CN I Name, Type, Location

Olfactory - Sensory - Smell

Anterior Frontal Lobe

CN II  Name, Type,  Function Location

Optic - Sensory - Vision - Midbrain/retina

CN III Name - Type - Location

Oculomotor - Motor - Eye Muscle - elevation of eyelid

Parasympathetic response - Pupil response & Accommodation

Midbrain, very sensitive to pressure changes

CN IV Name - Type - Location

Trochlear - Motor - Eye movement superior and oblique

Instruction if deficit

Hold on to rails going down stairs and feel out steps with heel

Lower midbrain

CN V Name, Function, Location

Trigeminal, Sensory Sensation to the face

Corneal Reflex

Motor Mastication

Location: Pons

CN VI Name - Function - Location

Abducens

Motor Moves Eye laterally

Location Inferior Pons

Deficit Diplopia , inability to look laterally

CN VII Name - Function - Location

Facial

Sensory Pain, Temp Taste 

Anterior 2/3 tongue

Motor facial muscles

Lacrimation(Tearing)/ Salivation (saliva

CN VIII Name - Function - Location

Acoustic/Vestibulocochear

Sensory Hearing, Vestibular balance

Deficits - dizziness, tinnitus, hearing loss

Location Pons Medulla Junction

Test Weber Test

CN IX Name - Function - Location

Glossopharyngeal

Sensory - pain, temp, sensation from ear

Taste Posterior 1/3 Bitter Sour

Motor skeletal muscles throat

 Parasympathetic parotid gland secrete saliva

Blood pressure Carotid/O2 status

Medulla

CN X Name - Function - Location

Vagus

Pharynx muscle contraction

Voice production, sensory of pharynx to larynx

Thoracic and abdominal viscera

Parasympathetic cardiac response and HCL stomach acid production

Medulla

CN XI Name - Function - Location

Spinal Accessory

Motor movement of pharynx, larynx, sternocleidomastoid, and trapezius

Medulla

CN XII Name - Type - Function - Location

Hypoglossal

Motor Movement of the tongue

Anisocoria

unequal pupil sizes

Hippus

Ptosis

Amaurotic Pupil

Miotic pupil

Mydriatic

ipsilateral

Linear Fracture

Simple, clean break in which the impacted area of bone bends inward and the area around it bends outward.

TBI Depressed Fracture

The bone is pressed inward into the brain tissue to at least the thickness of the skull

TBI Open Fracture

The scalp is lacerated, creating a direct opening to the brain tissue

TBI Comminute Fracture

Involves fragmented bone with

depression into the brain tissue

Closed Head Injuries

Contusion

Is a bruising of the brain tissue and is most commonly found at the site of impact

Closed Head Injury

Concussion

Shaky movement of the brain and may be mild  or more severe.  Some patients lose consciousness of a short time

come back if their our any changes in LOC, HA, N/V, no more than 2hrs sleeps without being woken up

Closed Head Injury

Diffuse axonal injury (DAI)

Usually related to high-speed acceleration/deceleration as with automobile accidents.  Significant damage occurs to axons in the white matter. Damage may be found in the corpus callosum, midbrain, cerebellum, and upper brainstem

Mild, Moderate, - vessels intact

Large - could be some bleeds

Mild complete recovery

Injuries before 5yrs have a better change of recovery

Closed Head Injury

Laceration

Causes actual tearing of the cortical surface vessels, which may lead to secondary hemorrhage and significant cerebral edema and inflammation.

Acceleration Injury

caused by an external force contacting the head, suddenly placing the head in motion

Tension HA

Causes Sleep Deprivation, Stress

Treatment ASA, Ibuprofen, Tricyclic (must do depression screening first), beta blockers (must do cardiac profile, how is this going to effect the cardiovascularly)

Migraine HA

Women affected more than men

Has the same pattern:

Triggers (PMS)Premenstral, food oriented (red wine, caffeine, allergies,Sensor stimuli, change in sleep pattern, medications, weather changes

1st phase aura - vasoconstriction

2nd phase vasodilation N/V

3rd phase wipedout - tired

Treatment Imitrex and topamax must sign release, to take birth control

Cluster HA

Affects mostly men

Have couple of headaches and then don't experience any for several months

Duration is 30-90 minutes

Visual

Treatment ASA, Oxygen

Wedge Fracture

Intense pressure to a single point

Blood clots under it..  could be subdural hematoma

Penetration - Shock Theory

Object or bullet - not where the bullet enters but exits, movement of the head in transport; if the head has been joustle it can cause additional injury

