Emergencias neurológicas Flashcards
(35 cards)
Quais os fatores de risco para AVE?
Risk factors: Age, hypertension, hyperlipidemia, smoking, diabetes, hypercoagulable states, cardiac arrhythmias such as atrial fi brillation, cardiomyopathy, & presence of a car diac thrombus, among many others.
Qual a definição de síndrome neurovascular aguda?
An acute neurologic event, secondary to ischemia or hemorrhage
Quais os exames iniciais frente a uma síndrome neurovascular aguda?
- Avaliação neurológica (<10 minutos): Obtain NIH stroke scale (NIHSS) & document vitals & time
- Exames complementares (<25 minutos, interpretados em < 45 minutos): EKG, cardiac monitor, vital signs, accucheck, keep O2 sat > 92%, CBC, ESR, T & S, PT-INR, PTT, Chem 7, LFTS, cardiac markers, STAT CT/CTA head & neck, & CT perfusion. If ordering MRI, make sure pt doesn’t have pacer or metal in body.
- Decidir sobre terapia de reperfusão: Determine if pt meets criteria for IV TPA or intravascular procedure
Quais as indicações da trombólise?
Indications: Age ≥ 18 yr; signifi cant neurologic defi cit expected to result in long-term disability; CT Brain that does not show a hemorrhage or well-established new infarct; acute ischemic stroke sx with time of onset clearly defi ned as <3 h. For cases where onset is 3–4.5 h, IV TPA may be considered (NEJM 2008;359:1317).
Quais as contraindicacoes a trombolise?
Contraindications to IV TPA: Hypodensity > 1/3 territory on head CT; blood on CT; recent stroke, head trauma, or intracranial procedure (<3 mo); h/o intracerebral hemorrhage (ICH), brain aneurysm, vascular malformation, brain tumor (may consider w/ CNS lesions w/ very low likelihood to bleed, such as small unruptured aneurysms or benign tumors w/ low vascularity); resolving or minimal defi cit; suspicion of SAH; recent trauma or surgery (<15 days); active internal bleeding; h/o GI/GU bleeding (<22 days); recent LP or noncompressible arterial puncture (<7 days); bleeding diathesis (INR > 1.7; PT > 15; PTT > 40; platelets < 100, or known bleeding diathesis); uncontrollable HTN: SBP > 185, DBP > 110 despite medications to lower it; seizure at onset if defi cits are believed to be due to postictal state. If dx of vascular occlusion made, then Rx may be given; for the 3–4.5 h window, other contraindications include: NIHSS > 25, h/o oral anticoagulant use, combination of previous stroke & DM.
Como administrar a alteplase?
# Cuirados antes: Initial workup & labs as above. Check list of contraindications. Double check time window (<4.5 h). Obtain consent from pt or family. # TPA dose: 0.9 mg/kg w/ a max dose of 90 mg. Give 10% as bolus IV over 1 min & the remainder over 60 min. # Cuidados durante e após: Maintain goal SBP < 180, DBP < 105. If BP needs to be lowered, use labetalol 5–20 mg IV q10–20min or nicardipine infusion 5–15 mg/h. Monitor pt in an intensive care unit for at least 24 h observation. Avoid arterial sticks, anticoagulation, antiplatelet agents for 24 h. During the fi rst 24 h after TPA is given, check BP q15min × 2 h, then q30min × 6 h, then q1h for 24 h after starting Rx. F/u CT brain at 24 h. STAT CT if change in neurologic exam. When pt is stabilized, complete routine stroke workup. (See chapter on Stroke and Cerebrovascular Neurology.) (NEJM 1995;333:1581; MGH Acute Stroke IV/IA Thrombolysis Protocol 2005)
Quais as indicações de tratamento endovascular?
