NCM 103: CASE ANALYSIS 1 2.

Parasympathetic Nervous System

HEAD AND SPINAL CORD INJURIES - Responsible for rest and relax
SKULL actions (digestion)
- Composed of thick bone
- 3 protective membranes between the skull 4 Major Parts of the Brain
and the brain - MENINGES Cerebrum
a. Dura Mater - Part of the crevices that we most associate
- Thick layer of tissue with the mental images of the brain
attached to the skull and - Consist of 2 cerebral hemispheres; divided
forming sheets between 2 by the longitudinal fissure down the sensor
cerebral hemispheres, of the cerebrum
and between the Functions:
cerebrum and cerebellum - Sensory input
b. Arachnoid Mater - Skeletal movement
- Thinner layer, separated - Intellect
from the dura - Emotions
c. Pia Mater - Memory
- Thin layer, closely applied
to the brain itself Cerebellum
- High brain
THE NERVOUS SYSTEM - Posterior region of the brain and inferior to
Central Nervous System that of the cerebrum
- Consists of the brain and spinal cord - Cross-section cauliflower appearance
- Responsible for sensory activities, storing - Consist of parallel folds
memories and emotions Functions:
- Information processing
Peripheral Nervous System - Balance
- Consists of cranial and spinal nerves - Posture
- Brings messages to and from the CNS to
the rest of the body. Brain Stem
- Connected directly to the spinal cord;
a. Somatic Nervous System noticeably thicker than the spinal cord
- Responsible for voluntary muscle Functions:
movements - Conduction pathway
- Respiratory nuclei
b. Autonomic Nervous System - Site of decussation of tracts
- Responsible for involuntary - Regulates skeletal movement
actions (heart beat, pupil dilation)
1. Sympathetic Nervous System
- Responsible for flight or fight
response
Diencephalon
- Interior of the brain
- Can only be seen in its entirety if the brain
is cut open
- Floor of diencephalon can be seen directly
superior to the brain stem
Neuron
- Primary components of the nervous system
- Detect environmental changes, initiate
body responses to maintain homeostasis
- Composed of cell body, axon and dendrites
Axon
- Transmit messages throughout the central
and peripheral nervous system
- Axonal branching common for broader
dissemination of neuronal transmissions
Dendrites
- Conduct electrical impulses in the cell body
- Branching patterns: Efficient transmission
and reception of impulses throughout the
body
Functionally:
- Neurons are recognized as being motor,
efferent neurons, sensory afferent neurons
- Neuronal messages are transmitted
through electrical impulses with the
necessary voltages created by + and - forces
produced while ions line up inside and
outside the cell’s plasma membrane
- Resting membrane potential electrical
charge outside the wall is + while charge
inside is -
Chemical Synapsis
- located where axons and dendrites meet
- employ various neurotransmitters which
are stored in and released from axon
terminal ff an action potential
- Neurotransmitters diffuses and attaches to
postsynaptic receptors
Cerebrospinal Fluid
- protects brain and spinal cord from trauma
- Acts as shock absorber
- Medium for transfer of elements from
bloodstream to nervous system tissues
Characteristics:
● clear, colorless
● Formed in choroid plexus (capillaries in the
4 brain ventricles)
● Component: 99% H2O and CHON, Na, Cl, K,
HCO3, glucose
● Usual amt: 80-200 mL
● Other Purposes:
○ Cushion
○ Nourishes brain
○ Removes waste products
Cerebral Circulation
● BRAIN receives 750ml of blood/min
● Brain uses 20% of total O2 uptake
● GLUCOSE: brain’s only source of energy
- provides blood supply to brain