? ate meal before being shot

Coup & Contracoup

Coup Original injury

Contracoup first compensation ventricles enlarge

2nd compensation their is a shift...  causing 2ndary injury

Epidural Hemorrhage

Inner most area, very vascular, fast bleed.  Most patient die

Subdural Hematoma

Slow bleed, veins, instruct them to return if they begin experiencing 2-3weeks later, decreased level of consciousnes

glasgow coma

Subarchnoid Hemorrhage

mainly posterior - basalar artery

Very fast, very extensive, hard to control

Rehab difficult. 24-48 r/f secondary bleed

Intercerebral Hemorrhage

Massive amount of pressure changes on vessels

long term hx of HTN, progressive of bleeds

ICP Classic Triad

Bradycardia, decreased respirations, rising systolic, wide pulse pressure (

ICP Symptoms of the Eye

CN II Change in Snellen Eye Chart - Change in field cuts

CN III

Nystagmus - The involuntary eye movements of nystagmus are caused by abnormal function in the areas of the brain that control eye movements. ,

Midratic - dilation of the eye

Myopia - near sightedness

CN IV

ICP Airway Assessment

Not going to be able to control the airway so you vent the patient

Oral Gastric tube

CN X Vagus Nerve

Stimulate HCL production in stomach

ICP 2 Arterial Lines

One for delivery warm saline 0.9%

One for Blood

Neuro likes blood high HCT/HBG

Normal Urine output

Adult 30-60ml/hr

Child 0.5-1ml/kg/hr

Monroe-Kellie Hypothesis

Only so much space in the brain

May drill holes in the skull to relieve pressure

Intraventricular/Camino Catheter

Inserted into ventricles 1or 2

Can remove CSF; control method of managing ICP, only one

Subarchnoid screw can only monitor fluid

Both are r/f infection

Licox system

Monitoring temp and oxygen

Brain always 2 degrees higher than body

IICP Concept

Initially dilating; an increase in blood flow to brain...  increase oxygenation

Ventricles enlarge; shunting of CSF from cranial compartment to ventricles

Compensatory Mechs - midline shift then enlargement of 3 and 4

Problem decrease in cerebral blood flow leads to further hypoxia

Cytotoxic or cellular edema occur as a result of hypoxic insult

Interstitial edema

CPP (Cerebral Perfusion Pressure)

Normal Value 80-100 below 60 brain is dying

CPP = MAP - ICP

Map we like it 90

ICP Normal 10, 15 a problem, 20 Major

Transcranial Doppler

Monitors cerebral blood flow - indicating brain activity

Barbiturate Coma - ICP Treatment

Phenobarbital 5-10g/kg/IV over 60 minutes initial dosage by Anesthesiologist - can reduce brain metabolism by as much as 50%

Cause a decrease in cerebral perfusion pressure, can't go below 60

Pt able to tolerate drug - lab data to assessment before treatment - O2 state (respirator) BUN (enough fluid on board) & Creatinine, LFT (AST Substance, ALT Liver function)

Short term sedation treatment 24-48 hrs

Worry about rebound hypertension

Pavulon/Norturon - neuromuscular blocking agent

s/e Bradycardia

Antedote is Atropine

R/f for Blood Clot need to make sure SCD's are on

Hypothermia

Decrease temperature by 1 degree decrease 7% of metabolic demand

Monitor temperature on foley (measuring the urine), or with a thermal blanket a rectal probe may be used.

S/E Get too cold you shiver, pull the temp done but not too much

CSF Removal

Intraventricular/Camino Catheter

Promote Venous Drainage

45 degree angle, straight neck, promotes venous drainage

Mannitol

Osmotic diuretic - 

give bolus then use lasix to get it out of the body

Orders for Electrolytes

Decadron

Glucocorticoids - to reduce swelling

Got to watch glucose...  don't want metabolic acidosis

Prophylatic Hyperventilation

Used initially to get additional oxygenation

Long term it increased ICP

Hydrocephalus

Water on the brain - fluid is trapped

Put in a shunt - into the juglar in adults, stomach of child

How do you know its working? mental status change

Indictations its not working

HA, Visual changes, N; head thrashing, screaming

Herniation

closure of ventricle 3-4

Not controlling ICP

Look at eyes - dilation of one side; pressure change in that eye, Hippus dilating constricting

