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E-med exam 3 > Neuro emergencies > Flashcards

Neuro emergencies Flashcards

1
Q

Normal ICP in adult

A

<15 mmHg

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2
Q

Following increase in ICP, brain injury can result from:

A

-brainstem compression (herniation)
OR
-decreased cerebral perfusion pressure

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3
Q

Simple terms for how brain injury can occur d/t increased ICP

A

smash brainstem

decreased blood flow to brain

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4
Q

CPP (cerebral perfusion pressure) is important to

A

deliver oxygen and nutrients to the brain

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5
Q

Cushing’s triad

bad finding of increased ICP

A

Bradycardia
HTN
Respiratory depression

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6
Q

Other signs of increased ICP

A 
Fixed pupil
N/v
Papilledema
HA
Decorticate or Decerebrate posturing
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7
Q

Neuro exam components (review)

A 
Mental status- GCS
CN
Sensory exam
Motor exam
Reflexes
Cerebellar testing
Gait
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8
Q

GCS

15 points max

A

Eye: 4
Verbal: 5
Motor: 6

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9
Q

Decorticate posture

A

Flexion and adduction of arms

Damage to: Cortex, Upper midbrain

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10
Q

Decerebrate posture (WORSE)

A

Extensor posturing, internal rotation of arms, extension of legs

Damage to: Brainstem (Pons or Medulla)

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11
Q

Increased ICP tx

A

Resuscitation
-oxygenation
O2 sat: >90%
CO2: 26-30

Mannitol 1-1.5 mg/kg

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12
Q

ICP tx continued

A 
Elevate head of bed
Pain med/ sedation (decrease metabolic demands of brain)
Treat fever aggressively
ICP monitor
IVF
Anti-seizure
STAT Neuro Consul
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13
Q

What will Neuro do once they get to increased ICP pt?

A

Decompressive craniectomy
Ventriculostomy
ICP monitor
(keep <20)

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14
Q

Gold standard of ICP monitoring

A

Intraventricular monitor

surgically placed into ventricular system, fixed to drainage bag and pressure tracker

allow for drainage of CSF

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15
Q

Types of skull fracture

A

Linear
Depressed
Basilar

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16
Q

Linear skull fracture

A

Most have no neuro sx

Usually: temporoparietal, frontal, or occipital

if temporal: caution vascular structures

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17
Q

If linear fracture and CT is clear and pt has no neuro deficits,

A

Observe in ED 4-6 hours and d/c home with supervision

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18
Q

Depressed skull fracture

A

Req significant force/ direct blow

Often involves injury to brain parenchyma

HIGH RISK of Cns infection, seizure, death if not early managed

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19
Q

Depressed skull fracture tx

A

CT, admit to Neurosurgery

Tetanus
Proph Abx
Anticonvulsant

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20
Q

3 things to consider with Depressed skull fracture

A

Tetanus
Abx
Seizure meds

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21
Q

Basilar skull fracture

A

“ticking time bomb for infection” if there is DURAL TEAR which results in comm b/w Subarachnoid space, Paranasal sinus, and Middle ear

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22
Q

Clear/blood tinged rhinorrhea/otorrhea

liquid from NOSE or EARS

A

may indicate leakage of CSF

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23
Q

Other sx of Basilar skull fracture

A

Battle sign (1-3 d later)
Raccoon eyes
Hemotympanum

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24
Q

Basilar skull fracture tx

A

ADMIT NO MATTER WHAT, v risky

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25
Q

Risks assoc w/ Basilar Skull fracture

A

infection
Intracranial hemorrhage
CN injury
Epidural hematoma

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26
Q

Penetrating skull injury

A

Usually involve sig brain injury and Intracranial hemorrhage

Consult Neurosurg immediately

IV abx

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27
Q

Tangential skull fracture

A

usually assoc w/ GSW (gunshot wound)

Risk for Intracranial Hemorrhage

EMERGENT CT SCAN

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28
Q

Skull fracture imaging

A

CT without contrast (we want to see blood)

MRI secondary for suspected vascular injury

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29
Q

If Skull fracture has AMS as well, what to order

A

CT of cervical spine

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30
Q

Coup mechanism of closed head injury

A

Coup: direct blow, primary impact

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31
Q

Contrecoup

A

Secondary impact

after brain accelerated backwards and hit back of skull

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32
Q

Instances in Closed Head Injury (concussion) that requires URGENT imaging and NEUROSURG CONSULT

A 
GCS <15
Suspected open or depressed skull fracture
2 or more vomiting
New neuro def
Bleeding abnormality
Anti-coag use
Seizures
Age >60 YO
Retrograde amnesia >30 min b4 trauma
High impact inj
Intoxicated, HA or abn behavior
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33
Q

Closed Head injury ED precautions- when to return back to ED

A 
Unable to awaken
Severe/worsening HA
Somnolence or confusion
Restless, unsteady, or seizures
Vision change
Vomit, fever, stiff neck
Urinary/bowel incontinence
Weakness/numb
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34
Q

Diffuse Axonal Injury- DAI

A

Shearing of white matter from traumatic sudden DECELERATION injury

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35
Q

Diffuse Axonal Injury- DAI

associated with

A

Post-trauma COMA

frequent cause of Persistent Vegetative State

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36
Q

Diffuse Axonal Injury- DAI

A

No surgical intervention

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37
Q

What will CT scan show with Diffuse Axonal Injury?

