Neuro emergencies Flashcards
(49 cards)
1
Q
Neuro exam in emergency setting?
A
- key is medical hx
- time of onset
- sx progression
- assoc sxs
- exacerbating factors
- once at ER assess neuro status
- use glasgow coma scale - if pt deteriorated during transport needs immed non-contrast CT scan and possible neurosurgery consult
- if pt stable and not comatose with stable VS and no focal neuro findings: you can proceed more slowly
- goal is to prevent brainstem or uncal herniation and brain edema with elevated ICP that causes further brain injury
2
Q
What is impt hx information for head trauma injury?
A
- when, where and how injury happened
- mechanism of injury
- if there was LOC at the scene
- if ETOH or drugs were involved
- length of time from injury
- underlying medical problems (diabetes, previous stroke, CVD)
- allergies and meds
3
Q
What should be eval on a head trauma physical exam?
A
- vital signs
- glasgow coma scale
- examine head for signs of outward trauma (penetrating trauma, lacerations, swelling, bruises, abrasions)
- pt should be in cervical spine collar
- neuro exam:
pupils
level of alertness
look for focal deficits: facial droop, leg or arm not fxning
4
Q
What is a TBI? GCS ratings?
A
- head injury due to contract or accel/deceleration forces
- mild: GCS 13-15 measured 30 min after injury
- moderate: 9-12
- severe: 8 and lower
5
Q
WHat is a concussion?
A
- trauma indcued alteration in mental status may or may not involve LOC
- caused by direct blow to head, face, neck or body
- fxnl not structural neuropathologcial changes
- normal imaging studies
6
Q
What are associated sxs with TBI?
A
- LOC or not, confusion, amnesia, length of these sxs
- assoc sxs:
HA, dizziness, vertigo or imbalance, lack of awareness of surroundings (disorientation), N/V
7
Q
Signs assoc with TBI?
A
vacant stare inability to focus gross incoordination memory deficits delayed verbal expression slurred or incoherent speech emotionality out of proportion to events
8
Q
Presentation of complicated TBI?
A
- post traumatic seizures
- focal neuro signs
- neuro deterioration
- worsening HA, confusion, focal neuro signs or lethargy - think Intracranial hemorrhage
- other injuries to head and neck (esp in older pts)
9
Q
PP of primary injury phase of TBI? Cortical contusion and indirect trauma?
A
- cortical contusion: direct trauma
coup and contrecoup - diffuse axonal injury: disruption of axonal neurofilament organization - impairs axonal transport leads to axonal swelling
- indirect trauma: SBS or severe whiplash that shakes or rotates the brain
- greatly stretches and damages nerve cells causing sig damage and even death in adults and may cause perm brain damage
10
Q
Indications for CT scan in ER?
A
- GCS of less than 15
- susp open or depressed skull fracture
- any sign of basilar skull fracture: CSF leak, battle’s sign, raccoon eyes, hemotypanum
- 2 or more episodes of vomiting
- 65 or older
- amnesia before impact of 3 or more minutes
- dangerous MOI (eject from vehicle)
- bleeding diathesis or oral anticaog use
- seizure
- focal neuro sign
- intoxication
11
Q
What to look for on CT scan in ED?
A
- cranial contours
- cisterns (any opening in subarachnoid space created by sep of arachnoid and pia mater) - open vs closed
- midline shift?
- lesions? type, location
- acute blood - white
- old blood - dark
- ventricles and cisterns are black
12
Q
CT scan abnorm that require a consult?
Likelihood of neuro normal pt with normal CT scan having a problem?
A
- subdural hematoma
- intracranial bleeding
- cerebal edema
- sig skull trauma
- low risk for neuro deterioration with normal CT scan
13
Q
What pts should be hospitalized or transfered?
A
- GCS of less than 15 or deteriorating
- abnorm CT
- seizures
abnorm bleeding parameters
14
Q
What pts can leave?
A
- if GCS = 15
- normal CT scan
- responsible caretaker to awaken pt from sleep q 2 hrs to check for warning signs:
- inability to waken pt
- severe or worsening HAs
- somnolence or confusion
- diff with vision
- urinary or bowel incont.