Stress Ulcers

CN X Vagus - secretion of HCL - Pepcid, PPI

Intercranial Cerebrospinal Fistula

Abnormal opening in brain, sometimes occurs with infection, brain injury leads to tunneling sometimes occurs with craniotomy(abnormal opening)

From Head to nose - glucose drip from nose

Diabetes Insipidus

decreased posterior pituitary ADH, injury of hypothalmus

Usually discovered in 1st few days

Increase in urine output, specific gravity low

Serum Na High

Treatment Pitresson (IV) Desmopressin (can be given PO, Nasal Spray, Sub-q

CN IX, X, XI, XII

Glossalpharyngeal, Vagus, Spinal Accessory, Hypoglossal

SIADH

Adnormal Hi secretion of ADH

Water intoxication

IICP MAJOR

Injury Subarchanoid bleed, encephalitis, menigitis, guillam barre,Tegretol, Barbituates

decreased urine output - 4-5ml/hr major emergency

SG very high, Serum Na low

Treatment Lasix, Antibiotic Declomycin

Demeclocycline works by increasing the amount of water in your urine to more normal levels

Arteriovenous Aneurysms

Malformation between artery and vein

Artery blows and the person dies

Neurogenic Pulmonary Edema - ARDS

Pressure mismatch, cardiac failure, stress of cardiac sent them into this.  Treat PEP, greater lung expansion..  causes IICP

Temperature regulation

Issue infection or hypothalamus issues with regulation

Seizures

Electronic malfunction of the brain

increases O2 demand by 250%

seizure is related to areas of injury

Grand Mal - Tonic Clonic

Whole brain seizure

change in vein pressure

Myoclonic Seizure

movement seizure

Single, cluster, jerk

Generalized/ Absence/ Petite Mal

Associated with part of the brain

Type children get - associated with lip smacking, staring

Have to rule out sleep deprivation, glucose exchange      (don't have good glucose control, glucose levels drop)

Have diagnostic marker look at EEG and you can see a difference in the pattern

Atonic

Just lose muscle control and fall down

Some get an aura or prewarning sign

Significant risk for head injury, have to be very aware of Can be unconscious for several minutes

Signs flash of light, legs feel heavy,

Partial Seizures - Complex/Simple

Huge category - only a portion of head

Used to be cause Temporal Lobe seizures

Muscle Movement, Partial loss of consciousness, no warning

Status Epilepticus

Continuation of seizures activity lasting up to 30minutes

seen in a noncompliant patient stopped taking dilantin

Procedures for seizure

Nothing in the mouth during seizure

Turn their head to the side

Loosen their clothing at neck line

Will be very tired after seizure

May be incontinent of B & B provide privacy afterwards

Can work in many fields but will have certain limitations

Phenytoin (Dilantin)

Used for Tonic-Clonic, partial, status epilepticus

Therapeutic levels 10-20mcg/ml

HALF LIFE 15-30hr 7days reach a steady level

DO NOT MIX WITH DEXTROSE - results in crystallization in the IV tubing, IV admin must be separate sign, must be diluted with saline (can cause phlebitis)

Do not admin faster than 50mg per minute; rapid admin can cause CARDIAC ARREST

Carbamazepine (Tegretol)

Used for Tonic-Clonic, partial seizures

 Must have CBC before first use.

Cell Specific

Contraindicated for Bone marrow depresssion (CA), hematologic alteration

Therapeutic level 5-12mcg/ml

Half life 12hrs 2 days for steady drug levels

Given PO Oil preparation c meals rinse cup 3x min

Inhibit Birth Control and coumadin

S/e HA, vertigo, unstead gait, visual nystigmus, blurred vision, diplopia, leukopenia, anemia, thrombocytopenia (clotting anormality)

Phenobarbital

Used for Tonic-clonic, partial seizures, convulsive Status epilepticus

Half life 5-12 hrs

Seperate iv sites has many incompatibilities - mix with sterile water/ if precipitate discard, use within 30 minutes check vial dose calcultation (do not admin faster than 60mg/min

