Ross - common Neuro complaints Flashcards by Andrea Coder

What is a “FAST” exam?

FAST or Cincinnati scale is a prehospital stroke scale 
F - Facial droop
A - Arm Drift
S- Speech
T - Time of onset (must get exact time)

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If a patient has focal weakness what should be your first consideration

It is from a neurological origin

i.e. CVA, MS, CN palsy, Guillain Barre, ETC

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What is Guillain Barre…

A post-infectious polyneuritis causing autoimmune demyelination

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Condition that causes ascending Paralysis, loss of deep tendon reflexes but sensation is preserved

Guillain Barre syndrome
acute flaccid paralysis that ascends quickly
24hrs

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Condition that occurs 3-4 weeks after a viral infection. What is the most common cause of that infection?

Guillain Barre Syndrom

Camphylobacter jejuni
But can also occur after previous GI illness, mycoplasma infection, post vaccination

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Treatments for Guillain Barre syndrome?

Consider CT - rule out intracranial event (can be done with history)
Lumbar Puncture - elevated protein, no WBC in CSF
Admit - monitor respiratory status (NIP test)
Plasmapheresis - filters out antibodies
IVIg

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True or False: Bell’s palsy only causes weakness in the lower half of the face.

False: causes weakness of entire face (including forehead)

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True or False: Bell’s palsy never have taste difficulties or ear pain.

False: BP may have taste difficulties and/or ear pain

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What other neurological deficits will present in a patient with Bell’s palsy?

none. No other neurological deficits are present with isolated BP

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True or False: Bells palsy has an acute onset, usually develop over 24-48 hours.

True

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Name one way to differentiate Bell’s palsy from a CVA.

Forehead sparing. A CVA will spare the forehead because each 7th nerve nuclei innervate both sides of the forehead

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Should a 68 yo person with suspected Bell’s palsy get a CT scan?

Yes. People over the age of 50 should get a CT to assess for CVA. MRI is also an option

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Treatments for Bell’s palsy

Protect the eye (they are unable to close it)

Consider steroids and acyclovir if 1-4 days within start of symptoms

If persistent 6-8 weeks consider MRI

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Which organism produces Botulism Toxin?

C. botulinum

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What TOXIN inhibits acetylcholine release from pre-synapse at neuromuscular junction?

Botulism toxin

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What are the 4 D’s of botulism?

1) diplopia
2) dilated eyes
3) dysphagia
4) descending flaccid paralysis

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What are the 3 types of Botulism?

Food born - mainly from home canned goods
Wound form - IV drug users, incubation of 10 days
Infant form - constipation, feeding difficulties, weak cry

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Treatment for Botulism

Antitoxin - binds to neurotoxins and prevents binding to NMJ

Admit to hospital for monitoring - especially respiratory status

Peds may use Botulinum immune globulin BIG-IV

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Causes Descending paralysis

Botulism

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Bacteria that causes Tetanus

Clostridium tetani

Found in soil infected wounds

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This pathology starts by causing lockjaw and them moves down

Tetanus

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How does clostridium tetani cause lockjaw?

Bacteria produces toxin tetanospasm by inhibiting the inhibitory neurotransmitter Glycine at the motor nerve endings

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You have a person with a very dirty wound at high risk for tetanus. Within how many years should they have had a tetanus shot?

5 years

Immunization lasts 10 years but for high risk it is within 5.

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Farmer cuts his hand and then falls into the cow pile next to the fence. He has never been immunized for tetanus what should the treatment be?

Needs tetanus immunoglobulin AND tetanus immunization.

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True or False: Die Hard is a Christmas movie?

Yes no other answer is acceptable

Large Vessel CVA's have a mortality of...

