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X Emergency Med Exam 2 > CNS Emergencies I > Flashcards

CNS Emergencies I Flashcards

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1
Q

When do you want to think about a possible CNS infection?

A

Fever, HA and neurologic signs/sxs

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2
Q

What might be seen in survivors of bacterial meningitis?

A

Neurologic sequela

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3
Q

How can bacteria get into CNS?

A

Bloodstream or contiguous spread (ex sinus infection)

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4
Q

Pathogenesis of bacterial meningitis

A

Inflammation damages BBB causing increased per so alterations in protein and glucose transport–progressive cerebral edema with increased ICP and decreased cerebral perfusion leads to neurologic damage

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5
Q

Etiology of bacterial meningitis from exposure during delivery (up to 4 wks old)

A

E coli, Group B strep

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6
Q

Etiology of bacterial meningitis from colonization from nasopharynx

A

Sinusitis, otitis media, mastoiditis–strep pneumo

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7
Q

Etiology of bacterial meningitis from crowded conditions

A

Military, college–N meningitides

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8
Q

Etiology of bacterial meningitis from head trauma

A

Staph species

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9
Q

Etiology of bacterial meningitis from post-neurosurgical procedures

A

Staph species, gram (-)

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10
Q

2 most common organisms of bacterial meningitis

A

N meningitides and s pneumoniae

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11
Q

Risk factors for s pneumoniae infection

A

Cochlear implants, fractures of face/skull

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12
Q

Who is listeria monocytogenes meningitis seen in?

A

Elderly and neonates

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13
Q

What meningitis do you worry about with breaks in the skin?

A

Coag neg staph or s. aureus

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14
Q

Which meningitis do you worry about with unvaccinated children and adults?

A

H. influenzae

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15
Q

How might bacterial meningitis present?

A

Progressively over a couple days or after febrile illness

Acutely with signs and sxs of sepsis (rapid progression over several hrs and cerebra edema)

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16
Q

Manifestations of bacterial meningitis

A

HA, photophobia, n/v/anorexia, focal neurologic deficits (weakness, cranial nerve palsies), seizures, AMS, nuchal rigidity, papilledema and increased ICP

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17
Q

Classic triad of bacterial meningitis

A

Fever
Nuchal rigidity
AMS

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18
Q

What organism produces a petechial rash and palpable purpura?

A

N meningitides

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19
Q

Tests for bacterial meningitis

A

Kernigs sign: won’t extend knee with hip flexed
Brudzinskis: flexion of hips with passive flexion of neck
Joint accentuation test: pt rotates his or her head 2 times per second and positive test is exacerbation of existing HA

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20
Q

Diagnostics for bacterial meningitis

A

Blood cultures x 2!!! (before abx)
Maybe CT
LP for CSF analysis
CBC with diff, CMP, ESR, CRP, serum and CSF glucose

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21
Q

Gold standard for bacterial meningitis diagnosis

A

CSF culture

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22
Q

CSF findings for bacterial meningitis

A 
Increased WBC (>1000 with mostly neutrophils)
Decreased glucose (<40)
Increased protein (100-500)
\+ gram stain and culture
Increased opening pressure
CSF/blood glucose
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23
Q

Recommendation to get a CT before LP

A 
With 1+ of following factors:
Immunocompromised
History of CNS disease
New onset seizure
Papilledema
Abnormal LOC
Focal neurological deficit
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24
Q

What might happen if there is increased ICP during an LP?

