Neuro Emergencies Flashcards
(90 cards)
1
Q
Common causes of primary HA
A
- Tension
- cluster
- miragines
2
Q
Secondary causes of HA
A
- Vascular- SAH, temporal arteritis, Arterial dissection
- Traumatic- Epidural, subdural hematomas
- Neoplastic- primary and metastatic tumors
- Infectious-meningitis, encephalitis, sinusitis
- Pressure-hypertension, pseudotumor cerebri/ IIH
- Ophthalmologic-acute angle glaucoma
3
Q
When someone presents with a HA first __
A
tx the pain!!
- Tailor the treatment to the patient
- Turn down the lights, reduce stimuli
- Route of med: PO vs IV?
- IVF
- Antiemetics
4
Q
What meds are commonly used to tx HA pain
A
- OTC Analgesics: motrin/ tylenol
- Dopamine agonists
- Abortive meds (triptan) -are good if patient has an aura, or early onset HA
- Opiates : not as effective as dopamine agonists
5
Q
Describe the phases of ED head pain protocol
A
Phase I: treat the acute head pain
Phase II: Decrease cortical irritability
Phase III: Additional RX to decrease central sensitization
6
Q
Pros and Cons of Dopamine agonists
A
60% efficacy IM; placebo type efficacy for PO
- The faster it gets to the brain the better it works
- Cautions: QT prolongation, akasthesias
7
Q
Important Hx questions to ask for HA
A
- Has the patient ever had a headache similar to this one?
- Has the patient experienced recent head trauma?
- What was the patient doing at the onset of the headache?
- Was the headache sudden in onset?
- Is this the worst headache of the patient’s life?
- (OPQST for pain)
8
Q
Big Red Flags for HA
A
- Onset after 50 years old
- Sudden onset or onset during exertion
- First or worst headache
- Accelerating pattern
- Change in the normal headache pattern
6, Abnormal vital signs or neurologic exam
9
Q
Red flags of association: HA with…
- Hard neurological findings
- Sudden onset/ exertional/ maximal at onset
- Fever/ immunocompromised
- Temporal artery pain/jaw claudication
- Neck pain
- Coagulopathy/pregnancy
- Progressive daily HA
- Multiple patients
- Dizziness
- Trauma
- Eye Pain
A
- Hard neurological findings- stroke
- Sudden onset/ exertional/ maximal at onset- SAH
- Fever/ immunocompromised: meningitis
- Temporal artery pain/jaw claudication: Temporal arteritis
- Neck pain- cervical artery dissection
- Coagulopathy/pregnancy- venous sinus thrombosis
- Progressive daily HA- tumor
- Multiple patients- CO poisoning
- Dizziness- Cerebellar infarct
- Trauma- Subdural hemorrhage
- Eye Pain- acute glaucoma
10
Q
What is Cushings reflex
A
physiological nervous system response to increased intracranial pressure (ICP) that results in Cushing’s triad of increased blood pressure, irregular breathing, and a reduction of the heart rate.
11
Q
rapid mental status exam
A
- Note fluency of speech, appropriate responses
- Orientation to person, place, time president
- Count backward from 10
- Object recall
12
Q
decreased awareness of self and others, decreased eye contact with family and staff
A
lethargic
13
Q
can be aroused with vigorous noxious stimuli. Decreased eye contact and motor activity, unintelligible vocalizations
A
stuperous
14
Q
disorientation, fear, misperception of sensory stimuli, visual hallucinations, need to ID cause due to high m&m. Abnormal vital signs, fluctuating course
A
delirious
15
Q
unarousable to verbal or painful stimulation
A
Comatose
16
Q
Consider the overall management of HA
A
- If a primary headache is suspected then aborting the symptoms can be addressed
- If the patient has never had migraine, consider CT
17
Q
Evaluation of secondary HA
A
- Head CT usually non contrast
- Contrasted study useful for mass effect, brain abscess
- Lumbar puncture
- Laboratory tests may help in diagnosing infection (ESR, CRP, WBC)
- MRI prn
18
Q
Describe the characteristics of migraine HA
A
- Unilateral; pulsatile; moderate/severe pain
- N/V; sensitivity to light and sound
- Aggravated by activity
- Pain builds over 1-2 hours; last 4-72 hours
- +/- aura (80% are w/o)
- Typically women (adolescene to early 20s)
*Thought now to be a neurogenic process w secondary changes in cerebral perfusion and inflammation and herdiatry
