non-traumatic neurological complaints in the ED Flashcards
1
Q
big question if you suspect a seizure
A
primary: without provocation-epliepsy
secondary: response to something
2
Q
what does a post ictal state look like both in presentation and specifically with regards to chemistry panel
A
Disorientation, sleepy, amnesia, HA,
lactic acidosis (from the clonic muscle movements)
high PC02 metabolic acidosis
3
Q
how long does a post ictal state last
A
Commonly lasts 30min-1hr – LOC gradually improves
4
Q
grand mal seizures have been replaced by
A
generalized seizures
5
Q
tell the store of a generalized convulsive seizure
A
the person experiences LOC
tonic movement followed by clonic
resolves spontaneously with post ictal state
6
Q
rhythmic jerking of seizure pt
A
clonic phase
if they bit down they can
swallow it and swallow
7
Q
what can you see that would point to a generalized seizure in a pt that has loc
A
stigmata of a seizure
urinary incontinence and tongue biting
8
Q
generalized non-convulsant seizures
A
aka absense
like daydreaming
lasts seconds
formerly petit mal
9
Q
simple partial seizure is now known as
A
focal aware seizure
10
Q
three things key in focal aware seizure
A
awareness consciouness and memory preserved
11
Q
sxs of focal aware seizures
A
Awareness, memory, consciousness is preserved
Uncontrolled movement, visual, auditory sx, autonomic sx’s
12
Q
focal impaired awareness seizures aka
A
used to be a complex partial
13
Q
focal impaired awareness
A
déjà vu,
jamais vu (You are in your house but you don’t know where you are; the familiar becomes the unfamiliar), sounds,
smell (“who is smoking a cigar right now? Nobody, we are in church”),
taste,
numbness,
automatisms,
fear/panic
14
Q
Partial what is this and what are the 2 types
A
Limited area of brain
Sx’s match area affected
simple and complex or focal imparied and focal aware
15
Q
Status Epilepticus
A
Seizure activity lasting > 5min
or repetitive seizures without CLEARING of mental state in between
16
Q
what is the probelm with seizing for more than 5 minutes
A
Seizures >5min are unlikely to spontaneously resolve
17
Q
Often result of secondary cause, so start looking… with status epilepticus
A
Electrolytes (especially: glucose (hypoglycemic), sodium, magnesium (hypomagnesemic))
Intracranial bleed, trauma
Tox, OD-until it is eliminated will not stop
18
Q
status epilepticus tx
A
ABORT seizure before neuronal injury occurs
Benzodiazepines FIRST
THEN 2nd or 3rd line drugs (Dilantin, Phenobarb, etc)
these people are often intubated because they are not breathing
19
Q
concerns with paralyzing someone
A
need to for intubation but can’t tell if your pt is still seizing
20
Q
Most common cause of seizures in EDMost common cause of seizures in ED
A
Out of meds? Most common cause of seizures in ED
21
Q
Hx of a seizure
A
have you ever had this before
if you have epilepsy is the pattern changing?
Trauma Hx?
people that see fall with abandon
Substances used?
recent illness?
LMP?
Country of origin
22
Q
seizure after trauma
A
concern for internal bleeding in the brian
23
Q
why are we worried about substance abuse with seizing
A
lack of alcohol can cause seizing
if you are too sick to get alcohol you need to know
24
Q
why are we asking lmp in a female pt
A
do not want to miss pre eclampsia
25
PE with seizure
Post-ictal or still seizing?
ABCDE’s first
VS should improve with recovery
Tongue trauma, urinary incontinence
AND head to toe exam
26
what is the head to toe exam in a pt with a seizure
* Trauma
* Neuro deficit
* Infection
* Evidence other Dz
* Stigmata of EtOH
* Toxidrome
27
Red flags in a seizure
First seizure: Why??
Head trauma: Bleed, ICP
VS not resolving: Why??
Alcohol withdrawal (these folks are SICK – ICU admit)
Fever, infection: Need LP? Shock?
Rash: Meningitis?
Vomiting: Airway disaster, aspiration risk
Electrolytes: Which ones? Mg,
Stimulants: Bleed? CVA?
Prolonged post-ictal state: Why?
Focal neuro deficit: CVA, bleed?
Travel/Endemic area?
