emergencies

Question 1

What is Subdural hematoma (SDH)

Answer 1

caused by bleeding in the potential space between the dura and the arachnoid membranes.
-r/t tearing of the bridging veins that drain from the surface of the brain to the dural sinuses, but arterial rupture accounts for approximately 20 to 30 percent of cases.

Question 2

What is the most common cause of SDH in middle aged men

Answer 2

Head trauma in motor vehicle accidents, falls, and assaults

Question 3

high risk factors for SDH

Answer 3

• old pt with history of chronic alcohol abuse, and those with previous traumatic brain injury
• **overall incidence of SDH is highest among older adults

Question 4

common mental status is 50% of cases:

Answer 4

coma

-38% = transient “lucid interval” that is followed by a progressive neurologic decline to coma.

Question 5

s/s of chronic SDH

Answer 5

insidious onset of headaches, light-headedness, cognitive impairment, apathy, somnolence, and occasionally seizures.

Question 6

radiology for suspected SDH

Answer 6

CT of the head

Question 7

pt c/o sudden, severe headache & described it as “worst headache of my life”

Answer 7

• aneurysmal subarachnoid hemorrhage (SAH)

- r/t hemorrhagic stroke

Question 8

associated s/s with SAH

Answer 8

brief loss of consciousness, seizures, nausea or vomiting or meningismus

Question 9

if SAH suspected, np should order ____to dx

Answer 9

Noncontrast head CT

Question 10

if non contract CT is negative for SAH, what needs to be done is there is a high suspicion

Answer 10

Lumbar puncture is mandatory if there is a strong suspicion of SAH despite a normal head CT.

Question 11

what are the Complications of SAH

Answer 11

rebleeding, vasospasm and delayed cerebral ischemia, hydrocephalus, increased intracranial pressure, seizures, hyponatremia, cardiac abnormalities, and hypothalamic dysfunction.

Question 12

what is Anaphylaxis

Answer 12

an acute, potentially lethal, multisystem syndrome resulting from the sudden release of mast cell- and basophil-derived mediators into the circulation

Question 13

how is anaphylaxis classified?

Answer 13

“immunologic” or “nonimmunologic.”

Question 14

what is Immunologic anaphylaxis

Answer 14

it includes both immunoglobulin E (IgE)-mediated and immunoglobulin G (IgG)-mediated reactions (which have not been identified in humans), as well as immune complex/complement-mediated mechanisms.

Question 15

what is Nonimmunologic anaphylaxis

Answer 15

caused by agents or events that induce sudden, massive mast cell or basophil degranulation, without the involvement of antibodies.

Question 16

How to confirm Anaphylaxis and determining the cause(s)

Answer 16

detailed hx!!! - r/o asthma, COPD. Meds may exacerbation- i.e. Ethanol, NSAIDs, and opiates; beta blockers, ace inhibitors, Beta-adrenergic blockers administered orally or topically
-refer to allergy/immunology specialist

Question 17

major causes of community-acquired bacterial meningitis in adults in developed countries

Answer 17

Streptococcus pneumoniae, Neisseria meningitidis, and, primarily in patients over age 50 to 60 years or those who have deficiencies in cell-mediated immunity= Listeria monocytogenes.

Question 18

major causes of healthcare-associated bacterial meningitis

Answer 18

staphylococci and aerobic gram-negative bacilli

Question 19

how to differentiate bacterial from viral meningitis

Answer 19

conduct CSF analysis including Gram stain and culture

Question 20

what is the Kernig sign

Answer 20

used to r/o meningitis
-Place patient supine with hip flexed at 90 degrees. Attempt to extend the leg at the knee. (+) = resistance to extension at the knee to >135 degrees or pain in the lower back or posterior thigh

Question 21

what is the Brudzinski sign

Answer 21

used to r/o meningitis
-Place patient in the supine position and passively flex the head toward the chest. (+) = when there is flexion of the knees and hips of the patient.

Question 22

what is Jolt accentuation of headache

Answer 22

Patient rotates his/her head horizontally two to three times per second. (+) = exacerbation of his/her headache with this maneuver.

Question 23

what is a hypertensive crisis?

Answer 23

• systolic pressure ≥180 and/or diastolic pressure ≥120 mmHg

- acute rise in blood pressure over a previously normal baseline, even if the presenting pressure is <180/120 mmHg

Question 24

tx of hypertensive crisis

Answer 24

DONT lower the blood pressure too quickly or too much, as ischemic damage can occur in vascular beds that have grown accustomed to the higher level of blood pressure (ie, autoregulation).
*****For most hypertensive emergencies, mean arterial pressure should be reduced by about 10 to 20 percent in the first hour and then gradually during the next 23 hours so that the final pressure is reduced by approximately 25 percent compared with baseline.

Question 25

What are the major exceptions to modest and gradual blood pressure lowering over the first 24 hours?

Answer 25

• The acute phase of an ischemic stroke – The blood pressure is usually not lowered unless it is ≥185/110 mmHg in patients who are candidates for reperfusion therapy (table 1) or ≥220/120 mmHg in patients who are not candidates for reperfusion therapy.
• Acute aortic dissection – The systolic blood pressure is rapidly lowered to a target of 100 to 120 mmHg (to be attained in 20 minutes).
• Spontaneous hemorrhagic stroke – The systolic blood pressure can be rapidly reduced if no contraindications exist.

Question 26

T/F: The most important aspect of care for the patient with a hypertensive emergency is assuring that high-quality outpatient follow-up is available.

Answer 26

TRUE