AVOIDED in MS pt.'s...why?
Definition
If the patient has paralysis, parasthesia, or is bed/chair bound due to risk of hyperkalemia (UP REGULATION)
Term
An OR temperature increase of ______ degree(s) Celsius may cause complete ______ ______!!!! AVOID INCREASING BODY TEMPERATURE.
Definition
0.5 degrees Celsius
Conduction Block
Term
Caused by enterovirus that initially infects the reticuloendothelial system (mononuclear phagocyte system).
Definition
Poliomyelitis
Term
The polio virus usually enters the CNS and prefers to target (motor/sensory) neurons in the brainstem and anterior horn of the spinal cord? (choose one)
Definition
motor
Term
S+S of Post Polio Sequelae
Definition
Fatigue, skeletal muscle weakness, joint pain, cold intolerance, dysphagia, and sleep and breating problems. The RAS system may be impacted
Term
The RAS system may be impacted in post-polio pt.'s, this is impacted by their (sensitivity/insensitivity) to sedatives and anesthetics? (choose one)
Definition
Sensitivity to sedatives and anesthetics which may cause delayed waking in post-polio pts
Term
True or False: Keeping post-polio pt.'s WARM in the OR is priority?
Definition
True; HIGHLY sensitive to cold
Term
Besides post op shivering, what other post operative issue impacts post-polio patients in assessing appropriateness of outpatient surgery?
Definition
Post op PAIN also seems to be increased due to poliovirus damage to endogenous opioid secreting cells in the brain and spinal cord
Term
Neurodegenerative disease that effects the MOTOR neurons (50-60 yo). Variations follow familial patterns. RAPIDLY progressive that starts on 1 side of the body but eventually impacts both sides. RESPIRATORY muscles are effected leading to death. Heart usually unaffected.
Definition
Amyotrophic Lateral Sclerosis (ALS)
Lou Gehrig's Disease
Term
Anesthetic Implications for ALS
Definition
1. Progressive motor weakness to RESPIRATORY-judicious respiratory care
2. NO SUCCS-often have limited movement; bedbound; W/C
3. NDMR sensitivity
Term
Would you extubate an ALS pt. deep v. awake?
Definition
Awake-pt. may remain on a ventilator-VERY DIFFICULT to wean
Term
Would you do a regional technique on an ALS pt.?
Definition
Yes!
Term
True or False: A detailed preoperative functional assessment should be performed to confirm postoperative return of function in ALS (all neurodegenerative diseases) pts.?
Definition
True!
Term
Common immune reaction against myelin typically follows after a viral/GI infection. Progressive rise in motor function and autonomic instability. Associated with neoplastic/HIV. Some respond to plasmaphoresis.
Definition
Guillain Barre Syndrome
Term
Can be acquired, familial or congenital and is a set of symptoms that may be included in many other disease processes and vary based on the nerves involved.
Definition
Autonomic Dysfunction
Term
Common concerns (2) for anesthetists concerning autonomic dysfunction pts.?
Definition
Hypotension and HTN; Based on their symptoms, pt.'s will be on several different drug classes (sympathomimetic, beta-blockers, etc.)
Term
Pt. with autonomic dysfunction experiences hypotension...pt. will not do well with significant drops in BP, how do you treat it?
Definition

DIRECT acting drugs

(Epi, Norepi...)

VERY SENSITIVE to vasopressors, so "start low and go high"

Term
Pearl concerning autonomic dysfunction
Definition
Pts. with diabetes develop autonomic dysfunction
Term
Most spinal cord transections injuries are due to?
Definition
Fractures and dislocation of the vertebrae; thoracic spine=compression or over flexion; cervical spine=over extension
Term
A SCT injury above C3-C5 requires?
Definition
Ventilatory support
Term
Transections above______ result in quadraplegia and above _______ results in paraplegia.
Definition

T-1

L-4

MOST common injuries are C5-6 and T12-L1

Term
The period of spinal shock occurs for _______ following the injury.   After this time, the reflexes begin to return.
Definition
1-3 weeks
Term
Common features of spinal shock?
Definition

Hypotension and Bradycardia

(the bradycardia can be distinguishing factor spinal vs. hemorrhagic shock)

