5 Neuro Emergencies Flashcards
(117 cards)
1
Q
What leads to increased intracranial pressure?
A
Abnormal increase in volume of any component of the intracranial space
Brain parenchyma - 80%
CSF - 10%
Blood - 10%
2
Q
Brain injury following increased ICP can result from….
A
Brainstem compression (herniation)
Reduction in cerebral perfusion pressure (CPP) - important for delivery of O2 and nutrients to the brain
3
Q
Successful management of increased ICP requires…
A
Prompt recognition
Judicious use of invasive monitoring
Therapy aimed at reducing ICP and addressing underlying cause
4
Q
Clinical presentation of elevated ICP
A
Headache N/V PAPILLEDEMA**** UL or BL fixed pupil Decreased consciousness Decorticate or decerebrate posturing Cushing’s triad
5
Q
What is cushing’s triad?
A
Ominous findings in cases of elevated ICP
Bradycardia
Hypertension
Respiratory depression
6
Q
Breakdown of Glasgow Coma Scale scores
A
GCS 15 - max score
GCS max for intubated patient - 10
GCS<8 customary to intubate (usually in coma)
GCS 3 - deep coma or FUCKING DEAD
7
Q
What is decorticate posturing?
A
Flexor response, flexion with addiction of arms and extension of the legs
Reflects destructive lesion in corticospinal tract from cortex to upper midbrain
8
Q
What is decerebrate posturing?
A
Extensor posturing, extension, adduction, and internal rotation of the arms and extension of legs
Associated with damage to corticospinal tract at level of brain stem (pons or upper medulla)
9
Q
Which is worse - decorticate or decerebrate posturing?
A
Decerebrate
10
Q
Some possible causes of intracranial hypertension
A
TBI/intracranial hemorrhage CNS infection Ischemic stroke Neoplasm Vasculitis Hydrocephalus Hypertensive encephalopathy
11
Q
How do you manage increased ICP
A
Refer to Neurosurgery
• Decompressive craniectomy
• Ventriculostomy
Resuscitation:
• Oxygenation (avoid hypoxia), maintain O2 >90%
• BP - control HTN/avoid hypotension
Goal is to maintain end organ perfusion
12
Q
Specific support measures to take in managing ICP patients
A
Elevate head of bed to 30 degrees
Analgesia and sedation
Treat fever aggressively (Tylenol), even mechanical cooling
ICP monitors
IVF (normal saline)
Mannitol to reduce brain volume
Anti-seizure meds
13
Q
What skull fractures need a protected airway?
A
AMS Cranial nerve or other neuro deficits Scalp lacs or contusions Bony “step-off” of the skull Periorbital or retro auricular ecchymosis
14
Q
What are the three types of skull fractures?
A
Linear
Depressed
Basilar
15
Q
Skull fracture that typically has no neuro symptoms (though minority develop significant intracranial hemorrhage)
A
Linear skull fracture - usually a single fracture
16
Q
When might you be concerned that a linear skull fracture could produce significant intracranial hemorrhage?
A
If temporal bone is involved - it can disturb vascular structures w/ significant bleeding
17
Q
Should you admit someone with a linear skull fracture?
A
If CT shows no underlying brain injury, pt has no neuro deficits, and it wasn’t a high speed trauma (MVA) —> observe in ED for 4-6 hrs then discharge with HOME SUPERVISION***
If any suspicion of brain injury patient should be admitted for observation
18
Q
What is a depressed skull fracture?
A
Segment of the skull is driven below the level of the adjacent skull
Often involve injury to brain parenchyma***
19
Q
Patients with depressed skull fractures are at high risk for…
A
CNS infection, seizures, and death if not identified early and managed
20
Q
What are the two types of depressed skull fracture?
A
Closed (simple)
Open (compound)
21
Q
Open depressed skull fractures should be examined but not…
A
Probed
22
Q
How do you manage a patient with a depressed skull fracture?
A
CT scan
Admit to neurosurg (may need surgical intervention)’
Td if needed
Prophylactic abx and anticonvulsants
23
Q
Why do we care so much about basilar skull fractures?