Max dse 20mg/kg always double check with another nurse

Must stay with patient for the 1st 30 minutes of IV dosage(Airway)

Pregnancy Cat D 

S/E Hepatic failure, CNS somnolence, depression coma, death

Ethosuximide (Zarontin)

Used for absence seizures

Half life 30 hrs 3 days to reach steady level

Monitor CBC, Liver, Mood changes,

Admin c food

S/E Hiccups, N&V Leukopenia,

Valproic Acid (Depakote)

Used for Tonic-clonic, partial, absence, myclonic, atonic,

Half life 5-20hrs 3 day for steady level

Liver toxic

Monitor CBC, LFT (AST, ALT), PT/PTT

Used for instutitionalize

Potentiates Phenobarbitol, Dilantin

S/E GI upset, weight gain, retinal detachment, Thrombocytopenia, Jaundice, and Lots of others

 Clanazepam (Klonopin)

Used for Absence, myoclonic, atonic seizures

Contra liver dysfun and narrow angle glaucoma

Half-life 50hrs, 10days steady drug level

Pregancy C

S/E Sedation, Alopecia, Hirsutism

Gabapentin (Neurontin)

Used for partial seizures and nerve pain

take two hrs after antacid

no liver interaction, excreted intacted

S/E somnolence, ataxia, drowiness, increase in appetite/weight gain

Oxcarbaxepine (Trileptal)

Used for Partial Seizures

Half life 5 hrs

Monitor sodium; hangs onto sodium

Lamotrigine (Lamictal)

Half life 24hrs

Excreted in urine Blocks sodium channels

Rash supposed to report it including Steven Johns

Topiramate (Topamax)

Uses partial seizures

peak 2hrs not affected by food

Lots of S/E

Can cause Metabolic acidosis, reduced sweating, hyperthermia with increased activity, angle closure glaucoma,

Meningnitis Symptomology

Classic s/s HA, Fever, Stiff Neck

Photophobia, Dec LOC N&V

Infants alert Petechial Rash - initial symptom of DIC in babies; associated with meningacoccal bacteria

Meningitis symptom

Kernig's sign

Flexing the patient’s hip 90 degrees then
extending the patient’s knee causes pain.

Meningitis symptom

Brudzinski Sign

Flexing the patient’s neck causes flexion of
the patient’s hips and knees.

Probably the most common

Bacterial Meningitis

Strept Pneumonia (G+) seen most in children under 5

Neisseria (G-) most common; Prisons, military, big college campuses (progressive outbreak) why vaccines are required

Listeria (G+) usually hotdogs, unpasteurized yogurt

Meningitis Summary of Symptoms

Kernigs/Brudzinski

IICP

SIADH

Septic Emboli - damage to vessel structure (CMST Eval)

Labs - Gram staining (determine organism), WBC, Electrolyte mismatch, coag profile

Neuro Assessment - Altered Pupils Size Shape-

CN II Optic Nerve

CN III Oculomotor

CN IV Trochlear

CN VI Abducens

CN VII Facial

CN VIII Vestibulocochlear - Loss of hearing

Hemophilius Influenza - Vaccine

Given 2mo, 4mo, 6mo, booster 12-15 mo

Spinal Tap

Very cloudy

Important to understand kit

labeling of tubes, slide prepared

Viral Meningitis or Aseptic Meningitis

Common in summer or fall, had chicken pox or measles

Could be herpes associated

Fungal Meningitis

100% Fatal for AIDS patient it is fatal, extreme HA

Go into coma less than 48hrs

Parasitic Meningitis

Water areas unprotected, Amoeba or Worm

Pond, water areas, where freezing for frost doesn't occur

Hard to

Meningitis Treatment

Isolation, ADL slowing down, BR, IV fluid monitor - lytes

Meds

Decadron - Anti-inflammatory

Mannitol - Osmotic Diuretic

Lasix - remove fluid from body

Dilantin - seizure prevention

ASA - watch bleeding

Treatments for particular organisms

Neisseria - Penecillin G or Rocephin

Strep - Rocephin or Vancomycin (check levels watch kidneys)

