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Flashcards in Neuro Emergencies Deck (52)
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1

1. Consciousness has 2 main components what are they?

2. Describe how they are different in Delirium and Dementia?

1. Arousal and Cognition.

2.
Delirium: alteration of both arousal and cognition. Dementia: alteration in cognition, not arousal

2

1. Arousal is controlled by the what?

2. Cognition is controlled by ?

1. ascending reticular activating system (ARAS) in the brainstem.
2. cerebral cortex.

3

AMS - PE
3

1. ABCs; Vital signs
2. Bedside glucose

3. Look quickly for immediate life threats

4

AMS PE
Look quickly for immediate life threats, such as:
5

1. Hypoglycemia
2. Hypotension/ Hypertension
3. Hypoxia
4. Abnormal respirations
5. Hypo/ Hyperthermia

5

AMS PE
Head to toe exam
1. Head? 5
2. Neck? 1
3. CV? 3
4. Pulm? 1
5. Abd? 2
6. Skin? 4

1. Head –
-trauma;
-Pupil size, symmetry, and reactivity.
-Pinpoint pupils: OD vs pontine hemorrhage;
-Blown pupil: uncal herniation;
-Fundi: papilledema

2. Neck – stiffness?

3. CV –
-dysrhythmia (atrial fib),
-murmurs (endocarditis),
-rubs (pericarditis)

4. Pulm-
-symmetry of sounds, rate, wheezes

5. Abd –
-masses?
-Organomegaly? (alcoholic liver, splenic sequestration in sicklers)

6. Skin –
-color,
-turgor (dehydration);
-rashes (petechiae, purura: TTP vs meningococcemia?);
-Infection (cellulitis, fasciitis)

6

AMS – DDx: AEIOU TIPS

A – Alcohol
E – Epilepsy; Electrolytes; Encephalopathy (HTN, Hepatic)
I – Insulin (hyper and hypo); Intuss (peds)
O – Overdose; Opiates
U – Uremia
T – Trauma; Temperature (Hyper and hypo)
I – Infection; Intracerebral hemorrhage
P – Psych; Poison
S - Shock

7

When would you intubate?

GCS less than 8

8

Are they brain dead/herniating?
PE?
6

1. DTR
2. Cranial nerves best they can
3. responsive to pain
4. suction and see if they have a cough or gag reflex
5. dolls eye test- stays in line is bad
6. anyone with a blown pupil is uncle herniation until proven otherwise

9

Status Epilepticus
1. Considered how long without return to preconvulsive neurologic baseline?

2. Traditionally considered to be convulsions > ______, however do not halt treatment!

1. 5 minutes or more of convulsions or 2 or more convulsions in a 5 min interval

2. 30 min

10

Status Epilepticus
Etiologies
6

1. Vascular: stroke, SAH, hypoxic encephalopathy
2. Toxic: drugs, alcohol withdrawal, medications (Isoniazid, TCA’s, chemo agents), AED non-compliance
3. Metabolic: Hyper/hypo-natremia, hypoglycemia, hypocalcemia, liver/renal failure
4. Infectious: meningioencephalitis, brain abscess
5. Trauma
6. Neoplastic

11

Initial Assessment/Treatment of status epilepticus
3

1, ABC’s – O2, airway, BP
Monitor for hypotension
2. Labs:
3. Dx hypoglycemia as cause

12

Initial Assessment/Treatment of status epilepticus
5

1. CBC,
2. BMP,
3. Ca,
4. Mg,
5. AED levels

13

How would you treat status epilepticus if hypoglycemia was the cause? 2

-D50W amp and Thiamine 100 mg IV
-Needs to have thiamine given before dextrose as 20-40% of seizure pts are alcoholics

14

Treatment for status epilepticus:
1. Initially? 2
2. Then? 2
3. Refractory? 4

1. Benzodiazepines are first line
Ativan 4mg IV or Valium 5mg IV
2. Second line
-Fosphenytoin load 20 mg/kg (up to 150 mg/min)
-Valproic acid load 40 mg/kg, 2nd dose of 20 mg/kg

3. Refractory status
-Phenobarb 20 mg/kg,
-Pentobarb,
-Versed gtt,
-Propofol, etc.)

15

Post-ictal State
1. What do we have to differentiate this from?
2. What does the post ictal state consist of? 4
3. tx?
4. Work up?

