CNS Emergencies II Flashcards
(120 cards)
1
Q
What is increased intracranial pressure?
A
Abnormal increase in vol of any component (brain mostly, CSF or blood in constant space)
2
Q
How might brain injury happen with increased intracranial pressure?
A
Brainstem compression (herniation) Reduction in cerebral perfusion pressure (CPP) which is needed to get O2 and nutrients to the brain
3
Q
Management for increased intracranial pressure
A
Prompt recognition
Judicious use of invasive monitoring
Therapy aimed at reducing ICP and addressing cause
4
Q
Presentation of ICP
A
HA, n/v Papilledema Unilateral or bilateral fixed pupil Loss of consciousness Decorticate or decerebrate posturing Cushings triad
5
Q
What is Cushings triad?
A
Ominous finding
Bradycardia, HTN or respiratory depression
6
Q
Max GCS for intubated pt
A
10
7
Q
What does decorticate posturing suggest?
A
Destructive lesion in corticospinal tract from cortex to upper midbrain
8
Q
What does decerebrate posturing suggest?
A
Damage to corticospinal tract at level of brainstem (pons or upper medulla)
9
Q
Causes of intracranial HTN
A
TBI/intracranial hemorrhage CNS infection Ischemic stroke Neoplasm Vasculitis Hydrocephalus Hypertensive encephalopathy
10
Q
Diagnostics that might be ordered with ICP
A
Type and cross CBC, BMP Osmolality Toxicology Blood alcohol level Glucose INR/PT/PTT CT/MRI (brain, C/T/L, spine)
11
Q
What can referral to neurosurgery do for ICP?
A
Decompressive craniectomy
Ventriculostomy
12
Q
Resuscitation for increased ICP
A
Oxygenation (avoid hypoxia)–maintain O2 at >90% (or PAO2>60) and may need mechanical ventilation
BP (avoid hypotension and control HTN)
Maintain end organ perfusion
13
Q
Other management for increased ICP
A
Elevate head of bed to 30 degrees Analgesia and sedation Treat fever (maybe mechanical cooling or tylenol) ICP monitors IV fluids (normal saline) Mannitol to decrease brain vol Anti-seizure therapy
14
Q
Things you might see with a skull fracture
A
AMS Cranial nerve or other neuro deficits Scalp lacerations of contusions Bony step off Periorbital or retroauricular ecchymosis
15
Q
Types of skull fractures
A
Linear
Depressed
Basilar
16
Q
What is a linear skull fracture?
A
Single fracture but majority have minimal or no clinical significance
17
Q
Sxs of linear skull fracture
A
No neuro sxs usually
Only small amt get significant intracranial hemorrhage
If on temporal bone- can disturb vasculature and get bleeding
18
Q
What to do if CT shows no underlying brain injury and no neuro deficit with linear skull fracture?
A
Observe in ED for 4-6 hrs and then discharge home with supervision (admit if suspicious for brain injury)
19
Q
What is a depressed skull fracture?
A
Segment of skull is driven below level of adjacent skull
20
Q
What to worry about with depressed skull fracture
A
Often involves injury to brain parenchyma
High risk of CNS infection, seizures and death
Can be closed or open
21
Q
What to do with open depressed fractures
A
Examine but not probe them
22
Q
Management for depressed skull fracture
A
Get CT, admit to neurosurgery (Td tetanus if needed, prophylactic abs and anticonvulsants)
23
Q
What might occur with a basilar skull fracture?
A
Dural tear resulting in communication b/w subarachnoid space, paraspinal sinus and middle ear
24
Q
Presentation of basilar skull fracture
A
Clear/blood tinged rhinorrhea/otorrhea due to leakage of CSF
Retroauricular or mastoid ecchymosis (Battles-1-3 days after)
Raccon eyes (periorbital ecchymosis)
Maybe hemotympanum
25
Canadain head CT rule for basilar skull fractures
+Battle sign/racoon eyes, hemotympanum and otorrhea/rhinorrhea are predictive of significant injury
26
What to remember with basilar skull fracture
Can have CSF leak, infection or cranial nerve injury
Risk for intracranial hemorrhage
Can occur through temporal bone (epidural hematoma)
27
Management for basilar skull fracture
Admit for observation regardless and get neuro consult
| Close monitoring
28
Penetrating injuries with skull fractures
Typically with significant brain injury and ICH
| Consult neuro immediately and then give IV abx
29
Tangential skull fractures
Usually due to gun shot wound
| Risk for ICH so get emergent CT
30
Imaging for skull fractures
Non contrast CT
MRI secondary for suspected vascular injury
If can't get CT, get x-rays with 2 views (but hard to see depressed skull fractures and cannot rule out intracranial injury)
CT of cervical spine if positive findings of cervical spine or AMD (always assess!!)
31
What is a concussion?