A
Can produce a dural tear resulting in communication between subarachnoid space, paranasal sinus and the middle ear
24
Q
What is typically the first thing you’ll notice in patients with basilar skull fractures?
A
Clear or blood-tinged rhinorrhea/otorrhea (indicating leakage of CSF)
25
SSx of basilar skull fracture
Clear/blood-tinged rhinorrhea/otorrhea
Retro auricular or mastoid ecchymosis (battle sign) - typically 1-3 days later
“Raccoon eyes” (periorbital ecchymosis) - typically 1-3 days later
Possible hemotympanum
26
Canadian Head CT rule
+Battle sign/raccoon eyes
Hemotympanum
Otorrhea/rhinorrhea
All are clinically highly predictive of a significant head injury
27
Complications of a basilar skull fracture
CSF leak, infection, or cranial nerve injury
Risk for intracranial hemorrhage
Commonly can occur through the temporal bone, risk for epidural hematoma
28
What is a patient at risk for if their basilar skull fracture is in the temporal bone?
Epidural hematoma
29
How do you manage patients with basilar skull fractures?
ALL must be admitted regardless of need for surgery
Neurosurg/neurology consult
Close neurologic monitoring required
30
Examples of penetrating skull fractures
Gunshot wounds, stab wounds, blast injuries
Typically involve significant brain injury and ICH
31
How to manage penetrating skull fractures
Immediate neurosurg consult
IV Abx
Tangential skull fractures (ie bullet graze) are at risk for ICH and should get emergent CT
32
Appropriate diagnostic imaging for all skull fractures
Non-contrast CT scan
MRI secondary for suspected vascular injury
If no CT available, xrays with 2 views (can’t rule out intracranial injury though)
CLEAR THE C-SPINE
33
5-15% of patients with skull fractures also have...
Cervical spine fractures
Need CT of cervical spine as well if positive findings or AMS
34
What are two examples of closed head injuries
Concussion
Brain contusion
35
Trauma-induced alteration in mental status that may or may not involve loss of consciousness
Concussion (Mild TBI)
Direct blow with an “impulsive” force transmitted to the head
36
What is a brain contusion?
Areas of bruising associated with localized ischemia, edema, and mass effect (follows a concussion)
Can be from:
Direct external contact force
Acceleration/deceleration trauma
May delay recovery from a concussion
37
What is the mechanism of injury in closed head injuries?
Coup vs Contrecoup (Primary Impact —> secondary impact)
38
What should you do if you suspect a patient has or had a concussion or mild TBI?
Neuro assessment with mental status testing
39
What head injury patients require urgent neuro Imaging and neurosurgical consult?
GCS <15
Suspected open or depressed skull fractures
Signs of basilar skull fracture
Two or more episodes of vomiting****
New neuro deficit
Presence of bleeding diathesis or use of anticoagulant meds
Seizure
Age ≥ 60
Retrograde amnesia >30 min or longer before traumatic episode
High impact head injury
Intoxication, HA, or abnormal behavior
40
Who gets admitted for a closed head injury?
GCS <15
Abnormalities on CT
Seizures
Underlying bleeding diathesis or oral anticoagulation
Other neuro deficit
Recurrent vomiting
No responsible person at home to monitor for progression*****
41
Who gets to go home after a closed head injury?
GCS = 15
Normal exam and CT of head
No predisposition to bleeding
Responsible monitor available for home
42
What is a Diffuse Axonal Injury (DAI)?
Shearing of white matter tracts from traumatic, sudden deceleration injury (blunt trauma) —> severe intracranial injury
Leads to axon disruptions, swelling, and cell death
43
How will you know someone has a diffuse axonal injury?
Variable presentation and prognosis, so.... 🤷♀️
Associated with post traumatic coma and frequent cause of persistent vegetative state
44
Do patients with diffuse axonal injury get surgery?
Nope
They just veg out for the rest of their lives
45
What will you see on CT in cases of diffuse axonal injury?
Blurring of gray to white matter margin, cerebral hemorrhage, or cerebral edema
46
Cerebral hemorrhages are subdivided into...