A

Blurring gray to white matter margin
Small lesion in white motor tract
Cerebral hemorrhage or edema

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38
Q

Cerebral hemorrhage (brain bleed) subtypes:

A

Epidural (lens)
Subdural (crescent)
SAH (“WHOL”
Intracranail

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39
Q

Epidural hematoma

LENS shaped

A

teens/young adults

skull fx/trauma

Middle meningeal artery

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40
Q

Epidural hematoma

A

Brief lucid interval –> rapid clinical deterioration

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41
Q

Epidural

A

Lens shaped
Trauma, MVC
Lucid period
Middle meningeal ARTERY

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42
Q

Subdural hematoma

A

Crescent
Elderly or alcoholic
Bridging VEINS
Falls

43
Q

Epidural hematoma

A

Arterial blood

Dura is peeled off the skull

44
Q

Subdural hematoma

A

Venous blood

Dura is STILL ATTACHED to skull

45
Q

Intracranial hematoma sx

A 
Momentary LOC to coma
HA, vomit, drowsy
Confusion
Aphasia
Seizure
Hemiparesis
46
Q

Intracranial hematoma tx

A

Emergent neurosurg consult
Stop anti-coag
Maybe surgery

47
Q

Interventions for Intracranial Hematoma

A

Open craniotomy

Burr hole evac (trephination) if surgery delayed

48
Q

SAH

“whol”

A

10% die prior to reaching hospital

overall mortality: 51%

49
Q

“WHOL”

“thunderclap” HA

A

Subarachnoid hemorrhage

Neck stiffness
N/v
Exertion or Vasalva immediately before onset
HTN

50
Q

Ottawa SAH rule

A 
Age >40 YO
Neck pain/stiff
Limited neck flexion
Witnessed LOC
Onset during exertion
Thunderclap HA (instantly peaking)
51
Q

SAH tx

A 
BP control
Stop Anticoags
DVT and Seizure prophylaxis
Pain meds
Maintain euvolemia- normal saline
52
Q

SAH diagnostic

A

CT first

if CT normal but SAH still suspected, MUST DO Lumbar Puncture

53
Q

Ultimate tx for SAH

A

Surgical CLIPPING

Endovascular COILING

54
Q

SAH complications

A 
*INCREASED ICP*
Vasospasm
Rebleed
Hydrocephalus
Seizure
Hyponatremia
55
Q

Intracranial HEMATOMA vs HEORRHAGE

A

Hematoma: OUTSIDE of the brain parenchyma

Hemorrhage: bleed IN the brain substance

56
Q

Intracranial HEMORRHAGE (within the brain substance)

A

2nd most common cause of stroke

57
Q

ICH (intracranial hemorrhage) presentation

A 
Acute onset focal neuro def
Increasing neuro sx over time
HA
Vomiting
Decreased LOC
Seizure
58
Q

Most common cause of Intracranial Hemorrhage

A

HTN

59
Q

Imaging choice for Intracranial HEMORRHAGE

A

Non contrast CT

60
Q

Tx for Intracranial HEMORRHAGE

A 
BP control
NPO
Manage elevated ICP
Avoid hyperglycemia
Seizure meds
Stop anticoag Emergent NEUROSURG consult: surgical decompression
Admit to ICU
61
Q

BP and Glucose goals for Intracranial Hemorrage

A

BP: 140-160/90

Glucose 140-180

62
Q

3 most predictive exam findings for dx of Stroke (CVA)

A

FACIAL weakness
ARM drift/weak, arm or leg paresis
Abn SPEECH

63
Q

Do not intervene in Blood Pressure for Ischemic stroke UNLESS

A

> 220/120

64
Q

If pt has extreme HTN, what is target

15% decrease

A

so get them to 185/110

65
Q

tPA administration

A

<4.5 hours onset of sx

CT or MRI within 20 min of arrival

Infusion <60 min after arrival

66
Q

Post traumatic seizure

A

may occur within 1st week after injury

67
Q

Status Epilepticus

A

Seizure >5 minutes OR

More than 2 discrete seizures in which there is no complete recovery of consciousness between