19
Q
Mneumonic for MIgraine
A
P Pulsatile O 4-72 hOurs U Unilateral N Nausea/ vomiting D Disabling intensity
If 4/5 are positive, high LR of migraine dx
20
Q
Triggers of Migraines
A
- stress
- sleep disturbance
- depression
- food
- hormonal changes
- caffeine withdrawal
21
Q
What are auras
A
- Visual auras most common - scotomata, flashing
- May include hemiparathesia, aphasia, hemiparesis
22
Q
What are atypical migraines
A
may present with neurologic abnormalities, weakness, numbness, may be bilateral or no HA at all
*don’t usually dx in ER–> present stroke like
23
Q
Describe the ED tx of migraine HA
A
Triptans: abortive meds; cause vasoconstriction, inhibit central pain transmitters
*Triptans and DHE can not be used within 24 hours of each other because of the excessive vasoconstriction
24
Q
Don’t use triptans in
A
CAD
pregnant patients
25
Describe Cluster HA
1. severe, unilateral pain in the orbital/periorbital pain
2. lasting 15 minutes to 3 hours
3. up to several times a day , for several weeks--Ie, “cluster”
4. Headache must be associated with at least one of the following on the ipsalateral side:
conjunctival injection, lacrimation, nasal congestion, rhinorrhea, facial swelling, miosis, ptosis, eyelid edema
26
"histamine HAs"
cluster HA
27
Tx of Cluster HA
HA protocol
| 2. High flow O2 via non-rebreather mask
28
Presentation of tension type HA
1. Last from 30 min – 7 days
2. Pressing/Tight, non pulsatile quality
3. Mild/moderate intensity; 4. Bilateral location
5. No aggravation with activity
6. And NO N/V; rarely have any photo/photo phobia
29
Ed tx of Tension HA
1. OTC meds – motrin, tylenol; caffeine
2. Headache protocol
3. Trigger point injections
30
MC cause of subarachnoid hemorrhage
most commonly from a ruptured cerebral aneurysm or AVM (arterio-venous malformation)
*genetic
31
Describe risk factors of SAH
1. Tobacco,
2. cocaine,
3. amphetamine,
4. HTN,
5. previous aneurysm,
6. connective tissue d/o;
7. recent alcohol binge
32
Classic presentation of SAH
1. thunderclap HA
2. exertional
3. Sudden onset – usually seconds (up to minutes) and reaches a maximum quickly.
4. “worst headache of my life”
Associated sx include:
5. vomiting,
6. syncope,
7. AMS,
8. focal neurologic findings,
9. neck pain
10. Sentinel bleed- A headache that precedes the SAH by days or weeks
33
What are PE findings of SAH
1. Hypertensive (>160/100),
2. tachycardic;
3. +/- fever (fever common following 4th day of bleed)
4. Fundoscopic exam looking for increased ICP/ papilledema
5. Retinal hemorrhages
Thorough neurologic exam
6. Motor, cerebellar function, mental status, gait
7. Signs of meningismus
8. Cranial nerve palsy (from increased ICP)
34
What lab testing should you order w/ SAH
1. Non-contrast CT-- If performed within 6 hours of onset of symptoms, has miss rate of 1-2/1000 patients (VERY SENSITIVE- less if anemic)
2. LP?-- looking for blood in CSF and xanthochromia
3. CTA brain? (more radiation and too many incidentalomas)
*do LP moreso if >6hrs out
35
Presence of xanthochromia in LP CSF is the gold standard for diagnosis of __
SAH
*Xanthochromia develops w/in 12 hrs, stays for 2 wks
36
Describe the Hunt Hess Grading System of SAH
Grade 0 Unruptured aneurysm
Grade I Asymptomatic or minimal headache, slight nuchal rigidity
Grade II Moderate to severe headache, nuchal rigidity, no neurologic deficit other than cranial nerve palsy
Grade III Drowsiness, confusion, mild focal deficit
Grade IV Stupor, moderate to severe hemipariesis, early decerebrate rigidity
Grade V Deep coma, decerebrate rigidity
*know 0 and 5
37
Describe the Tx of SAH
1. ABCs
2. IV access
3. Blood pressure control - <130/140 systolic
- Usually with beta blockers
4. analgesia
5. Emergent neurosurgical consultation
6. Admission to ICU
7. Surgical vs non-surgical treatment
38
RF for misdiagnosis of SAH in ED
1. normal neurologic exam,
2. small hemorrhage,
3. sentinel bleeds
4. Dismissing the diagnosis of SAH because the patient improved with pain medication
- --remember – response to analgesics is not diagnostic!
