Flashcards in Neuro Emergencies Deck (64)
What is a good imitator of a stroke?
give sugar and thiamine - reverse quickly
Why is it ok to have high BP in acute ischemic stroke (220/110)?
- what high BP so brain is still being perfused
Why do we want to keep Na on high end in a stroke?
- to prevent brain cells from swelling
Reversal agents for warfarin?
- FFP and Vit K
(FFP works faster)
What should you expect if pt presents w/ bradycardia and HTN?
- cushing's triad - ICP
- need to decrease CP: use mannitol if pt herniating, also give fluids to prevent hypotensive (give hypertonic saline0
PE of AMS?
- ABCs, VS
- bedside glucose
- look quickly for immediate life threats:
- don't be afraid to give glucose, thiamine, based on H and P
- Head to toe exam
DDx for AMS:
A - alcohol
E - epilepsy; lytes; encephalopathy (HTN, hepatic)
I - insulin (hyper, hypo); intuss (peds)
O - overdose: opiates
U - uremia
T - trauma
I - infection
P - psych; poision
S - shock
Tx of AMS?
- underlying cause
What is status epilepticus?
- considered 5 min or more of convulsions or 2 or more convulsions in a 5 min interval w/o return to preconvulsive neuro baseline
- traditionally considered to be convulsions longer than 30 min, however don't halt tx
Etiologies of status epilepticus?
- vascular: stroke, hypoxic encephalopathy
- toxic: drugs, alcohol w/drawal, meds (isoniazid, TCAs, chemo agents), AED noncompliance
- metabolic: hyper/hypo-natremia, hypoglycemia,hypocalcemia, liver/renal failure
- infectious: meningioencephalitis, brain abscess
Initial assessment/tx of status epilepticus?
- ABCs: O2, airway, BP: monitor for hypotension
- labs: CBC, BMP, Ca, Mg, AED levels
- dx hypoglycemia as cause: D50W amp and thiamine 100 mg IV
- ***needs to have thiamine given b/f dextrose as 20-40% of seizure pts are alcoholics
First line tx for status epilepticus?
- benzos 1st line:
ativan 4 mg IV or valium 5 mg IV
- 2nd line:
fosphenytoin load 20 mg/kg (up to 150 mg/min)
valproic acid: load 40 mg/kg, 2nd - 20 mg/kg
refractory status: phenobarb, pentobarb, versed, propofol - intubate if no response
Post ictal state?
- diff post-ictal state and syncope of another cause
- usually sleepy and may be confused
- during possible prior seizure pt has usually been incontinent
- tongue bitten
- supportive care
- w/u why seizure occurred
Cause of acute ischemic stroke?
- caused by sudden loss of blood circ to area of brain resulting in ischemia and corresponding loss of neuro fxn
- w/in seconds to min of loss of perfusion, an ischemic cascade occurs resulting in central area of irreversible infarction surrounded by an area of potentially reversible ischemic penumbra
- goal of tx: preserve ischemic penumbra
Hx questions for stroke pt and family?
- time last known well
- tPA CIs
- hx of diabetes, seizures?
- detailed description of sxs:
onset w/ HA, seizure, syncope, possible ICH
neck pain, hx of neck trauma, possible vertebral or carotid dissection
PE for ischemic stroke pt?
- level of consciousness
- eye exam
- motor exam
- sensory exam
- cerebellar exam
W/u of ischemic stroke?
- labs: POCT BG, CBC
Action time needed for AIS tx?
- door to clinician in less than 10 min
- door to stroke team less than 15 min
- door to CT initiation less than 25 min
- door to CT interpretation less than 45 min
- door to drug (more than 80% compliance) less than 60 min
- door to stroke unit admission: less than 3 hrs
Characteristics of ACA stroke?
- dysarthria, aphasia
- unilateral contralateral motor weakness (lower more than upper)
- LE sensory changes
- urinary incontinence
Characteristics of MCA stroke?
- contralateral hemiparesis (faces/arms more than legs) and hemianopsia
- ipsilateral gaze preference
- aphasia (if dominant hemisphere): Broca's/wernike's/global
- hemi-neglect (if non-dominant hemisphere)
Characteristics of PCA stroke?
- contralateral hemianopsia
- cortical blindness
- impaired memory
Initial tx for AIS?
- airway: intubate for GCS less than 8 or inability to protect airway
- breathing: O2 if hypoxic, keep PCO2 32-36
- circulation: maintain adequate CPPl allow permissive HTN (220/110)
- dextrose: maintain normoglycemia (hyperglycemia worsens neuro outcome)
fever: hyperthermia worsens outcome
- cerebral edema
- seizure control
Thrombolytics used for AIS? indications?
- Altepase (IV tPA): considered in eligible pts tx w/in 3-4.5 hrs of sx onset
acute neuro deficit expected to result in sig long term disability
- non-contrast CT w/ no hemorrhage
- stroke sx onset clearly ID b/t 3-4.5 hrs b/f tPA given
CIs to tPA?
- SBP over 185 or DBP over 110 (labetolol 10 mg q 10 min)
- CT head w/ ICH or SAH
- recent intracranial or spinal surgery, head trauma or stroke (more than 3 mos ago)
- major trauma or surgery w/in 3 months)
- hx of ICH or aneurysm/vasc. malformation/brain tumor
- recent active internal bleeding
- platelets less than 100K, heparin use w/in 48 hrs w/ PTT over 40, INR greater than 1.7
- known bleeding disorder
Use of mechanical thrombectomy in AIS?
- for pts w/ stroke in large territory vessel of proximal circa
- composed of direct IA tPA and stent removal of clot if necessary
- MR clean trial: demostrated that early IA intervention dramatically improved neuro outcome after ischemic stroke w/o increase in sx ICH or 90 day mortality
Diff types of ICH?
- intra-parenchymal (IPH)
- intra-ventricular (IVH)
- subarachnoid (SAH)
What is a IPH? Signs and sxs?
- hemorrhage w/in brain tissue
- often clinically silent
- signs and sxs depend on location of hemorrhage:
M/c are hemiparesis, aphasia, hemianopsia and hemisensory loss
- can mimic acute ischemic stroke sxs
- HTN number 1 cause!!!
- cerebral amyloid angiopathy
- anticoag/anti-platelet meds
- systemic anticoag states (DIC)
- sympathomimetic drugs (cocaine, MDMA, meth)
- aneurysms, AVMs, cavernous angiomas
- brain tumors
- often result from IPH extending into ventricular system
- s/s: HA, N/V, progressive deterioration of consciousness, increased ICP, nuchal rigidity
- increased risk of obstructive hydrocephalus