- weakness or numbness involving any part of the body
- unsteadiness or seizures
- vomiting, fever or stiff neck
15
Q
Scalp lacerations and tx of bleeding?
A
- common with head injuries
- source of sig bleeding
- hemostasis: is best achieved with closure of laceration
- may be delayed in unstable pt
- direct compression or compression bandage may be applied
16
Q
Scalp laceration repair?
A
- anesthetize wound edges with:
lidocaine1-2% with epi - thoroughly debride and irrigate
- if deep may use horizontal mattress sutures
- otherwise interrupted sutures or staples
- no need to shave head most of time
- when repairing scalp wound palpate skull for depression or step off fracture
17
Q
Clinical sig skull fractures?
A
- pass through an air filled space (sinus)
- assoc with overlapping scalp laceration
- depressed below level of skull’s inner table
- overlie a major dural venous sinus or middle meningeal artery
18
Q
When are linear skull fractures clinically impt?
What do they look like on xray? heal time?
A
- impt if they cross middle meningeal artery or major venous sinus
- most other linear fractures aren’t sig
- fractures are brighter on xray than sutures and usually are wider (3 mm compared to 2 mm for sutures)
- kids - fx heals 3-6 months
- adults: up to 3 years
19
Q
Depressed fractures presentation
A
- may be diff to view on X-ray
- can often be felt on palpation beneath scalp laceration
- impt b/c they predispose to sig underlying brain injury and to complications of head trauma (infection and seizures)
- with a depressed skull fracture traumatic impact drives bone piece below plane of skull
- 25% of pts with depressed fracture report LOC
20
Q
basilar fractures presentation?
A
- linear fractures at base of skull
- usually occurs through temporal bone
- often cause dural tear producing a communication b/t subarachnoid space and paranasal sinuses and middle ear: lead to infection of cranial cavity, can produce CSF leak through nose
- radiographs don’t detect basilar fracture well
- get CT if suspected
21
Q
Open skull fracture?
A
- open if there is an overlaping scalp laceration and dura is disrupted
- a fracture that disrupts paranasal sinuses or middle ear structures is also considered open
- reqr careful debridement and irrigation
- blind probing of wound should be avoided as contaminants can be introduced into wound and can further depress comminuted fracture pieces
22
Q
Characteristics and Tx of migraines?
A
- unilateral, aura ( feel unweel, flashing lights)
- 1st line: tryptans
- 2nd line: ketorolac (IV) + antiemetic (metoclopramide or prochlorperazine)
- IV fluids
23
Q
Cluster HA characteristics and tx?
A
- middle aged man, excruciating pain behind their eye (feels like a hot poker)
- tx:
1st line: 100% O2
2nd: Sumatriptan
24
Q
Thunderclap HA?
A
- subarachnoid hematoma (SAH)
- assoc with nausea and maybe vomiting
25
What are some potentially life threatening causes of HA?
- SAH
- bacterial meningitis
- cerebral ischemia
- subdural hematoma
- brain tumor
26
Etiologies of seizures?
```
- alcohol assoc:
withdrawal
exacerbation of idiopathic seizures
acute intoxication
- metabolic
- infectious
- trauma
- CVA
- sleep deprivation
- noncompliance with anticonvulsant
- 1st time idiopathic seizure (No good in adults!)
```
27
Status epilepticus etiologies?
- hypo- natremia, glycemia, calcemia
- CNS abscess
- meningitis or encephalitis
- neoplasm
- AV malformations
- acute hydrocephalus
- intracerebral hematomas
- CVA
- cyclic antidepressants (amitriptyline - Elavil)
- migraines
- failure to take anticonvulsants
28
Decerebrate posturing meaning?
- poor prognosis
- uncal herniation
- severe brain damage
29
Seizure management?