Indications for IA procedures: Signifi cant neurologic defi cit causing long-term
disability; defi cits attributable to large vessel occlusion (basilar, vertebral, internal carotid, or middle cerebral artery M1 or M2 branches); noncontrast CT scan w/o hemorrhage or well-established infarct; time of onset of ischemic stroke clearly defi ned. For anterior circulation, window is 6–8 h of nonfl uctuating defi cits. For posterior circulation, window less well defi ned & can be many hours or days of fl uctuating, reversible sx.
Quais as contraindicações ao tratamento endovascular?
Contraindications for IA procedures: ICH; well-established acute infarct on CT or MRI; major infarct > 1/3 cerebral hemisphere; CNS lesions w/ high likelihood of hemorrhage (brain tumors, abscess, vascular malformation); seizure at onset if defi cits are believed to be due to postictal state (if dx of vascular occlusion made, then Rx may be given); suspicion of SAH.
Como preparar paciente para trombectomia?
Preparing pt for IA TPA/mechanical thrombolysis: If pt is a candidate for IA TPA or mechanical clot retrieval, contact a neurointerventionalist or a facility with a neurointerventional service. Maintain O2 sat > 92%. Treat fever w/ Tylenol. Keep pt NPO. Avoid placing Foley, NGT, femoral catheters, a-line, or central venous line unless necessary. Do not give heparin. Do not lower BP unless MI or BP >220/120. If BP needs to be lowered, use labetalol 5–20 mg IV q10–20min or nicardipine IV 5–15 mg/h. Monitor BP q15min or continuously. Pt will need to be admitted to an intensive care unit for 24 h observation
Quais os cuidados pós-trombectomia?
After IA TPA/mechanical thrombolysis: Pt will need STAT CT head right after procedure to evaluate for hemorrhage & admission to an ICU for post-TPA/intervention monitoring. F/u CT head at 24 h. When pt is stabilized, complete routine stroke workup; see chapter on Stroke and Cerebrovascular Neurology ( JAMA 1999;282:2003).
Quais os fatores de risco para hemorragia intraparenquimatosa?
Risk factors or potential underlying causes: Hypertension, amyloid angiopathy, aneurysm, vascular malformation, trauma, neoplasm, venous sinus thrombosis, hemorrhagic conversion of a stroke, vasculitis, coagulopathy, cocaine, amphetamines, alcohol, a variety of infections among many others.
Qual o manejo da hemorragia intraparenquimatosa?
- Classificar pela imagem: To calculate volume of hemorrhage = ( a × b × c)/2, where a = length, b = width, & c = number of cuts on CT brain (assuming cuts are 0.5 mm each). If signifi cant mass effect, consider osmotic agents & hypertonic saline as needed. (See below for management of acute elevation in intracranial pressure.) Calculate ICH score.
- ABCs, intubation if depressed level of consciousness & inability to protect airway.
- Controle da PA e invasões vasculares: A-line, goal SBP 100–160. Central line, if anticipated will need 23% saline or become hypotensive
- Correção do coagulograma e demais laboratoriais: CBC, Chem 7, PT-INR, PTT, blood bank sample, d-dimer, fi brinogen, LFTs. If INR > 1.3, correct coagulopathy STAT. Give Vitamin K 10 mg IV × 1 & FFP 2–4 Units STAT for a goal INR of <1.3. Consider profi lnine if available. Check coags q4h × 24 h & repeat FFP & Vitamin K if needed for goal INR < 1.3.
- Avaliar neurocirurgia: Avoid corticosteroids. Surgical evacuation may be considered in select cases of cerebellar hemorrhages. No evidence of benefi t from surgical evacuation of basal ganglia, thalamic, & pontine hemorrhages (Stroke 1997;82:2126).
- Enviar a UTI: Consider admission to an intensive care unit for close monitoring. F/u CT brain in 6 h. STAT CT if change in neurologic exam (NEJM 2001;344:1450; Lancet 2009;373:1632; MGH Adult ICH Protocol 2008)
Qual o quadro clinico da hipertensao intracraniana?