- Divided into: Anterior and Posterior
circulation
- Because it’s sensitive to compromises in
cerebral blood flow, it exhibits water
regulation, active and reactive hyperenia ?
- Cerebral blood flow is controlled by local
metabolites
- Increases in partial pressure of
CO2, leading to vasodilation of
cerebral arterioles -> subsequent
increase in cerebral blood flow
- But many circulating vasoactive
substances don’t affect cerebral
blood flow because they can’t
cross the blood-brain barrier
Monro-Kellie Hypothesis/Doctrine
● pressure-volume relationship
● Aims to keep a dynamic equilibrium in the
skull
● Average intracranial volume in the adult =
1700 mL
● Composed of brain tissue (~1400 ml) ; CSF
(~150ml) ; blood (~150ml)
- Alexander Monroe: blood circulating in
cranium is of constant volume at all types
- Sum of volumes of brain, CSF, and
intracranial blood is CONSTANT.
- An increase in one must cause a
decrease in one or both of the
other
- Important in increased ICP and
decreased CSF volume
- MRI abnormalities: meningeal
enhancement, subdural fluid
collections, engorgement of
cerebral venous sinuses,
prominence of spinal epidural
venous plexus, and enlargement
of pituitary gland
Blood Brain Barrier
● Low permeability of brain capillaries
○ Prevent sudden extreme
fluctuations in composition of CNS
tissue fluid while allowing
nutrients to pass
● Capillaries are very tight due to astrocytes
(supporting cells)
○ Not considered part of barrier
● Only water, oxygen, carbon dioxide, and
alcohol can readily leave and enter CNS
capillaries
● MAY ENTER:
○ Lipids, glucose, some amino acids,
water, carbon dioxide, oxygen
● NO ENTRY:
○ Urea, creatinine, toxins, antibiotics
● Injuries and infections may increase
permeability
● Formed within capillaries by a continuous
layer of endothelial cells connected by tight
junctions with basement membrane
surrounding endothelium
● Doesn’t protect pineal body and posterior
lobe of hypothalamus
PERCEPTION AND COORDINATION
Why does P&C matter?
Perception
- Conscious recognition and interpretation
or awareness of sensory stimuli that serves
as a basis for understanding, learning and
knowing
- motivation for a particular action or
reaction
- The ability to interpret stimuli with the use
of sense
Coordination
- The ability to execute smooth, accurate,
and controlled motor responses
- Action or reaction towards a stimulus is
occurring in a purposeful orderly fashion
appropriate response to a stimulus
- If a person is unable to perceive through
the 5 basic senses or is lacking one, this can
affect their synchrony of movement or
coordinated muscular movement and
purposeful muscle movement
Result
- Appropriate response or feedback =
normal, expected
INCIDENCE OF HEAD AND SPINAL INJURIES - Any trauma to the scalp, skull or brain
(National and Global Data) - Head trauma includes an alteration in
consciousness no matter how brief
Fall and road injuries
- Leading causes of new cases of TBI and SCI TYPES OF HEAD INJURIES
in most regions (220-500k annually) - Scalp lacerations
Result : SCI - Skull fractures
- 40-80 cases per million population - A break in the bones surrounding
- Upto 90% of these cases are due to the brain
traumatic causes - Can occur with or without brain
Result: TBI damage
- 69 Million (95% CI 64-74 million) individuals - Symptoms:
worldwide are estimated to sustain a TBI - Pain
each year - Brain damage
- Southeast Asia and Western Pacific - - Fluid leaking from nose or
highest burden of disease ears
- Road Traffic Injuries (RTI) in Southeast Asia - Bruises around nose or
(1.5% of the population per year) eyes