A

Mass lesion present can result in cerebral herniation

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25
What do gram positive diplococci suggest?
Pneumococcal infection
26
What do gram negative diplococci suggest?
Meningococcal infection
27
What do gram negative coccobacilli suggest?
H influenzae infection
28
What do gram positive rods and coccobacilli suggest?
L monocytogenes infection
29
What is predictive of worse outcomes with bacterial meningitis?
AMS, seizures or hypotension
30
What is started immediately after blood cultures and LP
Empiric IV abx and dexamethasone (glucocorticoid) at same time or shortly before (if waiting for LP til after CT, still start the abx after cultures)
31
Empiric tx for newborn meningitis and the causative organism
Ampicillin + cefotaxime OR gentamycin (Group B strep, E coli, L monocytogenes) **do not use Vanco when 4 wks and younger
32
Empiric tx for meningitis at 1-23 mos and the causative organism
Vanco + ceftriaxone OR cefotaxime + dexamethasone | Strep pneum, H flu, E coli, N meningitides
33
Empiric tx for meningitis at 2-20 yrs and the causative organism
Vanco + ceftriaxone OR cefotaxime + dexamethasone | S pneum or N meningitides
34
Empiric tx for meningitis when >50 YO and the causative organism
Ampicillin + Vanco + ceftriaxone OR cefotaxime + Dexamethasone (Strep pneum, L monocytogenes, gram - bacilli, N meningitides)
35
Empiric tx for meningitis when immunocompromised and the causative organism
Ampicillin + Vanco + Cefepime OR meropenem + Dexamethasone | Strep pneum, L monocytogenes, gram - bacilli, N meningitides
36
What should be switched if there is a penicillin allergy?
Vanco + Moxifloxacin + Bactrim replace Ampicillin in >50YO and immunocompromised
37
Empiric tx for meningitis due to contiguous spread from basilar skull fracture and the causative organism
Ampicillin + cefotaxime OR gentamycin | Group A beta hemolytic strep, strep pneum or H flu
38
Empiric tx for meningitis due to contiguous spread from penetrating trauma and post-neurosurgery and the causative organism
Vanco + ceftazidime OR cefepime OR meropenem | s aureus, pseudomons, coag neg staph
39
What is the benefit of adding dexamethasone?
Decreased rate of hearing loss and neurologic sequelae and decreases morbidity and mortality in PNEUMOCOCCAL meningitis only
40
What must be added to the steroid if cultures are positive for S pneumoniae?
Rifampin (better CNS coverage)
41
Meningitis management algorithm for pt meeting criteria for CT before LP
Blood cultures STAT Dexamethasone + empiric abx CT of head (if contraindication for LP like increased ICP then continue med regimen) Perform LP if not contraindicated CSF for gram stain, cultures, cell count, glucose, protein
42
Meningitis management algorithm for pt not meeting criteria for LP before CT
``` Blood cultures LP Empiric abx + dexamethasone CSF sent for gram stain, cultures, cell count, protein, glucose Tailor tx based on results ```
43
Meningitis management algorithm for CSF gram stain positive
If gram positive diplococci, target abx therapy to strep pneum and continue dexamethasone and rifampin All other bacteria, target abx and d/c dexamethasone
44
Meningitis management algorithm for gram stain neg but other CSF findings consistent with meningitis
Continue empiric tx and dexamethasone
45
Complications of bacterial meningitis
Septic shock DIC Acute respiratory distress syndrome Possible neurologic long term complications (impaired mental status or cognition, sensorineural hearing loss)
46
Important vaccines to prevent bacterial meningitis
S pneum, N meningities, h flu
47
What is used for post exposure prophlyaxis for bacterial meningitis?
Cipro, rifampin or ceftriaxone (in pregnant pts)
48
What is aseptic meningitis?
Evidence of meningeal inflammation but bacterial cultures are neg--sometimes called viral meningitis
49
Presentation of aseptic meningitis
Similar to bacterial but usually less severe sxs so just supportive care
50
Most common cause of aseptic meningitis