Late findings: anisocoria, decerebrate or decorticate posturing, apnea, coma, Cushing triad (hypertension, bradycardia, & irregular respirations), papilledema.
Como fazer o manejo da hipertesao intracraniana?
# Estabilização inicial: ABCs, consider intubation if depressed mental status or inability to protect airway, vital, signs, cardiac monitoring, HOB elevated 30 degrees. # Decidir sobre monitorização invasiva: Goal ICP is <20 mm Hg & cerebral perfusion pressure > 60–70. Consult neurosurgery for possible EVD or ICP monitor or hemicraniectomy posterior fossa decompression if lesion with significant mass effect. # Tratar herniação (ex. anisocoria + rebaixamento do NC): 1. OSMOTERAPIA: STAT mannitol 100 g IV bolus, followed by 0.5–1 g/kg (No HC, manitol 20% 250mL EV). Contraindications: low BP, anuria secondary to renal disease, serum osm > 340. Hold dose for Na > 160, serum osm > 340, or osm gap > 10. Osm gap = measured − calculated serum osms. Calculated serum osms = 2Na + BUN/2.8 + Glu/18. Check Chem 7, serum osmolarity q6h. OR Hypertonic saline: Goal sodium 145–155. For 20% saline, give 40 cc × 1 via central line over 20 min, followed by 15–30 cc q6h via central line if needed. For 3% saline, 40–50 cc/h can go through peripheral IV for up to 12 h, then needs a central line. Contraindications: Na > 160. 2. Hyperventilation: For goal pCO2 ∼ 30 3. Avaliar benefício do corticoide: If ICP due to tumor or infection, then dexamethasone 10 mg IV × 1, then 4 mg q6h. 4. Cuidado com sódio: For any pt w/ a mass lesion, stroke, tumor, hemorrhage, keep goal sodium 145–155. Avoid free water in IVF, such as D5W, 1/2 NS, D5 1/2 NS, LR. This is especially important to monitor, since these are frequently used as maintenance fl uids ( J Emerg Med 1999;17:711–719).
Qual a manifestacao clinica da meningite bacteriana aguda?
Clinical presentation: Si/sx: Fever, nuchal rigidity, n/v, headache, photophobia, seizure, altered or depressed mental status, papilledema, neurologic defi cits, rash in meningococcus. Uncomplicated viral meningitis does not typically p/w neurologic defi cits. Classic triad of fever, neck stiffness, & altered mental status w/ low sensitivity (∼44%). Almost all pts p/w at least two of following sx: headache, neck stiffness, altered mental status (GCS < 14), fever
Quais os exames complementares na meningite bacteriana?
# Sangue: Labs: Chem 10, CBC, UA, CXR, blood cx × 2, coags. Consider PPD, HIV, ESR, CRP, further w/u for system infection depending on clinical history. # TC antes do LCR: When CT brain recommended before LP: altered mental status, seizures, immunocompromised state, abnormal neurologic exam, papilledema. If obtaining CT prior to LP, draw stat blood cultures & start empiric antibiotic coverage immediately (i.e., do not wait for LP to start antibiotics). (NEJM 2001;345:1727). # LCR: Lumbar puncture: should obtain opening pressure, cell count & differential, protein, glucose, Gram stain, & culture. Consider wet mount for fungal stain, AFB, India ink, VDRL, Lyme PCR, HSV PCR, PCR of other viruses, latex agglutination for specific bacterial infections depending on clinical history.
Como é um LCR sugestivo de meningite bacteriana?
# Celularidade: High (10– 10,000) PMN predom # Proteinorraquia: High (>50) # Glicorraquia: Low (<40) # Testes específicos: GS, cx, latex agglutination positive
Qual a conduta frente a uma meningite bacteriana?
Antibiotico: Empiric coverage: Antimicrobial choice depends on age of pt, allergies, & clinical setting. Modify antimicrobial choice based on organism identifi cation & sensitivities.