Trauma induced alteration in mental status that may or may not have loss of consciousness (direct blow with impulsive force to head)
32
Brain contusion
Areas of bruising with localized ischemia, edema and mass effect
Direct external contact force, acceleration, deceleration trauma
33
Possible MOI for closed head injury
Coup or contrecoup (hit forward and back
| Do a neuro exam with mental status testing if think so
34
Who needs urgent neuroimaging and neuro consulting?
GCS<15
Suspected open or depressed skull fracture
Signs of basilar
2+ episodes of vomiting
New neuro deficit
Presence of bleeding diathesis or use of antiocoag med
Seizure
>60 YO
Retrograde amnesia >30 min or longer before traumatic episode
High impact head injury
Intoxication, HA or abnormal behavior
35
When to admit with closed head injury?
```
GCS<15
Abnormalities on head CT
Seizures
Underlying bleeding diathesis or oral anticoag
Other neuro deficit
Recurrent vomiting
No person at home to monitor
```
36
When to send home with closed head injury
GCS of 15
Normal exam and CT of head
No predisposition to bleeding
Someone to monitor them
37
What is a diffuse axonal injury?
Shearing of white matter tracts from traumatic, sudden deceleration injury (blunt trauma) leadin to severe intracranial hemorrhage
Axon disruptions, swelling and cell death
38
Presentation of diffuse axonal injury
Variable
| Can be associated with posttraumatic coma (frequent cause of persistent vegetative state)
39
Management of diffuse axonal injury
No surgery
| CT scan to demonstrate blurring of gray to white matter margin, cerebral hemorrhage or cerebral edema
40
Types of cerebral hemorrhage
```
Intracranial hematoma which is external to brain parenchyma (epidural hematoma, subdural hematoma, subarachnoid hemorrhage/ bleeding into CSF)
Intracerebral hemorrhage (lesions within brain substance)
```
41
What is an epidural hemotoma?
Acute collection of blood b/w skull and dura mater
42
Presentation of epidural hemotoma
Usually adolescents/young adults
Associated with skull fracture and trauma!! (middle meningeal artery)
Brief LOC, then lucid interval and then rapid clinical deterioration
43
CT for epidural hemotoma
Lens-shaped or lenticular (bioconvex shaped)
44
What is a subdural hemotoma?
Collection of VENOUS blood between dura mater and arachnoid (tears bridging veins)
Usually with brain atrophy (elderly or alcoholics)
45
Presentation of subdural hemotoma
Usually due to fall
Acute: sxs in 24-48 hrs after onset
Subacute: sxs 3-14 days after onset
Chronic>2 wks after onset
46
CT for subdural hemotoma
Crescent shape
47
Sxs of intracranial hematoma
```
Momentary LOC to coma
HA
Vomiting
Drowsiness
Confusion
Aphasia
Seizures
Hemiparesis
```
48
Management for intracranial hematomas
Emergent neuro consult
Decide for surgery based on GCS, neuro exam/pupillary signs or brain imaging findings
Craniotomy with hematoma evacuation vs observation (burr hole-trephination)
49
What is a subarachnoid hemorrhage?
Bleeding within the subarachnoid space
| Can be traumatic or non-traumatic
50
Non traumatic causes of subarachnoid hemorrhage
Aneurysm, vascular malformations, cerebral venous thrombosis
**these are most cases (mortality pretty high)
51
Presentation of subarachnoid hemorrhage
```
Acute onset of worst HA of life (thunderclap HA)
Impaired consciousness
Neck stiffness
N/v
Exertion or valsalva immediately preceding onset of TCH
Elevated BP
Occipital HA
History of smoking
```
52
Management for subarachnoid hemorrhage
CT before LP (if needed)
Neuro consult
Support
Interventional neuroradiologist (surgical clipping or endovascular coiling)
53
Complications of subarachnoid hemorrhage
```
Rebleeding
Vasospasm and delayed cerebral ischemia
Hydrocephalus
Increased ICP!!
Seizures
Hyponatremia (if hypothalamic injury)
```
54
2nd most common cause of stroke
Intracerebral (intraparenchymal hemorrhage) after ischemic stroke being number 1
55
Initial goals of tx for intracerebral hemorrhage
Prevent hemorrhage extension
| Prevent and manage ICP
56
Imaging for intracerebral hemorrhage
EMERGENT noncontrast CT!!