Listeria - Ampicillin Gentamyacin (Nephrotoxic, Hearing loss usually kids

HI - Claforan

Mycobacterium - TB routine (Liver, Kidneys), pregnancy protected

Fungal - Amphotericin

Parasitic - Amphotericin (Liver, Kidney Toxic

Encephalitis

Inflammation of Brain tissue & Meninges

Cerebrum, Cerebellum (alteration in gait and balance), Brain Stem

Viral, Arboviruse, Herpes (Acute attack), Cytomegalovirus, Amebae

s/s HA, fever, N/V, vertigo, stiff neck, motor dysfunction, tremors, IICP, LOC, complications (DIC)

Treatment - Manitol decadron

Brain Abscess

Purulent Infection, Most bacterial Strep & Staph in the frontal and temporal area

Sources - Berr Holes, Craniotomy, Camino Catheter

Symptoms - HA, Chills,

CN II, IV, VI

Labs Specimens (Nose, throat, ears, wound)

Treatment PCN, if anerobic Flagyl

Manitol, Decadron

Stroke, Brain Attack, Cerebrovascular Accident

790,000 strokes per yea (75% 1st incident)

Non-modifiable - age, sex (male), low birth rate, race, genetic

Primary Modifiable R/F

HTN - lose weight, reduce stress, stop smoking

Cigarette Smoking - don't smoke in front of kids

Diabetes & PAD - controlled (watching HA1C), structure but its also exercise do step thing (give them an actually exercise routine

Atrial Fibrillation - coumadin

Dyslipidemia - family tendency, have to document patient teaching

Carotid artery stenosis - using doppler to examine, increased glucose levels irritates the veins

Sickle Cell Disease

Post-Menopausal Hormone Therapy - short term duration

Diet, Sedentary Lifestyle Obesity & Body distribution (focus on children)

2ndary Modifiable R/F

Metabolic Syndrome inability to regulate sugar

Excessive EtOH intake - alternative life

Drug Abuse

Oral Contraceptive >35, smoke, how often using

Sleep Disorder Breathing (Apnea) - small burst of hypoxia - mask, dental insert, pillows

Migraine -change in vessel structure, hormone, food, family hx

Hyperhomocytseinemoia - increased homocystine, DM

Elevate Lipoprotein

Hypercoag - high platelet levels major factor, meds to decrease

Infection

New role in ER

High portion of Americans w/o insurance

Identify risk - do screening (modifiable r/f)

Screen (glucose levels, LDL's)

Preventive Tx

Refer

Lifestyle Mod - diet and weight control, physical activity, smoking cessation, EtOH

Aspirin Regiment

Not recommended for low-risk subjects

Alliance for Healthier generation

1 in 3 children; 2-19 yrs are obese or overweight

Risk for HTN, Hi Cholesterol, DM II

Eliminate childhood obesity, inspire lifelong habits

Decrease prevalence, decreas obesty

School lunch program

Healthy Schools

Obesity counseling and management

Power to End Stroke

AA are at highest risk

increase awareness of impact of stroke and benefit of controlling HBP and DM

Stroke pledge and community outreach

 Empowerment of individual

Talk with Dr. Walking program, Stroke risk assessment, healthcare screening

Health Promotion program

Go Red for Women

Heart Risk Assessment

Choose to move (online 12wk exercise program)

Dietary planning

Heart Profilers

online learning guide for treatment of cardiovascular

Heart hub

Prevention and management

online discussion

Heart RX - Pt Ed

Personal Health Record - Home monitoring

Heart Savor CPR

Start - Employee Program

Stroke Registry

Warning Signs of Stroke

Sudden weakness or numbness of face, arm, leg (same side)

Sudden confusion, trouble speaking, or understanding (lang formation)

Sudden difficulty in vision in one or both eye (CN II, III, IV, VI)

Suddens difficulty in walking, loss of balance, dizziness, coordination - cerebellar test

Sudden, severe HA with no known cause - subarchnoid hemorrhage

Transient Ischemic Attack - Warning signs of stroke

5 million have them each year

Can occur in brain, spinal cord, retina

Symptoms: new definition <1 hr

Old definition <24hrs

Rationale

10-15% stroke within 3hrs, 50% stroke in 48hrs

RIND - Reversible Ischemic Neurological Deficit

Older term

Symptoms lasting 24hrs but less than 1 wk

Stroke

Caused by a change in normal blood supply to the brain; it can not store O2 or glucose therefore must receive constant flow of blood to provide for normal functioning, in addition blood flow is need for removal of metabolic waste.