39
Describe post LP HA
- Tear in the dura causes leak of CSF
| - Headaches worsen with upright posture and improve when the patient lies flat***
40
Tx of Post LP HA
Treatment includes IV caffeine and usually an epidural blood patch
41
Common presentation of tumors
1. Progressively worsening HA
2. Dull, constant, classic ?
3. “morning HA”
4. HA may wake patient at night
5. Worse with valsalva and recumbency
6. N/V (40%)
7. Seizures may occur
42
best way to evaluate for a brain tumor
Head CT with contrast
*usually start w/ CT w/o contrast
43
decribe the PEX of Pseudotumor Cerebri/ Idiopathic Intracranial Hypertension
1. Papilledema,
2. w/ Normal level of consciousness
3. Obese women on OCPs
44
DX of Pseudotumor Cerebri/ Idiopathic Intracranial Hypertension
1. First, a normal Head CT
2. Then measure opening pressure
- (>20 cm H2O) on LP is diagnostic
45
untreated Pseudotumor Cerebri/ Idiopathic Intracranial Hypertension may cause
vision loss
46
Tx of Pseudotumor Cerebri/ Idiopathic Intracranial Hypertension
1. Therapeutic LPs;
2. Acetazolamide or Lasix;
3. VP shunt
47
Describe the common presentation of Cerebral Venous Sinus Thrombosis
1. Slow progressive/persistent HA
2. Localizing neuro signs
3. Occ., seizure
4. Pregnancy (3rd trim – 6wks post partum); hypercoagulable--> like a blood clot of the brain
48
Dx of Cerebral Venous Sinus Thrombosis
MR venogram
49
Tx of Cerebral Venous Sinus Thrombosis
anticoagulants or thrombolytics
50
What is Temporal Arteritis/ Giant Cell Arteritis
Systemic inflammatory vasculitis of unknown etiology – commonly affects temporal arteries
51
Presentation of Temporal Arteritis/ Giant Cell Arteritis
1. >75y/o
2. F>M
3. : fronto-temporal HA,
4. often unilateral and throbbing,
5. severe, with jaw claudication,
6. vision changes,
7. palpable temporal arteries
52
How do you dx Temporal Arteritis/ Giant Cell Arteritis
ESR elevation
| Biopsy on temporal artery
53
Tx of Temporal Arteritis/ Giant Cell Arteritis
Steroids for 4-6 weeks
*risk of blindness if untreated
54
Describe the presentation of Cervical artery dissection
* *“neck pain, young, HA”
1. HA w/ neck pain
2. face pain
3. neuro c/o or findings
4. h/o trauma (hyperextension, flexion or rotation)
*Maintain high index of suspicion
55
Risk factors for Cervical artery dissection
1. trauma
2. CT disorder
3. smoking
56
Cervical manipulation therapy has significant (___) relationship to cervical artery dissection; temporally linked as well
5-12x as likely
57
Presentation of carotid artery dissection
1. Unilateral facial/eye pain w neck pain
2. Anterior circulation sx
3. Amarosis fugax: transient episodic blindness
4. Partial Horners: ptosis, miosis, anhydrosis
5. ”classic” stroke sx
58
Presentation of vertebral artery dissection
1. Occipital/posterior neck pain
2. Posterior circulation findings
3. Vertigo, n/v, hoarseness,
4. Gait instability
59
How do you dx cervical artery dissection
CTA head and neck
60
howo do you tx cervical artery dissection
1. depends on the presentation, but includes antiplatelet (ASA), anticoagulant (ie, Heparin/coumadin) Thrombolytics (Alteplase) or
2. endovascular intervention
4. Consult neurosurgery
61
What is Horners syndrome
1. Ptosis
2. Miosis
3. Anhydrosis
strokey---> seen w/ carotid artery dissection
62
What is meningitis
- Inflammation of the pia and arachnoid membranes
| - Bacteria enter via nasopharyngeal epithelium, cross the blood brain barrier and enter the CSF
63
#1 cause of meningitis in most age groups
S. pneumoniae
64
Risk factors for meningitis
1. Extremes of age (<5yo or >60yo)
2. DM,
3. CKD;
4. chronic alcoholism,
5. immunosuppression
6. Crowding (jails, military, college dorms)--> Meningococcus (Neisseria meningitis)
65
Describe the meningitis rash
a petechial rash on trunk and lower extremities in addition to typical s/s
*bad sign!
66
Describe the adult presentation of bacterial meningitis
“Fever, Nuchal Rigidity, AMS”
2. HA-- severe
3. most present w/in 24hrs
4. Seizures
5. Focal neuro findings
6. papilledema
67
Describe the pediatric presentation of meningitis
1. irritabilty,
2. inconsolability
3. hypotonia.