Can do MRI of brain for smaller lesions
Angiography (CTA or MRA) for vascular malformations and aneurysm
57
Causes of nontraumatic intracerebral hemorrhage
```
HTN (most common)
Amyloid angiopathy
Ruptured saccular aneurysm
Vascular malformation
Hemorrhagic infarction
Bleeding disorders
Brain tumor
CNS infection
Vasculitis
Drugs (cocaine, amphetamines)
```
58
Presentation of intracerebral hemorrhage
Acute onset of focal neuro deficit that corresponds to part of brain affected
Increasing neuro sxs/signs over time
HA, vomiting, decreased LOC or sezures
59
What to remember with intracerebral hemorrhage
Neuro and medical emergency that can lead to permanent disability and death
60
Imaging for intracerebral hemorrhage
CT without contrast or MRI
61
Management of intracerebral hemorrhage
```
Emergent neuro consult (maybe surgical decompression)
Admit to ICU
BP control
Manage ICP
Avoid hyperglycemia (glucose b/w 140-180)
Seizure prophylaxis
Reversal of anticoag
NPO
```
62
What is ischemic CVA?
Hypoperfusion
Thrombus formation in an artery leading to reduce blood flow resulting in localized hypoxic brain injury (Can be embolus)
63
Causes of ischemic CVA
```
Cardiac (a fib, valvular disease)
Large artery (atherosclerosis, thrombus formation, embolism, arterial dissection)
Small artery (HTN, DM, vasculitis)
```
64
Management for code stroke
```
ABCs rapidly
NIHSS for severity (>20 means severe)
O2 sat (maybe intubate)
ECG and troponins
IVF
Labs (coag, CBC, CMP, tox) and fingerstick glucose
Early noncontrast CT or MRI
Neuro consult
Evaluate for thrombolytic therapy or interventional txs
```
65
When to use ASA wtih stroke
If CT shows non hemorrhagic CVA
66
3 most predictive findings to diagnose ischemic stroke
Facial paresis
Arm drift/weakness
Abnormal speech
67
What is seen on CT scan for ischemic stroke
May be normal (may have early evidence of ischemia)
68
What is seen on CT scan for hemorrhagic stroke
Blood seen where stroke is occuring
69
BP control for hemorrhagicstroke
Risk of decreased cerebral perfusion if too low BP and increased bleeding if too high (keep it 140-160/190)
70
BP control for ischemic stroke
Candidate for IV thrombolysis??
No (allow for permissive HTN--no intervention unless SBP is >220 mmHg or DBP >120)
Yes (target BP pressures are SBP <185 and DBP <110)
71
Who are candidates for IV thrombolysis?
Onset of sxs<4.5 hrs before beginning of tx (or define as last time pt defined as being normal)
CT or MRI within 25 mins
Infusion should begin <60 min from time of arrival
72
Benefits of IV thrombolysis
Restore blood floow and stop progression of brain tissue ischemia but risks of hemorrhage
73
Classification of seizures
Primary (may present with clear cause)
Secondary (results from identifiable neuro condition or infection)
Post traumatic (may occur within first week after injury)
74
What is status epilepticus?
Seizure for 5 min continuously OR
| Multiple seizures without regaining baseline mental status in 30 min
75
Management during course of seizure
```
ABCs and maybe intubate
Prevent aspiration
Protect from bodily injury
2 IVs, CBX, CMP, tox screen, glucose
Maybe administer thiamine or glucose
```
76
Management during seizure: known seizure disorder
Check anticonvulsant levels
77
Management during seizure: eclamptic pts
Emergent obstetrician consult
78
Management during seizure: first seizure
MRI preferred!!
| EEG and LP in select pts
79
Management during seizure: status epilepticus
Correct metabolic abnormalities and continuous EEG monitoring
80
Meds for status epilepticus when 5-10 mins
IV lorazepam or diazepam
PLUS
IV fosphenytoin, phenytoin or levetiracetem
81
Meds for refractory status epilepticus when <30 min
```
IV midazolam (load with .2 mg and then infusion
OR IV propofol or Ketamine
OR
IV phenobarbitol
Intubate, neuro ICU and EEG monitoring
```
82
What to do for all pts with new seizure
CT or MRI indicated
83
When can pts with new onset seizure be discharged with outpt follow-up?
Returned to baseline AND
Normal CT AND
Normal lab eval AND
No prolonged postictal period or seizure relate injury
84
When can pts with established seizure disorders can be sent home?
Returned to baseline AND
Seizures have not recurred AND
Not acute abnormalities found
Follow up with neuro
85
Precautions that should be given to pts with seizures
Swimming
Working with heights, hazardous tools
No driving until cleared
86
Jefferson fracture
C1 (Atlas)
Caused by axial compression
Usually no spinal cord damage
87
C2 (axis) fracture
Odontoid (dens)
| Caused by forceful flexion or extension
88
Hangman's fracture
C2 fracture involving bilateral pedicles
Caused by hyperextension with compression
Can transect spinal cord
Usually instantaneous if going to die
89
Burst fracture
Lower cervical vertebra
Caused by direct axial load
Fragments displaced in all directions, can enter spinal canal
90
Complete spinal cord injury
Acute <1 day: absent reflexes, flaccid muscles, loss of sensation, priapism in men, urinary retention
1-3 days later: hyperreflexia, +babinksi, spasticity
91
Incomplete spinal cord injury
Presentation depend on location of lesion (anterior cord syndrome, central cord syndrome, posterior cord syndrome, Brown Dequard)
92
What is anterior (ventral) cord syndrome?
