18 Jan 24 Flashcards
(68 cards)
Pt with cauda equina syndrome and recent spinal anasthesia , anticoagulant history ?
Spinal epidural hematoma due to epidural
Spinal epidural hematoma Management
MRI spine
Urgent Surgical decompression (laminectomy)
Bleeding is venous so symptoms are slowly progressive in days.
Spinal epidural hematoma CF
Pts taking anticoagulants or thrombocytopenia
Epidural block recent
Spinal point tenderness
Neurologic deficits
Slowly progressive hematoma expansion in days as bleeding is venous
Common site of epidural hematoma
Fracture of pterion ( junction of frontal parietal temporal sphenoid bones )
Initial immediate ttt for cerebral edema
Hypertonic saline.
Osmotic therapy decreases the parenchymal volume by creatjng osmolar gradient that draws water out of edematous brain.
Hypertonic saline is prefrred over mannitol.
Interventions to lower ICP
- Decrease brain parenchymal volume:
Hypertonic saline mannitol
- Decrease cerebral blood volume :
Head elevation to increase venous outflow Sedation to decrease metabolic demand Hyperventilation to dec PaCO2
- Decrease CSF volume;
CSF removel (External ventricular drain)
- Increase Cranial volume ;
Decompressive craniectomy
Shaken baby syndrome. CF
- Subdural bleeding due to shearing of bridging veins
- Coup- countercoup injury as brain impacts skull
- Subdural hem presenting as incr HC, bulging/tense anterior fontanelle , papilledema , AMS
- Vitreoretinal traction
- Retinal hemorrhages
Management of non accidental trauma
Ensure immediate safety
Skeletal survey
CT head
Fundoscopy
Epidural hematoma pt becomes obtunded with BTN bradycadia and bradypnea (cushing triad ) Dx
Uncal herniation
First sign fix , dilated pupil due to oculomotor nerve compression.
(Oculomotor muscles paralysis comes later and leads to ptosis and down and out position of IL eye)
CL hemiparesis
CL homonymous hemianopia with macular sparing (comp of PCA)
IL hemiparesis. (Kernohan phonemenon)
Post concussion syndrome CF
Charaterized by prolonged >4 week concussion syndrome.
Common SS tension like headache with phonophobia.
Dizziness
Sleep disturbance
Mood changes
Poor conc
Most pts improve in 3 months.
Orbital floor fracture CF
Weakest area of bony orbit (orbital floor ,medial orbital wall)
🤪Herniation of orbit in maxillaty sinus
🤪Entrapment of inferior rectus muscle
🤪Entrapped IR keep orbit in downward position causing diplopia on upward gaze. Despite normal visual acuitu.
🤪Prolonged entrapment causes ischemia,fibrosis , permanent dysfunction.
Brain death clinical criteria
Known cause TBI stroke
Evidence (clinical , neuroimaging) of devastating CNS event.
Exclusion of confounding conditions (electrolyte abnormality, intoxication, paralytics)
Core temp >36 (96.8) , SBP > 100
Brain death clinical exam
🛖Coma
🛖Brainstem reflexes absent
🛖Apnea test : no resp response to PaCO2 >60mmhg
🛖 DTRs still present as they origin in spinal cord.
What is apnea test of brain death?
Preoxygenate and disconnect from ventilator.
No spontaneous respirations for 8-10mins with PaCO2 >60 or >20 above baseline and arterial pH <7.28
Declares brain death (after meeting legal req)
Carotid artery dissection cause
Trauma
HTN
Smoking
Connective tissue dx
Carotid artery dissection CF
UL head n neck pain
Transient vision loss
IL partial Horner syndrome
Ptosis miosis without anhidrosis
Signs if cerebral ischemia (focal weakness)
Cause of partial horner in Carotid artery dissection
Distention of symoathetic fibers that travel along internal carotid lead to partial horner syndrome. (Ptosis miosis)
Anhidrosis does not occur as its sympathetic fibers travel along external carotid artery.
Ttt of carotid artery dissection
CT or MRA
Manage like ischemic stroke
Complication of carotid artery dissection
Injury to arterial intima allows blood to flow into vessel wall leading to formation of false lumen Aneurysm) or intramural hematoma.
This leads to arterial obstruction or thromboembolic events.
Cerebral ischemia or TIA is commin complication.
Child with hemiparesis And aphasia after injury to posterior pharynx
Carotid artery dissection due to trauma.
Intimal injury to ICA causes dissection or thrombus formation which occurs in hours to days and extends into MCA and ACA.
SS
Neck pain
Thunderclap headache
Ischemic stroke
Dx
CT or MRA
BHS age
Benign
Onset 6 mo to 2Y
Completely resolve by age 5
Represent a variant of Vasovagal syncope due to autonomic dysfunction.
Cyanotic. Child becomes cyanotic and crying related
Pallid. Child becomes pale and diaphoretic , related to minor injury.
Confused and sleepy afterwards for few mins.
New memory impairment and cogniyive decline patient who takes medication for rhinitis.
Always review drug history for drugs with anticholinergic properties.
Prior to pursuing workup discontinue non essential medications.
Lead poisoning in adults CF
Aborbed through lungs
Stored in skeleton
Released slow and exerts pathologic effect in decades
GIT. ;
Abd pain , constipation , anotexia
Neurologic ;
Cognitive deficits
Peripheral neuropathy
(Impaired dorsiflexion)
Short term memory loss
Hematologic :
Microcytic Anemia
Basophilic stippling
Hyperuricemia (impaired purine metabolism)
Neuropsych : Psychosis
Lead poisoning ttt
EDTA
