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Flashcards in Neuro Emergencies Deck (64)
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1

What is a good imitator of a stroke?

- hypoglycemia:
give sugar and thiamine - reverse quickly

2

Why is it ok to have high BP in acute ischemic stroke (220/110)?

- what high BP so brain is still being perfused

3

Why do we want to keep Na on high end in a stroke?

- to prevent brain cells from swelling

4

Reversal agents for warfarin?

- FFP and Vit K
(FFP works faster)

5

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

6

PE of AMS?

- ABCs, VS
- bedside glucose
- look quickly for immediate life threats:
hypoglycemia
hypotension/HTN
hypoxia
abnormal resp
hypo/hyperthermia
- don't be afraid to give glucose, thiamine, based on H and P
- Head to toe exam

7

DDx for AMS:
AEIOU TIPS?

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

8

Tx of AMS?

- underlying cause

9

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

10

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
- trauma
- neoplastic

11

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

12

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

13

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

14

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

15

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

16

PE for ischemic stroke pt?

- level of consciousness
- eye exam
- CN
- motor exam
- sensory exam
- reflexes
- cerebellar exam

17

W/u of ischemic stroke?

- labs: POCT BG, CBC

18

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

19

Characteristics of ACA stroke?

- dysarthria, aphasia
- unilateral contralateral motor weakness (lower more than upper)
- LE sensory changes
- urinary incontinence

20

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)

21

Characteristics of PCA stroke?

- contralateral hemianopsia
- cortical blindness
- AMS
- impaired memory

22

Initial tx for AIS?

ABCDs:
- 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

23

Thrombolytics used for AIS? indications?

- Altepase (IV tPA): considered in eligible pts tx w/in 3-4.5 hrs of sx onset
- indications:
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

24

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

25

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

26

Diff types of ICH?

- intra-parenchymal (IPH)
- intra-ventricular (IVH)
- subarachnoid (SAH)

27

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

28

IPH etiology?

- 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

29

IVH:
etiology, s/s?

- 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

30

Tx of IPH/IVH?

- ABCDs:
intubation if necessary
SBP goal: less than 160
- fluid and lytes:
NS, avoid dextrose, watch for SIADH/cerebral salt washing
-prevent hyperthermia
- seizure ppx
- correct underlying coag:
FFP, platelet infusion, Vit K
- management of ICP
- recombinant factor VII (NovoSeven): can be beneficial to give w/in 4 hrs, risk of MI and AIS
- surgical evacuation of hemorrhage