1. Differentiate post-ictal state and syncope of another cause
2. Post-ictal state
-Usually sleepy and may be confused
-During the possible prior seizure the pt has usually been incontinent
-Tongue bitten
3. Supportive care
4. Work up why seizure occurred

16

Acute Ischemic Stroke
1. Caused by? Results in?
2. Within seconds to minutes of loss of perfusion, an ischemic cascade occurs resulting what?
3. Goal of tx?

1. Caused by the sudden loss of blood circulation to an area of the brain resulting in ischemia and corresponding loss of neurologic function

2. a central area of irreversible infarction surrounded by an area of potentially reversible ischemic penumbra

3. Goal of treatment is to preserve ischemic penumbra

17

Acute Ischemic Stroke
Hx questions?
4

1. Time last known well
2. tPA contraindications?
3. History of diabetes? Seizures?
4. Detailed description of symptoms

18

Acute Ischemic Stroke
Detailed description of symptoms such as
1. What would indicate ICH? 3

2. What about a vertebral or carotid dissection? 2

1. Onset with HA,
2. seizure,
3. syncope .. Possible ICH..

1. Neck pain,
2. history of neck trauma ..
Possible vertebral or carotid dissection

19

PE for acute ischemic stroke?
7

1. Level of consciousness
2. Eye exam
3. CN exam
4. Motor exam
5. Sensory exam
6. Reflexes
7. Cerebellar exam

20

Work up: Acute ischemic stroke:
1. Labs? 6
2. Imaging?

1. Labs:
-POCT BG,
-CBC,
-CMP,
-PT/INR,
-cardiac enzymes,
-EKG

2. Imaging:
-Emergent non-contrast head CT

21

Why do we do a noncontrast CT for acute ischemic stroke? 3

1. Distinguished hemorrhagic from ischemic stroke
2. Defines age and anatomic distribution of stroke
3. Large hypodense areas seen within 3 area can indicate timing of AIS and can predict poor outcome

22

ED-Based Care
Action Time:
1. Door to clinician ___ minutes
2. Door to stroke team ____ minutes
3. Door to CT initiation ____ minutes
4. Door to CT interpretation ____ minutes
5. Door to drug (≥80% compliance) ____ minutes
6. Door to stroke unit admission: How long?

1. ≤10

2. ≤15
3. ≤25
4. ≤45
5. ≤60
6. ≤3 hours

23

ACA stroke symptoms?
4

1. Dysarthria, aphsasia
2. Unilateral contralateral motor weakness (lower > upper)
3. Lower extremity sensory changes
4. Urinary incontinence

24

MCA stroke symptoms? 4

1. Contralateral hemiparesis (face/arms > legs) and hemianopsia
2. Ipsilateral gaze preference
3. Aphasia (if dominant hemisphere)
4. Broca’s/Wernike’s/Global
Hemi-neglect (if non-dominant hemisphere)

25

PCA stroke symptoms? 4

1. Contralateral hemianopsia
2. Cortical blindness
3. Altered mental status
4. Impaired memory

26

Initial Treatment
for ischemic stroke?
7

ABCD’s
1. Airway: intubate for GCS

27

Thrombolytics for Tx of ischemic stroke:
1. What is the drug?
2. Considered in eligible patients treated within how long of symptom onset?

1. Alteplase (IV tPa)
0.9 mg/kg w/ max dose of 90 mg

2. 3-4.5 hours

28

Thrombolytics for Tx of ischemic stroke:
Indications? 3

1. Acute neurological deficit expected to result in significant long-term diasability
2. Non-contrast head CT w/ no hemorrhage
3. Stroke symptom onset clearly identified between 3-4.5 hours before tPa given

29

tPa Contraindications
8

1. SBP > 185 or DBP > 110 (Labetolol 10mg q10 min)
2. CT head w/ ICH or SAH
3. Recent intracranial or spinal surgery, head trauma or stroke (> 3 mos)
4. Major trauma or surgery within 3 mos
5. Hx of ICH or aneurysm/vascular malformation/brain tumor
6. Recent active internal bleeding
7. Platelets 40; INR > 1.7
8. Known bleeding disorder

30

2013 AHA Guidelines
for tPA
9

1. Give IV tPA in patients who meet 3 hour criteria (IA)
2. Getting it within window is not enough, shoot for the 2 days (assuming normal renal metabolizing function). Similar consideration should be given to patients being considered for intra-arterial rtPA (Class III; Level of Evidence C)