Term
Anesthetic Concerns-Acute spinal transection
Definition

1. Prevent further damage-stabilize cervical spine; secure airway techniques (awake fiberoptic SAFEST)

2. High dose methylprednisone (30mg/kg over 1 hr., gtts. 5.4mg/kg/h for 23 hrs.)

3. Hypotension and bradycardia-spinal shock=VASOPRESSORS and some fluid

4. Induction agents that don't drop BP (Etomidate/Ketamine)

5. Succs can safely be administered within 24 hours. of injury.

Term
Explain why succs should NOT be used in acute SCT 24 hours after the injury
Definition
Due to denervation, the acetylcholine receptors proliferate (UP regulate) both at the neuromuscular junction and outside the synaptic cleft (organs).  Produces HUGE release of potassium.
Term
What is the dose for the suggested corticosteroid therapy in acute spinal cord injuries?
Definition

Methylprednisone:  30mg/kg over 1 hour

5.4mg/kg/h for the next 23 hours

 

(there is some association with sepsis, pneumonia, and prolonged hospitalization-lack of evidence to support  corticosteroid therapy outcomes)

Term
Occurs in spinal injuries ABOVE T-5; rarely seen if injury is below T-10; cutaneous/visceral stimulation below cord injury sends impulses up thru spinal cord but cannot reach the brain past the level of injury.  A reflex arc activates the uninhibited sympathetic portion of the autonomic nervous system resulting in increased SVR, HTN, bradycardia, vasodilation above level of injury
Definition
Autonomic Hyper-Reflexia
Term
Once the reflex arc is activated by an impulse taveling through and injured spinal cord, the parasympathetic system is unable to inhibit the sympathetic response, why?
Definition
The parasympathetic system response is unable to extend from the brain down to the level of injury.  The result is increased in SVR and HTN
Term
What receptors are activated as a result of autonomic hyper-reflexia's HTN and increased SVR symptoms?
Definition
Baroreceptors
Term
With autonomic hyper-reflexia, the baroreceptors detect the elevated pressure and reflexively decrease heart rate and vasodilate vessels (above/below) the injury?
Definition
Above
Term
Steps to Autonomic Hyper-Reflexia
Definition

T-6 (or above) injury

1. Cutaneous/visceral stimulation

2. SANS stimulation-->HTN; "goose flesh", pallor, muscle spasms

3. Increased SVR-->Baroreceptor response signaled

 

4. Bradycardia and vasodilation ABOVE level of injury

Term
Symptoms for (above/below) cord injury:  Flushing, sweating, HA and nasal stuffiness in autonomic hyper-reflexia? (choose one)
Definition
Above
Term
Symptoms for (above/below) cord injury:  Pallor, pilomotor erection, muscle contraction/spasm in autonomic hyper-reflexia? (choose one)
Definition
Below
Term
Transient, synchronous discharge of neurons in brain; common and can occur at any age; many are related to treatable causes (hypoglycemia, hyponatremia, drug toxicity, hypoxia, fever, IICP); 10% of the population has experienced.  Symptoms vary depending on area of brain affected
Definition
Seizure Disorders
Term
True or False:   Most practitioners prefer to use a multi-drug approach when treating seizure disorders?
Definition
False; (1) drug preference; Seizure drugs are guided by the desired effect and TOXICITY levels-->neurologic toxic effects resulting in sedation, depression, ataxia, diplopia, hepatic failure, aplastic anemia, hyponatremia...
Term
Anesthesia Concerns-Seizures
Definition

Many drug side effects

Do the drugs stimulate the brain activity or lower the seizure threshold?

Drug levels?

Recent seizure?

Are they well controlled?

Sedate?

Term
Continuous seizure of two or more without a recovery phase (life threatening)
Definition

Status Epilepticus

 

Term
Treatement for status epilepticus includes...?
Definition
  1. IV acess-->IV benzodiazapine (versed or valium)
  2. Airway management, support respirations,
  3. Support cardiovascular system
  4. Find cause (r/o hypoglycemia-dangerous because extends brain injury boundaries)
  5. Propofol or pentothal will temporarily HALT the seizure to access airway
  6. Subsequent problems (metabolic acidosis, hyperthermia)
Term
Why are Succs and NDMR not recommended in status epilepticus?
Definition
Just blocks motor response, but neuronal activity of seizure still occuring
Term
What drugs INCREASE the seizure threshold?
Definition
  • benzodiazapines (versed and valium)
  • propofol
  • pentothal
Term
What drugs DECREASE seizure threshold, making a seizure 'more likely' to occur?
Definition
  • etomidate
  • demerol (metabolite)
  • atracurium and cisatricurium (NDMR-metabolite)
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