Intracranial hematomas (external to brain parenchyma)
• Epidural hematoma
• Subdural hematoma
• Subarachnoid hemorrhage
Intracerebral hemorrhage (lesions w/in the brain substance)
47
Name that hematoma:
Acute collection of arterial blood between the skull and the dura mater
Epidural
48
Name that hematoma:
More likely in adolescents/young adults
Epidural
49
Name that hematoma:
Typically associated with a skull fracture and/or trauma
Epidural
50
Name that hematoma:
Damage to the Middle Meningeal Artery
Epidural
51
Name that hematoma:
Brief LOC —> lucid interval —> rapid clinical deterioration
Epidural
52
Name that hematoma:
Lens-shaped or lenticular (biconcave) shaped appearance on CT
Epidural
53
Name that hematoma:
Doesn’t cross suture lines
Epidural
54
Name that hematoma:
Collection of venous blood between the dura matter and the arachnoid
Subdural
55
Name that hematoma:
Due to tears of the bridging veins
Subdural
56
Name that hematoma:
Brain atrophy (elderly or alcoholics)
Subdural
57
Name that hematoma:
Traumatic (most are falls)
Subdural
58
Name that hematoma:
Can be acute or subacute or chronic
Subdural
59
Name that hematoma:
CT shows crescent shaped bleed
Subdural
60
Clinical Sx of intracranial hematomas
```
Momentary LOC to coma
HA
Vomiting
Drowsiness
Confusion
Aphasia
Seizures
Hemiparesis
```
61
How do you manage intracranial hematomas?
Emergent neurosurgical consult
Decision to perform surgery based on:
Patient’s neuro status (GCS)
Neuro exam/pupillary signs
Brain imaging findings
Craniotomy with hematoma evacuation vs observation (burr hole/trephination)
62
Tell me all you know about subarachnoid hemorrhages
Bleeding within the subarachnoid space
Traumatic vs Non-traumatic (85%)
Non-traumatic —> aneurysm/vascular malformations/cerebral venous thrombosis
63
____% of subarachnoid hemorrhage patients die prior to reaching the hospital
10%
Overall mortality is 51%
64
Clinical presentation of subarachnoid hemorrhage
Acute onset of “worst HA of life” - “thunderclap headache”
Impaired consciousness
Neck stiffness
N/V
Exertion/valsalva immediately preceding onset
Elevated BP
Occipital HA
Hx of smoking
65
How do you manage subarachnoid hemorrhage?
CT before LP********
+/- LP
Neuro consult
Supportive tx
Interventional neuroradiologist can do: surgical clipping or endovascular coiling
66
Complications of subarachnoid hemorrhage
```
Rebleeding
Vasospasm and delayed cerebral ischemia
Hydrocephalus
Increased ICP
Seizures
Hyponatremia
```
67
2nd most common cause of stroke, following ischemic stroke
Intracerebral (intraparenchymal) hemorrhage (ICH)
Mortality and morbidity is high
68
Initial goals of treatment for intracerebral hemorrhage
Preventing hemorrhage extension
Prevention and management of elevated ICP
69
How do you manage ICH?
Emergent noncontrast CT
MRI of brain for smaller lesions
Angiography (CTA or MRA) for vascular malformations/aneurysms
70
Nontraumatic etiolgoies of ICH
```
Hypertension*********
Amyloid angioplasty
Ruptured secular aneurysm
Vascular malformation
Hemorrhagic infarction
Bleeding disorders
Brain tumor
CNS infection
Vasculitis
Drugs
```
71
Clinical presentation of ICH
Varies based on location
```
Typically:
Acute onset focal neuro deficits
Increasing neuro SSx over time
HA
Vomiting
Decreased LOC
Seizures
```
72
How do you manage ICH?
```
CT w/o contrast or MRI
Emergent neurosurgical consult for decompression
Admit to ICU
BP control
Manage elevated ICP
Avoid hyperglycemia (keep glucose between 140-180)
Seizure prophylaxis and treatment
Reversal of anticoagulation
NPO
```
73
Why do you want to avoid hyperglycemia in patients with ICH?