- a pt presenting with generalized seizure or status epileptics:
AIRWAY management: gag reflex suppressed, suction available, roll on side if vomiting
- consider thiamine
- get as much hx as possible - epileptic? trauma, infectious signs, sudden deterioration, drug or alcohol abuse
- IV est
- BENZODIAZEPINES 1st choice (lorazepam)
- dextrose bolus, narcan
- 2nd line drugs: phenytoin and phenobarbital. phenytoin long onset, acting, benzodiazepine support should be continued
- phenytoin IV can cause hypotension and bradycardia
- phenobarbital causes sedation, depression of resp drive and BP so pt must be monitored closely
30
What is the post ictal state?
- diff post-ictal state and syncope of another cause
- state:
usually sleepy and may be confused, often incontinent, tongue bitten
- supportive care: IV, O2, primary assessment
- underlying cause?
31
Etiologies of vertigo
```
- central:
migrainous
brainstem ischemia
cerebellar infarction and hemorrhage
MS
- somatic:
panic attack
weak dizzy, nearly fainting pt
```
```
- peripheral:
benign paroxysmal positional vertigo
vestibular neuritis
herpes zoster oticus
meniere's disease
labyrinthitis
perilymphatic fistula
acoustic neuroma
aminoglycoside toxicity (commonly seen in CF pts)
- otitis media
```
32
Dx cause of vertigo?
- N/V more severe with peripheral casues
- gait disturbances more pronounced with central etiologies
- generally central etiologies last for hrs - days, while peripheral are recurrent and last for few minutes to 2-3 hrs
- impt to get a good hx, PE (look for nystagmus and focal neuro signs)
- look at RFs for more serious central disease
33
What is a TIA? Sxs?
- brief stroke like attack, most sxs last 5-20 min, rarely longer than an hour, w/o evidence of acute infarction
- if neuro defects last 4 hrs or longer pt often has infarcts on MRI
```
- sxs:
hemiparesis, hemiparesthesia
dysarthria, dysphasia, and diplopia
circumoral numbness
imbalance
monocular blindness
```
34
TIA and CVA relationship?
- among pts who present to ER with TIA 5% will have CVA in 2 days and 25% will have recurrent event in 3 months
- urgently ID the cause of pts first stroke or TIA is crucial for determining proper therapy to prevent a second, more disabling event
- since neuro signs/sxs subte and timing inexact - should usually get CT or MRI to r/o infarct
35
Work up of TIA?
- depends on suspected area effected:
low flow - internal carotid (Duplex US or transcranial doppler), MCA: MRA or CT angiography, verterbrobasilar: CT angiography
embolic: echo - embolism
EKG - a fib
lacunar: r/o others, dx of exclusion
36
Differential for sudden loss of focal brain fxn?
- CVA
- seizures
- atypical migraines
- syncope
- transient global amnesia
- hypoglycemia
- MS
- brain tumors
- subdural hematoma
- infection
37
3 subcategories of ischemic stroke?
- thrombosis: large artery extracranial and intracranial occlusive disease or small penetrating artery disease
- embolism from: heart, intra-arterial, aorta, paradoxical
- systemic hypotension (hypoperfusion)
38
Distingiushing CVA - hx ?s and presentation?
| nature of sxs? (+ and -)
- focal or nonfocal nature of episode
- nature of sxs and their progression
- duration and timing of sxs
- assoc sxs during and after episode is more like a TIA
- nature of sxs:
+ sxs: indicate active d/c from CNS neurons (visual, auditory, somato-sensory, motor)
- sxs: indicate absence or loss of fxn (loss of vision, feeling or ability to move part of body)
39
CVA management? Goals of initial assessment?
- goals of initial assessment:
ensuring medical stability (ABCs)
- quickly reversing any conditions that are contributing to pts problem
- moving towards uncovering the pp basic of pts neuro sxs
- screening for potential CIs to thrombolysis in acute ischemic stroke pts
40
Hx and PE for CVA?
- Hx:
find out if diabetic, hx of seizures
hx of ETOH or drug abuse
meds and any recent trauma
PE:
- thorough CV exam: murmurs, pulses to check if irregular, listen for bruits
- skin: sign of endocarditis, cholesterol emboli, ecchymosis, tongue laceration
- fundoscopic exam
- neck immobilized if evidence of serious trauma or question of fall
- examine extremities for DVT, signs of systemic arterial emboli
41
Immed studies to get in suspected CVA pt?