Anterior 2/3 of spinal cord due to cord infarct or disc herniation
93
Loss seen in anterior (ventral) cord syndrome
Motor impairment, reflex changes, bilateral loss of pain and temp and bladder dysfunction
94
What is preserved in anterior (ventral) cord syndrome?
Tactile, proprioception and vibratory sensations
95
What is central cord syndrome?
Medial aspect of central cord (typically extension injury, spinal cord compression-spondylosis or slow growing lesion)
96
Loss seen in central cord syndrome
Motor impairment in upper extremities more than lower
Variable sensory loss (light tough/pin prick/ temp)
Bladder dysfunction
97
What is preserved in central cord syndrome?
Sacral sparing
98
What is posterior (dorsal) cord syndrome?
Bilateral involvement of dorsal columns and corticospinal tracts (MS, tumors, subluxation)
99
Loss seen in posterior (dorsal) cord syndrome
Motor Weakness
Hyperreflexia
Gait ataxia
Paresthesia
100
What is preserved in posterior (dorsal) cord syndrome?
Bladder initially
101
What is Brown Sequard?
Lateral hemisection, dorsal column unilaterally (penetrating injury and rarely tumors or disc herniation)
102
Loss in Brown Sequard
ipsilateral motor paralysis and loss of proprioception and vibration
103
What is preserved in Brown Sequard
Bladder function (good prognosis)
104
What can result from a spinal cord injury?
```
Neurogenic shock (systolic hypotension, bradycardia within hours)
More with cervical spins injuries
```
105
Management for spinal trauma
Airway (palpate entire spine and paraspinals, priapism, abnormal breathing)
Nexus and Canadian C-spine rule (x-rays, CT, MRI)
Surgery vs halo vs collar
106
Nexus criteria for spinal injureis
```
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 are met then don't need imaging!!!
```
107
Canadian C-Spine rule
Condition 1: perform x-rays when 65+, dangerous MOI and paresthesia in extremities
Condition 2: in pts without high risk factors assess for low risk factors that allow for safe assessment of neck ROM (simple MVA rear end, sitting in ED, ambulatory at any time, delayed onset of neck pain or midline pain, ROM to 45 degrees means no imaging needed)
108
Imaging for disk herniation
MRI preferred over CT
| Urgent is suspect spinal cord compression
109
What might be seen with disk herniation?
Radiculopathy (dermatomal pain or numbess)
| Myelopathy (weakness, loss of bladder or balance-consult neuro)
110
What is cauda equina syndrome?
Neurosurgical emergency!!
| Nerve compression below 1-2 interspace after termination of spinal cord
111
Causes of cauda equina
Disc herniation, abscess, tumor, spinal stenosis, metastatic disease, infection, autoimmune
112
Presentation of cauda equina
(lower motor neuron)
Leg weakness in multiple distributions (L3-S1)
Weak plantar flexion and loss of ankle reflex (S1-S2)
LBP with radiation to bilateral legs
Perineal sensory loss (S2-S4)
113
Examples of perineal sensory loss
Saddle anesthesia (butt, perineal region, post/superior thighs)
Urinary incontinence with or without overflow incontinence
Decreased anal sphincter tone
Sexual dysfunction
114
Management for cauda equina
Emergent MRI with contrast of lumbar and sacral spine (CT myelogram if can't get for whole spine)
Administer dexamethasone 10 mg IV if suspicious
Consult
115
What is Guillen Barre syndrome?
Acute onset of peripheral neuropathy (immune mediated)
| Most common demyelination neuropathy
116
Presentation of Guillen Barre syndrome
Progressive, starts distally ascending symmetric muscle weakness
Mild URI or gastroenteritis precedes onset of sxs by 1-3 wks
117
PE for Guillen Barre syndrome
```
Absent or depressed DTRs
Cranial nerve involvement
Difficulty walking/ paralysis
Severe respiratory weakness needing ventilation
Dysautonomia
No fever!!
```
118
What is dysautonomia?
```
Tachycardia/brady
Urinary retention
Alternating hypo/HTN
Loss of sweating
Arrhythmias
```
119
How to diagnose Guillen Barre syndrome
Presentation
Elevated protein on CSF
EMG-NCS (electromypgram-nerve conduction study- usually on admit tho)
120
Tx for Guillen Barre syndrome
Consult and admit to ICU
DVT prophylaxis
Monitor and maybe urinary cath
IVIG and plasmapheresis (usually done on admit and not in ED)