Neurocystercercosis
Malignancy: Mets to brain? – Often present with a first time seizure
Renal/liver Dz: Uremic or encephalopathic??
HIV: Toxo-, histo-, infection
Coumadin/Plavix: Bleed?
Pregnancy: Eclampsia
28
Head trauma with seizure concerns
: Bleed, ICP
29
Fever, infection:
LP
| meningitis
30
if vomiting we are worried about
airway
31
Travel/Endemic area couplex with first seizure worry about
• Neurocystercercosis
32
1. If history of seizures workup labs
a. D-stick on all, upreg
b. Observe, reassess
c. Safety: bedrails, etc
d. Measure drug levels
e. Alcohol, tox screen
f. Chem for electrolytes
ii. Sz causes lactic acidosis
Creatinine Kinase (CK) if prolonged down-time --> looking for rhabdomyolysis
33
Chem for electrolytes in a seizure where the pt has a history of seizure
If cause not obvious
34
2. If first seizure
D-stick on all, upreg
If sz stops, pt now normal, and there is no obvious cause:
Chem panel
Magnesium, phosphorus if EtOH
EtOH, U tox
Coumadin? PT/INR
HIV test
Consider Head CT non-con
Add lumbar puncture only if fever, suspect SAH, encephalitis, etc
EEG: on admission or as outpt
35
what drug levels would we measure in a pt with a hx of a seizures
Dilantin, Carbamazepine, Valproic acid, Phenobarb
| ii. Not: Keppra, Lamictal, etc
36
when would you be worried about rhabdomyolosis
why?
what would you order?
Creatinine Kinase (CK) if prolonged down-time
37
what would you do for a actively seizing pt
Protect pt, abort the seizure with meds
order lorazepam diazepam
When stop: suction oral blood/secretions, O2, time the event
Recheck d-stick, re-examine, cardiac monitor
38
what is the abortive treatment
Abortive Tx 1st line: Benzodiazepines – know 3
Lorazepam (2mg IM/IV)
Midazolam (2-5mg IM/IV),
Diazepam (5mg IV)
39
New Sz, now well and no Red Flags?
New Sz, now well and no Red Flags? Neurology consult to initiate EEG, tx and follow up.
40
etiology of febrile seizures
Rapid rise in temperature, not the number itself
Risks: hx same, family hx
41
want this on all children with a febrile seizure
D stick
42
• Search for source of fever or occult infection in children would involve getting a
CBC, Chem, UA, CXR
Blood and +/- stool culture
43
when would you get a CT or a LP in a kid with a seizure
No CT.
| No LP if dx clear and kid looks great
44
When would you get a LP on a kid with seizures
when would you get a LP on a adult with seizures
recent anbx use -->LP
you're missing whatever bug it is
kid look sick
Add lumbar puncture only if fever, suspect SAH, encephalitis, etc
if RBC are in CSF--> SAH
45
febrile seizure tx
for the most part febrile seizure are partial or generalized?
NOT MEDS
**
they are generalized
46
5 essential questions for syncope
1. Ever had this before? What was the Dx?
2. Really lose consciousness? Fall? Hurt yourself?
3. What were you doing? Last thing you remember?
4. Sick lately? Upset? EtOH, drugs?
5. PMHx, Meds, Fam Hx, Soc Hx
47
Pseudoseizure
```
Psych, emotional distress
• Atypical movements
• Brief post-ictal period
this is where you can tell
• Good Soc Hx
• Refer to psych, EEG outpt
```
say "it's a little inconsistent with a generalized seizure post ictal"
48
over the age of __ we are worried about syncope
>50yrs
49
how does syncope look like seizure
brief clonic activity is a thing
50
syncope and cardiac issues might be suspected if
Syncope w/ exertion (critical aortic stenosis) or when supine – think cardiac
51
Red flag hx with syncope (7)
before/after event
a. Chest pain
b. Palpitations
c. Headache
d. SOB
e. Abd pain
f. Back pain (aortic dissection)
g. Bleeding (coumadin)
have you been recently hospitalized
melena
pace maker?