Ischemic strokes

Occlusion of a Cerebral Artery - most important r/f HBP

Thrombotic

clot blocks flow = r/t arteriosclerosis, atheromas, plaques, lesions, and decreased vessel elasticity

Most common - points of division (Bifurcations)

carotid - s/s decreased vision, hemiparesis, aphasia

Vertebrobasilar - vertigo, tinnitus, and blurred vision

Lacunar Stroke - 25% of thrombotic strokes 2nd time around - non compliant HTN, hi lipids, EtOH abuse; usually frontal lobe

Embolitic Stroke

30% of all strokes; traveling clot

Common causes: atrial fibrillation, MI, Carotid post. op, mitral valve - middle cerebral artery most common in embolic stroke

symptoms based on location, paralysis and expressive aphasia, LOC: awake, no seizure

Hemorrhagic stroke

Bleed between the brain and skull

caused by aneurysm - ballooning or blistering along normal artery bleeding into the subarchnoid space, ventricles, and or intracerebral tissue.  Vasospasm, a sudden or periodic constriction of a cerebral artery,

Intracerebral Stroke

Bleed into the tissue of the deep brain

At risk for this type of bleed and stroke are chronic subdural hematoma becoming acute, bleeding disorders, coumadin patient

s/s HA vomiting, hemiplegia, seizure

Miami Emergency Neuro Deficits

Basic Data - Age, gender, chief compliant

Symptom onset - Last time w/o s/s 

 FAST Face Droop, Arm Drift, Slurred Speech, Time, Supplemental Info (recent surgery, trauma, or MI, meds and allergies, BP, Glucose

Labs for Stroke

CBC with diff, platelets, Factor Assays, Pt, ptt, fibrinogen, troponin, glucose

UA for sepsis, C&S BMP, BUN, creatinine

IV fluids, thrombolytics & meds ( no dextrose)

ER treatment

Bp - no antihypertensives in the field

O2 (2-3L) Pulse-ox >92

Glucose <50 ER Orders

IV - saline only, load and go

BP Treatment

Diastolic >120 or Systolic > 220

Rx: labetalol (tachycardia) nicardipin (bradycardia, CHF, COPD)

Causes of increased BP: hypoxia,  IICP, brain hemorrhage, pain,  nausea, full bladder, and loud environment

TPA Protocol

Time to give 3hrs that time has been extended to 6hrs

Labs results verify (Clotting factors)

CT w/ reading: verify no hemorrhage (if hemorrhage can't give TPA will kill pt)

All lines and tubes must be inserted before admin of TPA

If you have a leak it can be a major problem

Dosage: pt weight/kg

Total max dose 90mg

Safety alert remain portion of does not be infused must be discarded and waste must be verified

Given in divided dose - when drawing up med always verify

10% given as a bolus over 1 min

90% given over the next 60 min

10% given to make sure there is not reaction to med; allergy s/s airway order histamines, corticosteroids, epinepherine

Severe HA, acute HTN, N&V orders MD, CT scan

Monitor VS, Neuro, site q15min/2hrs

no anticoags or anti-platelets for 24hrs

Flat for 6hrs

ICU treatment

Monitor post TPA - cardiac monitor, VS, Neuro, Site, Arm and leg, weakness q 30min for 6hrs, then q1hr for 16hrs, then q4hrs

Monitor for bleeding

Position flat for 6hrs, legs straight with bedrest for 24hrs

Ct 24 hrs post TPA to exclude hemorrhage before anticoag admin

BP protocols differe before TPA and after

ICU Treatment Continue

Glucose monitor accu check >140 regular insulin

Hypoglycemia is 50% glucose

Cerebral edema may occur not or in the next 5 days is IICP same as trauma - treatment mannitol, decadron

Seizure medication Dilantin, Tegretol after stroke

MD verifies all meds

Acetiminophen 650mg prn q4-6hrs for pain or temp >99.6

O2 stats <92% 2-4L/ NC, Lung sounds q4hrs

Aspiration/Swallow assessment - video fluoroscopy (CN IX, X, XI, XII)

Nursing Unit Day 2-5

MD Verifies orders

Prepare for Rehab family/pt teaching

Swallow eval

PT/OT eval with ADL eval

Respiratory complications show up here

Cardio BP stable or variable

2nd stroke 48-72 hrs after 1st