Knowledge Nuggets / Paul Kelner, M.D.

Central Nervous System

I. Nervous System
A. Central Nervous System
1. Brain
2. Spinal Cord
B. Peripheral Nervous System
1. Autonomic NS
a) Sympathetic
b) Parasympathetic
2. Somatic Nervous System - 31 paired spinal nerves and branches (efferent -
spinal cord to periphery / afferent - opposite)
3. Cranial Nerves
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II. Cellular anatomy

A. Neurons - active processing cells in NS
B. Glial cells - supportive and nutritional support to neurons
C. Ependymal cells - form choroid plexi in ventricular system and make CSF
CSF travels through and protects CNS - then re-enters vascular system at
the Dural Sinuses - like superior sagittal sinus

D. Myelin producing cells

1. Schwann cell - within peripheral nervous system
2. Oligodendrocyte - within central nervous sytem

III. Vascular supply

A. The anterior 2/3 of brain is supplied by the two internal carotids. They
combine to form the Circle of Willis and the branches that come off of
this structure. The purpose of the circular structure is to maintain active
blood flow even if one total side is occluded.
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B. The posterior 1/3 of the brain is supplied by the vertebrobasilar system

which is composed of the vertebral and basilar arteries.

Pain Definitions and Terminology:

Nociceptive pain - pain secondary to stimulation of pain receptors - pain due to typical
stimuli like injury, burns, tissue damage, etc...

Non - Nociceptive pain - pain due to nerve damage like that occurring in peripheral
neuropathy like diabetes. Actual damage to the axon leading
to pain, altered sensation, etc...

Referred Pain - pain occurring in anatomically distinct area from painful stimuli due
to proximity of nerve supply. For example, patients with gallstones
often experience pain in right scapula due to nerve supplies entering
spinal cord close to each other.

Phantom Pain - pain felt to be located in limb that has been amputated. Due to
persistence of neural pathways. Can be as severe as real pain.

Reflex Sympathetic Dystrophy

Reflex sympathetic dystrophy (RSD), also called complex regional pain syndrome (CRPS), is
a chronic, painful, and progressive neurological condition that affects the skin, muscles, joints,
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and bones. The syndrome usually develops in an injured limb, such as a broken leg, or following
surgery. However, many cases of RSD involve only a minor injury, such as a sprain. And in
some cases, no precipitating event can be identified.

RSD/CRPS is characterized by various degrees of burning pain, excessive sweating, swelling,

and sensitivity to touch. Pain may begin in one area or limb and then spread to other limbs. In
some cases, symptoms of RSD/CRPS diminish for a period of time and then reappear with a new
injury.

Coma and Decreased Levels of Consciousness

In order for true coma to occur, one or both of the following conditions must be met:

1. The pathology effects both cerebral hemispheres (bleed / ischemia / infection / toxin / drug)

2. The Reticular Activating System (RAS) is affected. The RAS is the on / off switch for
consciousness.

The reticular activating system (RAS) is an area of the brain (including the reticular formation
and its connections) responsible for regulating arousal and sleep-wake transitions.

Posturing describes complete flexion or extension positions that occur with severe life -
threatening ischemia to the brain. There is what is called the decorticate and the decerebrate
posture. We do not need to know the order of events, but understand that these positions mean
that death is imminent unless definitive action is taken.
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Cheyne - Stokes Respirations describe ʻbrainstem breathingʼ that is totally dependent

of CO2 concentrations. It is a period of rapid and shallow respirations followed by a
period of deep / sonorous respirations.

Cheyne-Stokes respiration (pronounced /ˈtʃeɪnˈstoʊks/), also known as periodic breathing is

an abnormal pattern of breathing characterized by oscillation of ventilation between apnea and
tachypnea with a crescendo-decrescendo pattern in the depth of respirations, to compensate for
changing serum partial pressures of oxygen and carbon dioxide.

It is caused by damage to respiratory centers,[1] and is also characteristic of newborns with

immature respiratory systems. In the second case however it is a symptom of developmental
immaturity and not of a damaged or defective cardiopulmonary system.

Dolls - Eyes Phenomenon describes an ophthalmologic phenomenon that occurs with severe
neurologic injury. Instead of correcting to forward gaze, the eyes go with the head position.

Glasgow Coma Scale - a scale based on assessment of ocular, motor and verbal
conditions that we use to quantify a patient’s level of consciousness (LOC). Goes from 3
at the lowest to 15 at the highest. We need to know the three categories of assessment,
not all of the exact grading (ie. eyes / motor / verbal)

We use this scale to relate a patient’s LOC to other health care personnel - like giving
report to another nurse, etc...
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Seizure Disorders
Seizures are abnormal electrical discharges that occur in the brain. Basically, one can
think of a seizure as a sudden ‘short circuit’ involving neuronal networks. All people
have what is termed a seizure threshold. The threshold is a level of electrical
disorganization in the individual brain, above which, seizure activity will occur. In
patients without epilepsy or other seizure disorders, the seizure threshold is high, and the
only way that the electrical disorganization can exceed this level is due to severe
physiologic stress (ie. high fever, severe dehydration, electrolyte abnormalities, etc..). In
patients with epilepsy, the threshold is low enough that it does not take much electrical
disorganization to exceed it. Additionally, in patients with epilepsy (which is the term
describing any idiopathic seizure disorder), there is usually found a focus of electrical
disorganization - or a specific anatomic location in the brain from which spikes of
electrical activity emanate. This combination of frequent spurious discharges of
electrical activity and a low seizure threshold leads to frequent seizure activity.