Makes for worse outcomes
Keep glucose between 140-180
74
Thrombus formation in an artery —> reduced blood flow resulting in localized hypoxic brain injury
Ischemic CVA
75
Causes of Ischemic CVA
Cardiac - a fib or valvular disease
Large artery - atherosclerosis, thrombus, embolism, arterial dissection
Small artery - HTN, DM, Vasculitis
76
What is the goal for managing stroke patients?
<60 min door to CT****
Rapid assessment and NIHSS score
ABCs and other supportive care
ECG, troponin, Labs, and FINGERSTICK GLUCOSE***
77
What should you give your Ischemic CVA patient if CT shows non-hemorrhagic CVA?
325mg ASA
78
Three most predictive exam findings for diagnosis of ischemic CVA
Facial paresis
Arm drift/weakness
Abnormal speech
79
Differences on CT between hemorrhagic CVA and ischemic CVA
HCVA: Blood seen where stroke is occurring
ICVA: May be normal
80
How do you manage ischemic stroke
BP CONTROL
• for hemorrhagic stroke the goal is higher - 140-160/90
Are they a candidate for IV thrombolysis?
• No - allow for permissive hypertension (no intervention unless SBP >220 or DBP >120)
• Yes - target BP pressures are SBP ≤185, DBP≤110
81
Who gets thrombolytic therapy?
If onset of Sx <4.5 hours (can use last time patient was known to be normal if time of onset unknown)
CT/MRI within 25 min and infusion should be started ≤60 min from time of arrival in ED
82
What is status epilepticus?
Seizure for 5 min continuously
or
Multiple seizures w/o regaining baseline mental status in 30 min
83
How do you manage a seizure in the ED?
```
Protect patient from injury
Immediate ABCs, may need to intubate
Prevent aspiration
TWO IVs
CBC, CMP, tox screen, FS glucose
Consider administering thiamine and glucose
```
84
For a first seizure, what is the preferred imaging?
MRI
EEG and LP in select patients
85
Patients with status epilepticus need...
Correction of metabolic abnormalities and continuous EEG monitoring
86
What is the treatment for status epilepticus (5-10min)?
IV Lorazepam 2mg up to 0.1 mg/kg or IV Diazepam 10-20mg
AND, one of the following:
IV Fosphenytoin 20 PE/kg at 150 mg/min
IV Phenytoin 20 mg/kg at 50 mg/min
IV Levetiracetam 2000-4000 mg
Consider intubation
87
What is the treatment for refractory status epilepticus?
IV Midazolam
OR
IV Propolol or Ketamine
OR
IV Phenobarbital
Intubate, neuro ICU admission, continuous EEG monitoring
88
Patients with a new onset seizure can be discharged with outpatient follow up if...
Returned to baseline AND
Normal CT AND
Normal labs AND
No prolonged postcoital period or seizure related injury
89
Patients with established seizure disorders may be sent home if ...
Returned to baseline AND
Seizures have not recurred AND
No acute abnormalities are found
90
What precautions should you give to seizure patients when you send them home?
Swimming/baths
Worming with heights, hazardous tools/machines
NO DRIVING - needs to be cleared by neurologist or PCP first
91
What is a Jefferson Fracture?
C1 (Atlas)
Caused by axial compression
Typically no spinal cord damage
92
What is an Odontoid fracture
C2 fracture of the dens
| Caused by forceful flexion or extension (more unstable than C1)
93
What is a Hangman’s fracture
C2 fracture involving bilateral pedicures
Caused by hyperextension with compression
Can transects spinal cord
If death occurs, it’s usually instantaneous
VERY UNSTABLE
94
What is a Burst fracture?