52
important recent social/family hx as it pertains to syncope
Recent hospitalization, surgery, procedure
Fam Hx of sudden death (Thoracic aortic Dissection, PE, cardiac arrhythmias)
53
abnormal sxs after syncope that are of concern
Abnormal VS
• Hypotension
• Tachy-, bradycardia
• Fever
```
Diaphoresis
• Confusion, focal deficit
• Cardiac murmur
• Rales, wheeze, edema
• Melena (GI bleed)
• Head trauma
• Pregnancy
• Pacemaker (issue with it itself)
```
54
main categories for the syncope ddx
```
cardiac
intracerberal
aorta
GIB/anemia
ectopic pregnancy
pulm embolism
```
55
cardiac -three big causes of syncope
i. Arrhythmia
ii. Aortic stenosis
iii. Hypertrophic, other cardiomyopathies
56
intracerberal
i. Hemorrhage, SAH
| ii. Ischemic stroke: rarely
57
common reasons people faint
a. Volume depletion – dehydration or are you bleeding from somewhere?
i. Dehydration, n/v/d
b. Medication effect
c. Drug/EtOH effect
d. Vasomotor (vasovagal)
e. Emotional event/reaction
f. Mimic – unwitnessed seizure
g. Hypoglycemia**
58
what are you worried about with the aorta that can cause syncope
Dissection, aneurysm, aortic stenosis
59
Syncope in young, healthy, completely recovered person
All get:
EKG
consider D-stick (although you really wouldn't come back if you were hypoglycemic)
Hct +/- depending on history
60
Syncope in young, healthy, completely recovered person- female
All females (12-55yrs) get Upreg
61
what is not routine for syncope in young healthy person
CT, CBC, Chem, troponin, etc; not routine part of w/u
unless you have red flags
62
Other diagnostics driven by age, Hx, PE
IV hydration, O2, monitor, labs, troponin
CXR, +/-CT. Echocardiogram, Holter Monitor
c. >50yo – higher risk, more extensive work up
63
Young, healthy, completely recovered, stable?-syncope
Young, healthy, completely recovered, stable?
Likely benign cause. Home if stable w/ return precautions
EKG and UPT
Close follow-up, PO hydration, avoid risks
>50yo – bigger work up, home if w/u all neg, no risks
64
Vertigo
Sensation of motion, room spinning
is the room spinning or are you spinning inside the room
65
what are the two types of vertigo
Major question for us = Central or Peripheral?
3. Peripheral is usually benign
4. Central causes usually serious – red flag!
66
Hx of vertigo
1. Describe what you feel
2. OPQRST the sx to death
3. Trauma, recent illness?
4. Hearing changes, tinnitus?
5. Headache, weakness?
6. Associated sx’s – fever, bleeding, etc…
67
can you describe peripheral vertigo
onset
nystagmus is
worse with
associated sxs?
neuro deficits ?
sudden onset, intense, paroxysmal, w/ movement;
nystagmus is horizontal/torsional, fatigable; tinnitus, n/v,
+/- normal TM,
NO FOCAL NEURO deficit
68
BPPV -what is the cause
MOST common cause
Otolyth in the semicircular canal
Vertigo lasts seconds, positional
69
inflammation, after viral infection can cause this type of vertgio-ear sxs
labrynthitis
70
labrynthitis story
• Vertigo for days, ear/hearing sx’s
Movement exacerbates, post viral
71
Vestibular Neuritis:
inflammation
• Vertigo for days, no ear sx’s
• Movement worse, post viral
72
Story behind Meniere’s, what does it look like and what age do we see it most commonly present
40-70s
Episodic, chronic, incurable
SN hearing loss, tinnitus
73
central causes of vertigo
Cerebellar CVA, hemorrhage
Vertebrobasilar vascular insufficiency/CVA
Basilar artery migraine
Multiple sclerosis
Temporal lobe seizure
74
vertigo caused by drugs will be seen with
Drugs cause peripheral sx’s – ear sx’s predominate
75
nystagmus in central vertigo
Nystagmus present in all: type, direction, duration matter
76
peripheral vertigo presents with this type of nystagmus
horizontal and fatiguable
(bppv can be nonfatiguable_
77
Ptosis? w/ vertigo what are you worried about (4)
Botulism, MG, CVA, CN
78
what are you looking for in the ears with vertigo
Vesicles, cholesteatoma -tumor behind the eardrum, perforated TM?