Seizures are categorized as either Generalized or Partial. Generalized seizures involve

both cerebral hemispheres, while partial seizures are unilateral. Additionally, there
are subtypes within each category. We will focus on two types of generalized seizures:

Tonic / Clonic (Grand Mal) Seizure - this is the typical scenario one thinks of when the
term seizure is used. It is characterized by alternating flexion / extension and relaxation
of multiple muscle groups. Defined from an epilepsy website:

A generalized tonic-clonic seizure is a seizure involving the entire body. It is also called
a grand mal seizure. Such seizures usually involve muscle rigidity, violent muscle
contractions, and loss of consciousness.

Abscence (petit mal) Seizures - this type of seizure is most common is the pediatric
population. These seizures are characterized by maintanence of conciousness, but
absence of awareness. The child will be descibed as ‘staring into space’. They will not
answer when they are spoken to - they are not interactive with their surroundings. Again,
pulling a definition from the epilepsy website:

Most petit mal seizures last only a few seconds. Most commonly they involve staring episodes
or "absence spells." The person may stop walking or talking in mid-sentence, and start again
a few seconds later. The person usually does not fall. The person is usually wide awake and
thinking clearly immediately after the seizure. "Spells" can be uncommon or occur up to
hundreds of times in one day. They may occur for weeks to months before they are noticed,
and may interfere with school function and learning. The seizures may sometimes be mistaken
for a lack of attention or other misbehavior. Unexplained difficulties in school and learning
difficulties may be the first indication of petit mal seizures.
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Petit mal seizures are characterized by a well documented, ‘spike and wave’ pattern on
the EEG (electroencephalogram).

Partial Seizures involve only one cerebral hemisphere and are characterized by jerking
movements of one or both limbs on one side of the body. Conciousness is maintained.
These partial seizures can and often do degenerate into full generalized seizures.

Terms regarding seizure activity:

Aura - : a subjective sensation (as of voices or colored lights or crawling and numbness)
experienced before an attack of some nervous disorders (as epilepsy or migraine)

Post - Ictal State - a period of confusion and diminished awareness of surroundings that
can last from 15 - 30 minutes and almost always follows generalized seizure activity.

Pseudo - Seizure - apparent seizure activity that occurs without EEG evidence of seizure
activity in the brain. Often the result of traumatic episode or may be used to obtain
secondary gain (social security income / unemployment / attention, etc...)

Pharmacologic Treatment of Seizure Disorders

The pharmacologic treatment of seizures differs depending on the type of seizure we are
treating. We will discuss the treatment of generalized seizures in this course. Like many
pathologic disorders that we treat, the treatment of seizures involves acute treatment
modalities and prophylactic treatment modalities (in other words - what we use to stop
acute seizure activity and what we use to prevent further seizures from occuring).

Acute Tonic / Clonic generalized seizures are a common occurance in the hospital. They
happen in many patients - even in patients without a seizure disorder. As mentioned
previously, a patients seizure threshold is lowered when they are ill - and obviously -
many patients are very ill in the hospital. Thus - a general med/surg nurse can see
seizures in a normal shift - not just on a neuro floor.

Acute Tonic/Clonic Seizures (A T/C S) are treated with benzodiazepines. This category of
medicine includes diazepam (valium), lorazepam (ativan), midazolam (versed) and others. These
medications act by agonizing the GABA receptor in the central nervous system. The GABA
receptor is an inhibitory receptor that acts to quiet central nervous system activity. This is
somewhat obvious when we think about the typical affects these drugs have on most patients
(drowsiness / calmness / relaxation).
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central nervous system activity. This is somewhat obvious when we think about the
typical affects these drugs have on most patients (drowsiness / calmness / relaxation).

Patients with (A T/C S) are generally given a STAT, one time IV or IM dose of a
benzodiazepine. Frequently, this will be enough to ablate (stop) the seizure activity. A
repeat dose of the same agent or another benzo may also be required in some cases.
Benzodiazepines cause respiratory depression, so we must be aware of the patients
oxygenation status (Pulse Oximetry / Oxygen supplementation).

The prophylactic treatment of seizures is much more complicated and there are many
agents used in this way. We will focus on some of the agents which are used most
frequently in the medical environment. Again, we are discussing generalized tonic/clonic
seizures and not partial seizures or Petit Mal seizures at this point.

The first agent discussed is called Phenytoin (Dilantin). This agent has been around for
many years and is still frequently used in the hospital environment.

Dilantin Facts:

• Available IV /PO /IM

• Often given IV first to load the patient and then continued PO
• When Given IV - have to push slowly (over 15 - 30 minutes) to avoid hypotension and
arrhthmia
• Side effects include fatigue, weight gain, abnormal hair growth and gingival
hyperplasia (gum overgrowth) - these issues make this drug undesirable for use in
children or young adults
• P450 drug - many drug interactions

GINGIVAL HYPERPLASIA

Next Prophylactic Drug - Carbemazepine (Tegretol) - please look this up - remember

that this drug is also used for treatment of chronic peripheral neuropathy. Also, this drug
can not be taken at the same time as grapefruit juice - there is an interaction.

Next - Valproic Acid (Depakote) - again...see details in other sources. This drug is
used for Petit Mal (abscence) seizures. It is also used as a Mood Stabilizer and used
instead of lithium in some patients with Bipolar disease (manic / depressive illness).
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Gabapentin (Neurontin) is another commonly used prophylactic seizure medication. It

acts on the GABA receptors - thus quieting nervous activity. It is frequently used in
chronic pain conditions (chronic back pain / fibromyalgia / peripheral neuropathy, etc...)

There are many more - but we will not spend time on them individually in this class.

This link (http://homepage.ntlworld.com/foliot/liss/lissmeds.htm) is an excellent

summary of most of the meds used today. I will not test you on the ones that I did not
discuss specifically....but you may want to make yourself familiar with the names - as
you will run into many of them...