Enterovirus (think with diarrhea too) | Other viral causes are coxsackie and echovirus (summer and autumn), HSV-2, VZV, mumps, HIV, west nile etc
51
Other infectious causes of aseptic meningitis
Mycobacteria Fungi (crypto, cocci) Spirochetes (treponema or borrelia)
52
Malignancy causing aseptic meningitis?
Uncommon but may see due to direct invasion of mets into meninges Leukemia, lymphoma, melanoma, breast, lung or GI CA
53
Drug induced aseptic meningitis?
Uncommon but exclude other diagnoses Must tell if delayed hypersensitivity rxn or direct irritation NSAIDs! also abx like bactrim, chemo or pyridium
54
Clinical manifestations of aseptic meningitis
HA, fever, n/v, maybe photophobia or nuchal rigidity
55
What history clues are necessary for aseptic meningitis?
``` Travel and expsoure hx Sexual activity (HSV-2, syph, HIV)--look for genital lesions for HSV-2 ```
56
PE clue suggesting mumps as etiology of aseptic meningitis
Unvaccinated pt with parotitis
57
PE clue suggesting HSV-2 as etiology of aseptic meningitis
Severe vesicular genital lesions
58
PE clue suggesting enteroviral infection, HIV or syph as etiology of aseptic meningitis
Diffuse macpap exanthema in mildly ill pt
59
PE clue suggesting primary HIV as etiology of aseptic meningitis
Oropharyngeal thrush and cervical LAD
60
PE clue suggesting west nile virus as etiology of aseptic meningitis
Asymmetric flaccid paralysis
61
Diagnostis for aseptic meningitis
``` Blood cultures x2 before abx CT (same criteria) LP for CSF analysis CBC with dif, CMP, ESR, CRP Others based on suspicion ```
62
CSF findings for aseptic meningitis
``` WBC<500 and >50% lymphocytes if viral Normal glucose (40-80) Normal or mildly increased protein - gram stain and culture PCR (HSV, MMR, CMV, epstein barr) Cultures ```
63
Management for viral aseptic meningitis
Start empiric abx at presentation but d/c when r/o bacterial | Self limiting so just supportive (analgesics, antipyretics or acyclovir if severe or immunocompromised)
64
Management for malignancy induced aseptic managment
Malignant cells within CSF | Oncology
65
Management for drug induced aseptic meningitis
d/c offending med and then sxs resolver
66
Management for uncommon causes of aseptic meningitis
Treat accordingly | Require ID and neuro involvement
67
What distinguishes meningitis and encephalitis?
Presence of absence of normal brain function Meningitis: preserve cerebral function and more common to have fever, HA, meningismus Encephalitis: abnorm brain function due to inflammation of brain (AMS, seizures, motor/sensory deficits, personality changes, speech )
68
What is the primary infection of encephalitis?
Due to direct viral invasion of CNS and can be cultured from brain tissue (neuronal involvement)
69
What is post infectious encephalitis (acute disseminated encephalomyelitis ADEM)?
No virus is detected and neurons are spared but there is perivascular inflammation and demyelination Occurs as initial infection is resolving
70
Most common cause of encephalitis is US
West nile (arbovirus)
71
Other causes of encephalitis
Influenza, Lyme, RMSF, syph, VZV/EBV/HIV/MMR (immunocompromised mostly)
72
Most common cause of fatal encephalitis
HSV-1
73
More common in meningitis or encephalitis: coxsackie
Meningitis
74
More common in meningitis or encephalitis: west nile
Encephalitis
75
More common in meningitis or encephalitis: HSV-1
Encephalitis
76
More common in meningitis or encephalitis: HSV-2
Meningitis
77
More common in meningitis or encephalitis: varicella
infrequent in both
78
More common in meningitis or encephalitis: CMV
Encephalitis
79
More common in meningitis or encephalitis: EBV
Infrequent in both
80
More common in meningitis or encephalitis: HIV
Meningitis
81
More common in meningitis or encephalitis: Influenza
Encephalitis
82
More common in meningitis or encephalitis: mumps
Meningitis
83
More common in meningitis or encephalitis: measles
Meningitis
84
Manifestations of encephalitis