79
Head impulse with peripheral vertigo
Abnormal (saccade) suggests peripheral
80
Head impulse w/ central vertigo
Normal in central causes
81
peripheral vertigo nystagmus
one direction: horizontal/torsional – never vertical, fast phase away from affected ear, intensity decreases w/ fixation, fatigues on repeat
82
what type of peripheral vertigo would NOT fatigue
BPPV may not fatigue
83
nystagmus beats towards or away from affected ear with peripheral vertigo
away
| beats towards opposite eye
84
nystagmus with central vertigo
any direction (vertical, rotary), fast toward lesion, little effect with fixation/gaze direction change, does not fatigue
85
Test of Skew
Cover one eye, uncover, repeat. Eye position deviation when uncover, corrects.
86
positive test of skew indicated
b. Positive suggests central cause
87
Peripheral Motor Weakness differs from central how?
i. Not central nervous system
1. CVA/TIA is sudden onset, unilateral
1. Slower onset, progressive, bilateral
2. Neuromuscular junction vs. muscles
3. Respiratory compromise concerns
88
PE of peripheral motor weakness
1. Strength testing
2. DTR’s: +2 is normal
3. Cranial nerves
4. Sensation testing
5. Cerebellar testing
89
Most common cause of
acute
bilateral
flaccid paralysis
v. Guillain-Barre
90
story of Guillain-Barre
Autoimmune, demyelinating, progressive, symmetrical
91
paralysis with guillain barre starts with
Ascending pattern – legs first
loss of DTR
92
grade 1 strength
a trace of contraction is noted in the muscle by palpating the muscle while attempting to contract
93
the pt may move muscles against gravity but not resistance form the examinar with the grade of strength
grade 3
94
the patient is able to actively move the muscle when gravity is eliminated
grade 2
95
the patient may move the muscle agains some resistance
grade 4
96
tx of guillaine barre
immunoglobulins, plasmapheresis
97
who gets guillane barre
5. 2/3 have preceding viral illness (also Zika, etc)
| a. 1/6 GB cases after Flu shot
98
what sxs do you see with GB
Hand paresthesia, muscle pain, may involve CN’s
99
what are we concerned about with GB
Dx is clinical; worry about respiratory issues, dysautonomia
Neurology consult. Admit.
100
Most common disorder of neuromuscular transmission
MG
101
MG is seen most commonly in the population
Bimodal peak: 30’s (female predominant), 80’s (male)
102
SXS of MG
Eye, facial, swallowing, speech muscle sx’s predominate
Bilateral or unilateral ptosis, diplopia, vision changes
Peek sign: close eyes --> can’t maintain, can see sclera
Flat expression, “lost their smile”
Gets “tired” talking, chewing fatigue, difficulty swallowing
Generalized weakness, fatigue, can’t climb stairs
103
DTR w/ MG
intact
104
botulism pt looks like
IVDU with eye sxs, facial sxs, weakness
105
what is the key to MG
Key: sx’s get worse with use, better with rest
Descending, DTR’s intact
ED Dx:
Tensilon (Enlon)/ edrophonium test, ice pack test (their strength comes back but when their eyes warm up their deficit comes back).
Neuro consult, Admit.
106
sx of botulism
Sudden, severe, symmetric, bilateral weakness – eyes, face, neck first; extremities last
Mental status, sensory intact
Infants: floppy, lethargic
107
tx of botulism
These pt’s are sick: recognition is key, respiratory concerns
Tx: Antitoxin, supportive care. Neuro consult. Admit
108
Young, female > male, autoimmune?
MS
look for monocular vision changes
need labs LP and mRI
Episodic weakness, paresthesias, disequilibrium – atypical pattern
109
Abrupt, progressive, bilat, proximal muscle weakness – legs usually before arms
2. Can’t rise from chair, brush hair, lift, etc
May have dysphagia
Polymyositis
110
Must consider this Dx in anyone w/ low back pain!