Age 16–50 yr Vancomycin + third gen. cephalosporin N. meningitides, S. pneumoniae, H. infl uenzae
Age > 50 yr Vancomycin + third gen. cephalosporin + ampicillin N. meningitides, S. pneumoniae, L. monocytogenes, GNR
Immunocompromised Vancomycin + ampicillin + third gen. cephalosporin covering pseudomonas
N. meningitides, S. pneumoniae, L. monocytogenes, H. infl uenzae, GNR
# Corticoterapia: Consider dexamethasone for bacterial meningitis: dexamethasone 10 mg × 1 before or w/ fi rst dose of antibiotics, then 10 mg q6h × 4 days. Avoid empiric dexamethasone if allergy/sensitivity, antibiotic therapy, head trauma, CSF shunt, or infection is not bacterial (NEJM 2002;347:1549).
# Medidas de saude coletiva: recommended for close contacts of pts w/ meningococcal meningitis w/ either rifampin, ceftriaxone, ciprofl oxacin, or azithromycin. Respiratory isolation for 24 h in cases w/ meningococcal meningitis. Notify.
Quais são os tumores mais associados a metastase epidural com compressão medular? Qual o exame em doentes com lombalgia e antecedente de cancer?
# Malignancies that commonly metastasize to the cord: breast, lung, prostate, renal cell, & thyroid ca. # Imagem: Dx: Clinical history & MRI spine w/ gadolinium; in pt w/ h/o malignancy, obtain imaging of entire spine.
Qual a manejo da compressão medular maligna?
# Corticoide: If paraparesis & evidence of cord compression on imaging, give Dexamethasone 100 mg IV × 1, then 24 mg po qid × 3 days, followed by a taper over 10 days or when definitive Rx (surgery or XRT) is underway. For minor neurologic sx & no paraparesis & mild cord compression on imaging, administer dexamethasone 10 mg IV × 1, followed by 4 mg q6h, tapered over 10 days or when definitive Rx (surgery or XRT) is underway. # Descompressão: Consult neurosurgery for possible surgical decompression, radiation oncology for XRT, & neuro-oncology for long-term follow-up/ monitoring (Lancet 2005;366:643; Neurology 1989;39:1255; Curr Oncol Rep 2008;10:78).
Qual a apresentação clínica do status epilepticus?
Clinical presentation: Status epilepticus (SE): >5 min of persistent, generalized convulsive seizure activity or ≥2 discrete seizures where there is incomplete recovery of consciousness in between. Diverse causes & clinical sx, including unresponsiveness, obtundation, repetitive rhythmic movements. May be convulsive or nonconvulsive. Approximately 7% generalized tonic-clonic seizures will progress to SE ( J Intensive Care Med 2007;22:319).
Qual o manejo dos primeiros cinco minutos de crise?
0–5 min: ABCs, O2 sat, coma exam, ECG, IV access & draw labs for Chem 10, CBC, LFTs, PT-INR, PTT, AED levels, ABG, cardiac markers, urine & serum toxicology. Place pt on cardiac monitor
Não USAR DROGA!
Como administra BDZ no status epilepticus?
Lorazepam: 4 mg IV over 2 min (may give as 1–2 mg boluses); if still having seizures, may repeat × 1 in 5 min. OR diazepam 5 mg IV q3min × 4, while starting dilantin load. If no IV access, give diazepam 20 mg pr OR midazolam 10 mg intranasally, buccally, or IM.
Como administrar AED no status epilepticus?
Fosphenytoin: Load 20 mg/kg PE IV at 150 mg/min. Keep on cardiac monitoring. May give an additional 500 PE IV if no response. Dilantin 1,000 mg IV at <50 mg/min. May give an additional 500 mg IV if no response after 20 min. (Note: Do not give w/ glucose or dextrose due to precipitation.) Valproate 1 g over 15–20 min (20–40 mg/kg). Therapeutic level is 50–100. May give an additional 500 mg after 20 min.