4. LETHARGY
5. May have a less serious suggestive diagnosis like AOM, sinusitis
6. Older children – more classic presentation
68
describe specific PE of meningitis
Brudzinski sign: flexing the pts neck causes flexion of the pts hips and knees
Kernig’s signs: flexing the pts hip 90 degrees then extending the pts knee causes pain
69
When should you get a head CT before a LP w/ meningitis
1. AMS
2. Focal neuro deficit
3. Papilledema
4. Seizure in the past week
5. Immunocompromised
6. Elderly?
*CT before LP to to identify a possible mass lesion--> Otherwise, do not delay LP
70
Describe the workup of meningitis
1. Blood cultures x 2
2. CBC,
3. BMP,
4. glucose
5. CXR other lab studies dependant on differential diagnosis
6. LP
7. Consider assays for S.pneumonia, N.meningitidis, H.influenzae
71
Describe the tx of Meningitis
1. ABC’s
2. Mask and isolation
3. Dexamethasone IV 10-15 min prior to Abx
4, Antibiotics given immediately (2 hour window to get LP)
5. Treat hypotension, seizures, hypoglycemia
6. Admission, possibly ICU
72
What Abx do you commonly use for meningitis in a:
1. Neonate -1month:
2. 1month-adult:
3. 60+/immunocompromised:
1. Neonate -1month: ampicillin + cefotaxime or gentamycin
(GBS)
2. 1month-adult: Ceftriaxone 2gm IV (+ Vancomycin for MRSA)
(S. pneumo, N. meningitis)
3.60+ /immunocompromised:add Ampicillin
(Listeria)
73
When is chemoprohylaxis indicated for menigitis
Indicated for contacts of patients with N.meningitidis
1. Household contacts
2. Daycare in previous 7 days
3. Direct exposure to secretions
Treatment
Ciprofloxacin 500 mg po one time
74
When is viral meningitis most commonly occur
fall and spring
75
MC viruses that cause viral meningitis
1. HSV,
2. VZV,
3. EBV
4. CMV,
5. adenovirus,
6. West Nile
* Specific diagnosis based on immunoassay of CSF
76
Describe the tx of viral meningitis
1. After bacterial cause is ruled out, most patients can be discharged home with
2. pain medication,
3. anti-emetics,
4. return precautions
77
Describe the LP of viral meningitis
1. slightly increased opening pressure,
2. normal to low glucose,
3. slightly increased protein
78
Describe bacterial vs viral LP results
Bacterial: LOTS OF WBCS, low glucose
Viral: less WBCS, normal glucose
79
If concerned for HSV meningitis (ie. there is a cold sore present) consider adding
acyclovir
80
Viral encephalitis is infection of the brain __ leads to an inflammatory response
parenchyma
81
Viral encephalitis often coexists w/ __ (same bugs)
viral meningitis
82
How do you dx viral encephalitis
1. made by neurologic abnormality
2. Cognitive deficits
3. Seizures
4. Movement disorders
5. CT/MRI will be part of your workup
83
How do you tx viral encephalitis
1. Acyclovir / gancyclovir IV to treat
| 2. Most patients require admission
84
DDX of viral encephalitis
1. brain abscess
2. SAH
3. toxic encephalopathies
4. metabolic encephalopathies
5. psych
85
PE of acute glaucoma
Fixed pupil, mid dilated, hazy cornea
86
Compare the position and quality of migraine, cluster and tension HA
Migraine: unilateral, throbbing, pulsating, pounding, moderate-severe
Cluster: unilateral, burning, piercing, sharp, severe
Tension: bilateral, tightness, aching or pressure, mild-moderate
87
Compare the radiation and duration of migraine, cluster and tension HA
**NONE RADIATE
Migraine: 4-72hrs
Cluster: 15min-2 hrs
Tension: 30 min - 7 days
88
Compare the triggers of migraine, cluster and tension HA
Migraines: Foods, oversleeping, stress, depression, decrease barometric pressure, hormonal variations, caffeine w/d
Clusters: alcohol, change in temp, breezes on face, change in mental physical or emotional activity
Tension: stress
89
Compare the associated sx of migraine, cluster and tension HA
Migraine: N/V, photophobia
Cluster: NO N/V or photophobia
Tension: No N/V, occasional photophobia
90
Compare the tx of Migraines, Cluster and Tension HA
Migraines: lifestyle modification, biofeedback, acupuncture, meds, exercise, consistent sleep schedule
Cluster: 100% O2, meds
Tension: hot/cold packs, US, exercise, consistent sleep schedule, meds