Cauda Equina Syndrome
Transverse Myelitis
Spinal epidural abscess
111
Cauda Equina Syndrome sxs
Symptoms: Unilateral or bilateral radicular back pain with:
True leg weakness, bilat or unilateral
Bladder incontinence or retention, hesitancy
Stool incontinence, loss of anal tone
Numbness in the “saddle” and perineal distribution; genitals
Loss of or reduced lower extremity DTR’s
. Charting should reflect all of above in low back pain pt’s
"SENSORY IS INTACT in the b/l lower extremities INCLUDING the saddle region"
112
cause of Cauda Equina Syndrome
2. Cause: mechanical compression on “horse’s tail”
| a. Disc, fracture, infection, tumor
113
IVDU with fever + back pain, radicular sx’s
need to think about
Spinal epidural abscess
114
picture of transverse myelitis
Bilateral motor and sensory loss w/ radicular back pain, B/B dysfunction/incontinence, sensory changes
rapidly progressively
115
Low K+, Fam Hx, meds (diuretics)
Weakness local or generalized
Descending, DTR’s diminished
Hypokalemic Periodic Paralysis
116
Hypokalemic Periodic Paralysis triggers
Triggers: carbs, cold, exercise
117
Tick Paralysis looks like
1. Suggestive Hx
2. Ascending, DTR’s diminished
3. Remove tick – resolves 24-48hrs
118
“Saturday Night Palsy” can't do what
stop in the name of love
119
tx of “Saturday Night Palsy”
vi. Splint with wrist in extension
1. Resolves weeks to months
vii. Consider occult Fx
viii. Referral to PMD, neurologist
120
CN VII mononeuropathy
b. Bell’s Palsy
121
how do you know bells from stokre
persons forehead is involved in bells
in CVA the forehead is spared
122
Bell’s Palsy need a
ear exam
123
Diplopia can be caused by
cranial nerve palsy III, IV, VI
124
who gets diplopia
Idiopathic, traumatic; central: tumor, etc vs. peripheral: vascular (DM, vascullitis), cavernous sinus thrombosis
125
what do you need to do with pt w suspected palsy
need to isolate what is wrong (look at the chart)
3 and 6 is the most common
1. Monocular or binocular? Evoke the diplopia
2. Do the eyes line up on EOM’s/cover test?
3. Ptosis? Pupils?
126
1. Ptosis, “down and out” gaze, non-reactive, dilated pupil
iv. CN III – occulomotor – DM, temporal arteritis
127
1. “head-tilt” to opposite shoulder to avoid diplopia, eye “down and away”
v. CN IV – trochlear – rare, idopathic, kids
128
1. Lose lateral gaze, horizontal diplopia, cover affected eye – diplopia resolves
vi. CN VI – abducens – DM, increased ICP
129
what should you consider with palsy
: Lupus, Lyme’s, Botulism, Wenicke’s, Syphilis, Thyroid, Vit B Deficiency too
ix. Labs, CT head/face
130
most common location of a focal impaired awareness seizure
temporal lobe
131
Drug induced causes of vertigo will most likely present with
ear sxs predominate
132
very rare tumor that can be the cause of vertigo
cerebellar pontine angle tumor
133
vertigo tx
labs no necessary for peripheral
antiemetics
antihistamines
benzodiazepine
safety return precautions
epley in ED
semont at home
ENT refereal if reoccurent or hearing loss findings
134
central vertigo tx
w/u is necessary
MRI
135
UMN findings
hyper-reflexia
muscle tone: increased spastic
no fasiculations
no atrophu
babinski present
136
LMN findings
hyporeflexive
decreased or flaccid muscle tone
fasiculations
severe atrophy
and absent babinski
137
RF for transverse myelitis
```
Risks:
Herpes
MS
vasculitis
Lyme dz
TB
IVDU
IMZ
```
138
polymyositis
abrupt
progressive
bilat
proximal muscle weakness
USUALLY legs before arms
139
polymyositis common lab finding
increase CK
increase aldalase
Anti-JO1 antibody
DYSPHAGIA
HYSPHONIA
Proximal abrupt and progressive b/l weakness
legs usually before arms
cna't prush hair
140
dermatomyositis sxs
similar to polymyositis but with race to face chest and upper back in a shawl pattern
141
Tx for guillane Barre
immunoglobulins and plasmapharesis
142
age of MG pts
bimoda;
| 30s and 80s
143
what motor weakness syndromes would lead to a loss of DTRs
guillan barre- ascending
tick paralysis ascending (diminished)
hypo kalmeic paralysis (diminished) -descending
cauda equina (diminished
144
what would be an essential hx question to ask in a pt suspected of hypokalemic periodic paralysis
usually on diuretics
triggered by cold or carbs or exercise