Lower cervical vertebra
Caused by direct axial load (ie diving)
Fragments displaced in all directions, can enter spinal canal
95
Acute signs of a complete spinal cord injury (SCI)
```
Absent reflexes
Flaccid muscles
Loss of sensation
Priapism in men
Urinary retention
```
1-3 days later:
Hyperreflexia
+Babinski
Spasticity
96
Presentation of Anterior cord syndrome (incomplete SCI)
Affects anterior 2/3 of the spinal cord
```
Losses:
Motor impairment
Reflex changes
BL loss of pain and temp sensation
Bladder dysfunction
```
Preserved:
Tactile, proprioception, and vibratory sensation
97
Presentation of Central cord syndrome (incomplete SCI)
Medial aspect of the central cord - typically extension injury, compression, or tumor
Losses:
Motor impairment in upper extremities > lower
Variable sensory loss (light touch/pin prick/temp)
Bladder dysfunction
Preserved:
Sacral sparing
98
Presentation of Posterior cord syndrome (incomplete SCI)
BL involvment of dorsal columns and corticospinal tracts (MS, tumors, subluxation)
```
Losses:
Motor weakness
Hyperreflexia
Gait ataxia
Paresthesias
```
Preserved:
Bladder initially
99
Presentation of Brown Sequard (incomplete SCI)
Lateral hemisection, dorsal column unilaterally: typically PENETRATING INJURY
Losses:
Ipsilateral motor paralysis and loss of proprioception/vibration
Contralateral loss of pain and temp
Preserved:
Bladder function
Prognosis is excellent (90%)
100
Spinal cord injuries can result in ...
Neurogenic shock (systolic hypotension, bradycardia w/in hours) due to sympathetic tone
Cervical spine - 19%
Thoracic - 7%
Lumbar - 3%
101
What are the NEXUS criteria?
```
Absence of posterior midline tenderness
Normal level of alertness
No evidence of intoxication
No abnormal neuro findings
No other painful distracting injuries
```
If all 5 criteria met, no imaging is needed
102
Which spinal cord injury is most commonly associated with disc herniation or cord infarct?
Anterior
103
Which spinal cord injury is associated with extension injury, spinal cord compression, or slow growing lesions?
Central
104
Which spinal cord injury is associated with MS or tumors
Posterior
105
Which spinal cord injury is typically from penetrating trauma?
Brown Sequard
106
Canadian C-spine rule says you should perform radiography in patients with any of the following:
Age 65 or older
Dangerous mechanism of injury
Paresthesias in the extremities
107
Canadian C-spine rule says that in patients without high risk factors, assess for these low risk factors that allow for safe assessment of the neck ROM
Simple rear end motor vehicle accident
Sitting position in ED
Ambulatory at any time
Delayed onset of neck pain/or no midline pain
Can test ROM if rotation to 45 degrees no imaging needed
108
Diagnosis of disk herniation is usually
Suspected clinically
Could do an MRI but why?
109
What are the two types of deficits you can get with disk herniation?
Radiculopathy - dermatomal pain or numbness (not emergent)
Myelopathy - weakness, loss of bladder or balance (emergency)
110
Neurosurgical emergency where nerve compression takes place below the L1-2 interspace after the termination of the spinal cord
Causal Equina syndrome
111
Causes of cauda equina
Disc herniation, abscess, tumor, spinal stenosis, metastatic disease, infection, autoimmune dx
112
Clinical presentation of cauda equina
Saddle anesthesia
Urinary incontinence w/ or w/o overflow
Decreased anal sphincter tone
Sexual dysfunction
113
Treatment for cauda equina
Emergent MRI with contrast
Administer dexamethasone 10mg IV immediately (don’t wait for imaging)
Consult
114
Acute onset of peripheral neuropathy (immune-mediate), most commonly a demyelination neuropathy
Guillermo Barre
115
Presentation of Guillen Barre
Progressive, starts distally, ascending, symmetric muscle weakness
Mild URI or gastroenteritis precedes the onset or neuro disease by 1-3 weeks
NO FEVER
Absent or depressed DTR
116
What diagnostics do yo want for Guillen Barre?
```
CSF studies (elevated protein)
EMG-NCS (nerve conduction study)
```
117
Treatment for Guillen-barre
```
Consult neuro
Admit to ICU (may need vent)
DVT prophylaxis
Close monitoring
+/- urinary cath
IVIG and Plasmapheresis
```