HA, fever, AMS, seizures, focal neuro deficits (hemiparesis, CN palsies, increased DTRs)
85
What is rare in encephalitis?
Photophobia and nuchal rigidity (but can be seen in meningoencephalitis)
86
Clues for HSV-1 on encephalitis PE
Ulcers or vesicles
87
Clues for WNV on encephalitis PE
Flaccid paralysis and rash
88
Clues for rabies on encephalitis PE
Hydrophobia, hyperactivity, pharyngeal spasms
89
Clues for St louis virus on encephalitis PE
Tremors of tongue, lips, eyelids
90
Diagnostics for encephalitis
``` Blood cultures x 2 CBC with diff, CMP PCR of CSF for HSV, enteroviruses, HBV CSF tests (unless C/I) Cultures ```
91
What can indicated HSV-1 infection in CSF?
RBCs
92
CSF analysis in viral encephalitis
``` WBC<250 Glucose 40-80 (decreased in HSV tho!) CSF/blood glucose .6 Protein elevated <150 Gram stain - Increased lymphocytes ```
93
Study of choice for encephalitis
MRI with contrast (might take a couple days to see the changes)
94
Other diagnostics for encephalitis
CT with contrast if no MRI | Maybe EEG
95
What suggests HSV on MRI?
Temporal lobe changes (illuminating contrast)
96
What suggests bacterial/fungal/parasitic etiology of encephalitis on MRI?
Hydrocephalus
97
When is serology ordered with encephalitis?
If pt not improving or no diagnosis based on CSF, culture or PCR IgM testing for WNV, mumps, EBV
98
Brain biopsy for encephalitis
Only if etiology unknown | Last resort!!
99
Management for encephalitis
Acyclovir 10mg/kg IV Q8hrs--empiric ASAP Seizure prophylaxis and control (carbazepime) Diuretics if increased ICP (Mannitol or furosemide)
100
Prognosis of encephalitis
Poor neuro recovery and increased mortality if inital diffuse cerebral edema or intractable seizures Elevated initial ICP is not good Monitor serial ICPs
101
Causes of direct spread cerebral abscess
Usually single abscess Otitis media, mastoiditis, meningitis, head/facial trauma, sinusitis, dental infection or S/P neurosurgical or spinal procedure
102
How to determine etiology of cerebral abscess
Location of the abscess on MRI to determine direct spread
103
What does inferior temporal lobe or cerebellum abscess suggest?
Subacute and chronic otitis media | Mastoiditis
104
What do frontal lobe abscessed suggest?
Frontal or ethmoid sinusitis | Dental infection
105
Causes of hematogenous spread cerebral abscesses
Usually multiple and has bacteremia Chronic pulm infection, skin infection, pelvic infection, intraabd infection, bacterial endocarditis or after esophageal dilatation
106
Most common cause of cerebral abscess
Bacterial: Paranasal: strep or haemophilus Odontogenic: strep or bacteriodes Otogenic: strep, enterobacter, pseudomonas Penetrating head trauma: staph, enterobacter Neurosurgery: strep, staph, pseudomonas
107
Most common cause of cerebral abscess when there is an immigrant from mexico
Parasite (cysticercosis due to taenia solium/pork tapeworm)
108
Immunocompromised pathogens causing cerebral abscess
Toxoplasma, listeria moncytogenes or nocardia asteroides
109
Fungal pathogens causing multiple abscesses and poor outcomes
Crypto, cocci, aspergillus, candida
110
Manifestations of cerebral abscess
``` Unilateral HA (unless multiple) Sudden or gradual onset Severe pain not relieved with OTC pain meds Maybe fever or nuchal rigidity (more common in occipital lobe abscess) AMS (severe cerebral edema) Vomiting (increased ICP) Focal neuro deficits Seizures Papilledema (late) ```
111
Diagnostics for cerebral abscess
Blood cultures x2 CBC with diff, CMP MRI (study of choice!!!) CT guided aspiration or surgical excision for cultures (contrast!!)
112
What will be seen on an MRI of a cerebral abscess?
Ring enhancing lesion Early: lesion is poorly demarcated, localized edema, acute inflammation, no tissue necrosis Late (>2 wks): necrosis and liquefaction, lesion surrounded by fibrotic capsule
113
Management of cerebral abscess
``` Empiric abx (based on gram stain) for 4-8 wks after find out pathogen on culture (IV) Track progression on MRI every 4-6 wks ```
114