National Incidence - 4 major types:

Result 1: Moderate Severe Brain Injury - Linear skull fractures -
- 2nd most common cause of death due to break in the bone but
an internal cause while minor TBIs are 5th doesn’t move the bone
Result 2: Spinal Cord Lesion below the neck level - Depressed skull fractures
ranks 14th. - with or without cut in
Result 3: Transport injuries and falls are the top skull; part of skull is
causes of injuries in the Philippines sunken in from trauma
- Diastatic skull fractures -
Traumatic Brain and Spinal Cord Injuries fractures around suture
- May be subtle until it’s too late line of skull; normal
Causes : suture lines are widened;
- MVA more often in newborns
- Fire-arm related injuries and infants
- falls - Basilar skull fractures -
- Assaults most serious type; break
- Sports-related injuries in the bone at the base of
- Recreational activities the skull; bruises around
High potential for poor outcome eyes and behind ears;
Death occurs at three points in time after injury: fluid draining from nose
- Immediately after the injury or ears; require close
- Within 2 hours after the injury observation in hospitals
- Approx. 3 weeks after the injury -
- Minor head trauma - concussions
- Most common type
- When the brain is jarred or shaken
hard enough to bounce
- Signs and symptoms can be
immediate or take days to show
up
- Causes changes in mental status
and can disrupt the normal
functions of the brain
- Multiple concussions can have
long lasting and life changing
effects
- Confusion
- Depression
- Dizziness or balance
problems
- Double or fuzzy vision
- Feeling foggy or groggy
- Feeling sluggish or tired
- Headache
- Memory loss
- Nausea
- Sensitivity to light or
noise
- sleepiness
- Trouble concentrating
and trouble remembering
- May require emergency treatment
if:
- Changes in pupil size
- Clear or bloody fluid
draining from nose or
ears or mouth
- Convulsions
- Distorted facial features
- Facial bruising
- Fracture in skull or face
- Impaired hearing, smell,
taste or vision
- Inability to move limbs
- Irritability
- Loss of consciousness
- Low breathing rate
- Restlessness
- Clumsiness or lack of
coordinations
- Severe headache
- Slurred speech or blurred
vision
- Stiff neck
- Vomiting
- Sudden worsening of
symptoms after initial
improvement
- Swelling at site of injury
- Persistent vomiting
- Major head trauma - contusion, lacerations,
Diffuse Axonal Injury
- Hematomas - epidural and subdural
- Sudden leakage of blood into
brain tissue itself
- Leaks from very small artery and
pushes into brain tissue causing
injury and symptoms of stroke
- Long standing high blood pressure
often causes ICH
- Subdural hematoma
- occurs when a blood
vessel nears the surface of
the brain bursts
- blood builds up between
the brain and the brain’s
tough outer lining
- called subdural
hemorrhage
- Blood collects in dura
mater
- Life threatening as it can
compress the brain
 - Epidural hematoma
- Occurs when a mass of
blood forms in the space
between skull and
protective covering of
your brain
- Trauma or other injury
can cause brain to bounce
between the inside of the
skull
- This can tear the brain’s
internal lining, tissues
and blood vessels which
results in bleeding and
forming of hematoma
- Hematoma can cause
pressure and the brain to
swell; as it swells, your
brain may shift in skull
0 sensory, motor, reflex
- Pressure on and damage
to brain tissues can affect
vision, speech, mobility
and consciousness
- If left untreated, it can
cause lasting damage and
even death
- Secondary Injury
- Ongoing, progressive
damage after initial injury
- Complications:
- Spinal Shock
- Decreased reflexes
- Loss of sensation
- Flaccid paralysis below
level of injury
- Days to months
- Neurogenic Shock
- Loss of vasomotor tone
(hypotension,
bradycardia)
Spinal Shock Neurogenic Shock
Not true shock True shock
Hypotension,
vasodilation,
bradycardia
Edema, “concussed” Loss of sympathetic
cord tone
Resolves after days to Resolves over weeks
weeks

SPINAL INJURY
NEUROLOGIC ASSESSMENT
- A spinal cord injury (SCI) is damage to the
Mental status examination
spinal cord that results in a loss of function,
- Includes general observations made during
such as mobility and/or feeling
the initial encounter, as well as specific
- The higher the level of injury, the greater
testing based on the needs of the client and
the loss of function
physician
- Causes:
- Multiple cognitive functions may be tested,
- initial/Primary injury d/t trauma
including: attention, executive functioning,
- Cord compression by
nausea, ? (cut-off)
bone displacement
Mental Status
- Interruption of blood
3 parameters:
supply to the cord
1. LOC (“A-C-L-O-S-C”)
- Traction d/t pulling of
a. Describes a person’s awareness in
cord
understanding of what is
- “Laceration or Stretch”
happening in their surrounding
 b. There are 3 main levels of
consciousness:
i. Consciousness: awake
state, fully aware,
understands, talks, moves
and responds normally
ii. Decreased consciousness:
appears awake and
aware, conscious but not
responding normally
(may not answer when
spoken to, stares straight
ahead and have no facial
expression, acting
confused/ odd/sleepy,
may not recall what
happened)
iii. Unconsciousness: not
aware of what’s going on
and not able to respond
normally
*thinking is a brief form of unconsciousness
Coma: deep, prolonged state of unconsciousness,
and general anesthesia is a controlled state of
unconsciousness

Levels of consciousness:
● Alertness
● Confusion
● Lethargy/Lethargic
● Obtundation/Obtunded
● Stuporous/Stupor
● Severe Irreversible Brain Damage/Coma

2. Speech
3. Cognitive Function