68
Q

After giving neuromuscular blocking agent used for intubation,

A

motor fx stops but SEIZURE ACTIVITY DOES NOT, must continue to monitor with EEG

69
Q

Monitoring for Seizures

A

Cardiac
Pulse ox
Two IVs
CBC, CMP, Tox screen, Glucose, Ca, Mg, Phosphorus, ABG

70
Q

If seizure pt is hypoglycemia, consider giving

A

IV thiamine and

Glucose

71
Q

It pt has known seizure disorder, check

A

Anticonvulsant levels

72
Q

Status Epilepticus tx

A

Benzo + Antiseizure med

Can repeat 1x

73
Q

Antiseizure med

A

Phosphenytoin
Levetiracetam
Valproate

74
Q

After 20 min if pt is still seizing,

A

Start IV of Midalozam OR
Propofol OR
Pentobarbital

75
Q

C-Spine Nexus Criteria

If all 5 criteria are met, this pt does NOT need imaging

A

Absence of:

Posterior midline tenderness
AMS
Intoxication
Abnormal neuro
Painful, distracting injury
76
Q

Jefferson, “burst” fracture

A

C1, Atlas

77
Q

Jefferson “burst” fracture of C1

A

Vertical compression or
Forced neck extension

HIGHLY UNSTABLE

X ray, then CT

78
Q

C2 Pedicle fracture

“Hangmans”

A

Extreme hyperextension
Abrupt deceleration
HIGHLY UNSTABLE

often little spinal cord damage since AP diameter of C2 is greatest

79
Q

C2 Odontoid (dens) fracture 3 types

A

1: stable
2: unstable
3: unstable

80
Q

Cervical burst fracture

A

Lower cervical vertebrae

Direct axial load
Fragments displaced in all directions, can enter spinal cord

81
Q

COMPLETE Spinal Cord Injury- Acute sx <1 day

A 
Absent reflex
Flaccid musc
Loss of sensation
Priapism in men
Urinary retention
82
Q

COMPLETE Spinal Cord Injury- sx 1-3 days later

A

Hyperreflexia
+Babinski
Spasticity

83
Q

INCOMPLETE Spinal Cord Injury

presentation dependent on location

A

Anterior cord synd
Central cord synd
Posterior cord synd
Brown Sequard

84
Q

Anterior cord syndrome

A

Motor imp
Reflex change
BILATERAL loss of pain and temp
Bladder dysfx

85
Q

Central cord syndrome

A

Motor impairment in UPPER EXTREMETIES

86
Q

Posterior cord syndrome

A

Motor weakness
Hyperreflexia
Gait ataxia
Paresthesia

87
Q

Brown Sequard

A

Lateral hemi section

Dorsal unilateral- often PENETRATING injury- knife/bullet

88
Q

Brown Sequard Sx

A

SAME SIDE loss of motor paralysis and loss of Proprio/vibration

CONTRA loss of pain and temp

89
Q

Prognosis of Brown Sequard

A

Excellent- 90% regain ambulation

90
Q

Neurogenic shock can occur d/t Spinal Cord Injury

A

Systolic hypo
Bradycardia

most often d/t Cervical spine injury

91
Q

Cauda Equina syndrome

A 
Lower back pain w radiation
Leg weakness
Weak plantar flexion
"Saddle anesthesia"
Urinary retention
Decreased sphincter tone
Sexual dysfx
92
Q

Tx of Cauda Equina synd

A

Dexamethasone ASAP

93
Q

Imaging for Cauda Equina synd

A

EMERGENT MRI with and without contrast

scan entire spine

94
Q

Tx for Cauda Equina

A

Urgent Ortho surgical consult- decompression and/or radiation if METs tumor

95
Q

Guillen Barre

A

Acute peripheral neuropathy

immune mediated

96
Q

Most common demyelination neuropathy

A

Guillen Barre

97
Q

Starts distally, ascending, symmetric muscle weakness

A

Guillan Barre

98
Q

Mild URI, gastroenteriits precedes Neuro dz by 1-3 weeks

A

C. Jejuni most common

99
Q

Guillen Barre presentation

A 
Absent/depressed DTR
CN involvement
Mild diff walking --> Nearly complete paralysis
Severe respiratory weakness
Dysautonomia
100
Q

Dysautonomia

common in Guillan Barre

A 
Tachy/brady
Urinary retention
Alternating hyper/hypo tension
Loss of sweating
Arrhythmia
101
Q

CSF will show what with Guillan Barre

A

Elevated protein

normal wbc

102
Q

What to order with Guillan Barre

A

EMG-NCS

103
Q

Tx of Guillan Barre

A 
Consult neuro
Admit to ICU
Ventilate if needed
DVT proph
Urinary cath

After admitted:
IVIG OR PLASMAPHARESIS

E-med exam 3 (5 decks)

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