Empiric tx of cerebral abscess due to oral, otogenic, sinus spread
Oral: Metro + Pen G | Otogenic or sinus: Metro + ceftriazone OR cefotaxime
115
Empiric tx of cerebral abscess due to hematogenous spread
Vanco + Metro
116
Empiric tx of cerebral abscess due to post op neurosurgery
Vanco + ceftazidime OR cefepime OR meropenem
117
Empiric tx of cerebral abscess due to penetrating trauma
Vanco + ceftriaxone OR cefotaxime
118
Empiric tx of cerebral abscess due to unknown source
Vanco + cetriaxone OR cefotazime + Metro
119
Most common reasons for intracranial epidural abscess
Usually complication of neurosurgery or can be spread from osteomyelitis of skull from fetal monitoring probe (infections!! sinusitis, otitis)
120
What is an intracranial epidural abscess?
Localized lesion with central collection of pus surrounded by wall of inflammatory tissue which may calcify (rarely spreads caudally due to tight attachment of dura at foramen magnum)
121
Manifestations of intracranial epidural abscess
Fever, HA, lethargy, n/v If secondary to sinusitis: purulent drainage from nose or ear Compressing brain: increased ICP, papilledema, focal neuro changes
122
Diagnostics of intracranial epidural abscess
CBC with diff, ESR MRI with contrast CT with contrast if can't MRI CT guided aspiration or open drainage for stains and cultures
123
Management for intracranial epidural abscess
Drainage and abx Burr holes or craniotomy (neurosurgical) MRI every 4-6 wks after initiation of tx
124
What to remember about abx with intracranial epidural abscess!!!
Empiric abx once sample of abscess fluid is obtained (so waiting 1-2 days before start!) Can be earlier with immunocompromised pt or concerning findings
125
Management of intracranial epidural abscess due to contiguous spread
Metro+ceftriaxone OR cefotaxime
126
Abx for all other intracranial epidural abscesses
Vanco + Metro + ceftriaxone OR cefotaxime OR ceftazidime
127
How does spinal epidural abscess happen?
Bacteria get access by hematogenous spread, direct extension (osteomyeltis) or direct inoculation into spinal canal (epidural cath)
128
How does spinal epidural abscess spread?
Longitudinal extension so can go through whole spine! (more common in thoracolumbar area)
129
Why do sxs occur with spinal epidural abscess?
Direct compression on spinal cord Thrombosis of nearby vessels Bacterial toxins or inflammation Arterial blood supply interruption
130
Major players in spinal epidural abscess
Staph aureus (mostly), gram - bacilli, streptococci, coag neg staph
131
Risk factors of spinal epidural abscess
Immunocompromised (DM, alcoholism, HIV) Direct inoculation (epidural cath, paraspinal injection, trauma) Hematogenous (tattooing, acupuncture, bacteremia, IV drug use, hemodialysis)
132
Classic triad of spinal epidural abscess
Fever, spinal pain and neurologic deficits (at or below abscess)
133
Manifestations of spinal epidural abscess
May be non-specific at first Absent fever may be seen (present multiple times before diagnosed!!) Back pain focal and severe Nerve root pain (shooting or electrical) Motor weakness, sensory changes, bowel or bladder dysfunction Paralysis that quickly becomes irreversible
134
First line diagnostic for spinal epidural abscess
MRI with contrast ASAP (skip lesions on entire spine, want to see epidural soft tissue edema vs abscess)
135
Other diagnostics for spinal epidural abscess
CBC with diff with ESR CT with contrast is 2nd line Ct guided extraction of pus fro abscess for culture
136
Management of spinal epidural abscess
Blood cultures x2 Empiric abx after suspect (after cultures!!)--Vanco + cefotaxime OR ceftriaxone OR cefepime OR ceftazidime for 4-8 wks Surgical decompression and drainage Follow up MRI in 4-6 wks
137
Prognosis of spinal epidural abscess
Can have death due to sepsis or complications but rare Irreversible paraplegia can happen Degree of neuro recovery related to duration of deficit

X Emergency Med Exam 2 (6 decks)

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