- noncontrast CT or MRI of brain
- EKG
- CBC w/ platelets
- CMP
- serum glucose
- PTT, PT, INR
- O2 sats
- preg test (woman child bearing age)
- blood cultures x2 if fever
42
Tx of CVA? BP importance?
- pt should be flat or elevate head of bed no more than 15 degrees
- BP:
ischemic: often elevated, need elevation for perfusion pressure, don't tx unless SBP greater than 220 or DBP greater than 120
hemorrhagic: balance b/t increased BP worsening bleeding and decreased BP decreasing perfusion (titrate BP to SBP 140-160)
hemorrhagic stroke on warfarin: need to reverse effects of warfarin - IV vit K, prothrombin-complex concentrates, FFP
- thrombolytic therapy: within 3-4.5 hr window
- R/O hemorrhag
- meet eligibility criteria (no CIs)
- antithrombotic therapy: initiate antiplatelet agent w/in 48 hrs of stroke onset
43
What is a Myasthenic crisis? Myasthenia Gravis?
Myasthenia gravis: disorder of neuromuscular transmission affecting ocular, bulbar, limb and resp muscles
- myasthenic crisis occurs when there is severe enough weakness to necessiate intubation: severe bulbar weakness produces dysphagia and aspiration that often complicates respiratory failure
- often pt experiences generalized weakness as warning
44
Management of myasthenic crisis?
- if pt presents with weakness and not acute resp failure the FVC can be monitored q 1-2 hrs
- elective intubation should be considered if serial measurements of FVC consistently decline approaching 15 ml/kg body weight
- at times b/c weakness of oropharyngeal muscles, secretions can't be handled and pt is at risk for aspiration so elective intubation in done in this setting
- if pt in obvious respiratory failure emergent intubation is done, but elective intubation is preferable
- plasmapheresis or IV immune globuline are done for tx
45
MS acute exacerbations?
| Tx?
- result in fxnally disabling sxs with objective neurologic impairment (Loss of vision, motor and or cerebellar sxs)
- tx with high dose IV glucocorticoids: such as methylprednisolone 1000 mg IV a day for 5 days
- sometimes MS causes seizures - tx the seizure
46
Tx of neuropathic pain syndromes?
-generally pts with chronic pain - may be on prophylactic meds to control pain, but are having breakthrough pain
- first elicit if anything new or different about pain to r/o new injury or illness
- if its chronic pain exacerbation discuss with pt level of pain and options for tx:
1 time IM dose of dilaudid or morphine
1 time dose PO opioid
start or increase proph med (neurontin)
importance of regular f/u with PCP and or pain specialist
- DONT give rx for narcotics
- reassure pt pain will decrease and can be controlled but it takes time
- assess for assoc depression and/or anxiety that may be making pain worse and make approp referral
47
Presentation of guillian-barre syndrome?
- symmetric ascending muscle weakness
- weakness usually starts in proximal legs: begins in arm and facial muscles in 10% of pts
- progressive to severe resp muscle weakness: 30% of pts will need ventilatory support, it can happen quickly
- 80% will have paresthesias in hands and feet: sensory abnorm on exam most the time mild
- often severe back pain
- dysautonia: 70% - tachycardia, urinary retention, HTN-hypotension, bradycardia, ileus, loss of ability to sweat
48
Dx of GBS?
- LP: marked elevation of CSF protein with normal WBC count
- neurophys studies: characteristic findings on EMG and nerve conduction
- serum: glycolipid abs to gangliosides
- features that make GBS doubtful:
having a demarcation in sensation (sensation stops abruptly)
marked persisent asymmettry of weakness
severe and persistent bowel and bladder dysfxn
more than 50 WBCs in CSF
49
Tx of GBS?
- close monitoring of resp failure - may reqr intubation and mechanical ventilation
- close monitoring of heart rhythm, pulse and BP
- fluids for hypotension
- admission to ICU for further stabilization and tx