40%

Ischemic stokes account for what % of CVA's

80%

Hemorrhagic strokes account for what % of CVA's

20%

CVA's are caused by

``` Atherosclerosis Either Thrombosis (plaques in the arteries) or emboli ```

The minimum cerebral blood flow the brain needs is ..

750ml/min

What cerebral blood flow amount indicates brain death?

Below 60 ml/min

These types of strokes usually present with pure motor or sensory deficits; usually associated with chronic HTN.

Lacunar strokes

What are the 4 large vessels of the brain?

Anterior cerebral artery Middle cerebral artery Basalar artery posterior cerebral artery

True or false: tPA is very helpful in treating lacunar strokes?

False. tPA not really helpful

Areas most commonly impacted by lacunar strokes.

small penetrating vessels of basal ganglia internal capsule upper brain stem (lenticulostriate arteries)

Examples of Stoke mimics

``` diabetic - low blood sugar seizure - postictal, Todds paralysis Complex Migraines Bell's palsy Brain tumor infection MS Conversion disorder ```

4 main risk factors for CVA

HTN Smoking DM known atherosclerosis

Exam used to assess CVA's (not the FAST)

NIHSS | National institutes of health stroke scale

True or false: tPA can be given up to 5 hours after onset of symptoms.

False. tPA can be given within 3 hours and 4 if at stroke center

What at the 6 must haves before admin of tPA?

``` non-contrast head CT - read by radiologist NIHSS score Make sure no stroke mimics Blood pressure under control Go though exclusion criteria Get consent from patient / family ```

What is the mechanism of action of tPA

Breaks up fibrin clots by plasmin activation

Controversy of tPA

2% mortality rates in those receiving the drug due to ICB

Which large vessel would you suspect if a patient could not move their leg?

Anterior cerebral

Which large vessel would you suspect if a patient presented with face / arm paralysis, gaze towards defect, and homonymous hemianopsia?

Middle cerebral

In CVA's localized to the areas of posterior circulation what signs / symptoms would you expect?

Impaired vision, visual agnosia and 3rd nerve palsy can have LOC impairment of thought process

Contralateral motor/sensory loss in limbs and facial sensory findings (pain/temp) are indicative of what area of infarct?

Cortical infarcts

In brain stem infarcts what location would you get deficits?

Crossed findings - Left limbs and Right arm (visa versa)

A lesion in this area would cause coma, miosis, and gaze paralysis

Pontine lesion

This type of brain lesion would result in dizziness, nausea, and difficulty standing.

Cerebellar lesion

While waiting to get your patient to CT for a suspected CVA what general treatments would you provide?

Oxygen / airwary management - prevent hypoxia address any hypoglycemia - give glucose if needed HTN management - Labetalol Head of bed - 30 degrees No PO fluids

Transient episodes of neurologic dysfunction caused by ischemia of spinal cord, retina or CNS with infarction are called.

Transient ischemic attacks

10% of TIA patients develop _____ _______ ______ within 3 months, half of them within the first 48 hours

Acute ischemic stroke

ABCD2 scale for hospitalization

``` Age > 60 Blood pressure >140/90 Clinical feature unilateral motor Duration: greater than 60 min Diabetic ```

Which medciation should a patient be on "for life" after suffering a TIA?

Asprin. Reduces mortality and morbidity

The #1 risk factor for hemorrhagic bleeds?

Anticoagulation (Warfarin)

Are from which more subarachnoid bleeds originate?

5 ARM STAR OF DEATH!!!! or circle of willis

What is the gold stardard diagnostic test for Subarachnoid hemorrhages?

Lumbar puncture

Pt reports sudden onset of "worst headache of my life" and possibly began during exertion or valsalva is experiencing what time of event?

Subarachnoid hemorrhage

Meningitis / brain abscess have which classic symptoms?

Photophobia, neck stiffness, fever

Limitation or pain with eye movments can be caused by?

Cavernous sinus thrombosis

Red flags of new onset HA after age 50 could indicate?

glaucoma temporal arteritis Intracranial lesion

Work up for first time headache or red flag headache?

Electrolytes, CBC CT head with and without contrast - masses or blood Subarachnoid bleeds need LP CT angiogram MRI - bad for acute blood but good for tumor, masses, small strokes

Pt with fever, HA, and RAPID DECLINE you should consider _______ _______

Herpes enchephalitis

Cluster Headaches

``` Age 2-50 M>F Periorbital pain and unilateral tearing, nasal discharge and conjunctival irritation can have ptosis Treatment is with 100% O2 ```

ICH pseudo tumor

``` Typically female Overweight HA for months Papilledema CT / MRI normal Need LP to measure opening pressure ```

A clear definition of migraine is..

3 attacks in 6 months

A sphenopalatine ganglion block is used to treat?

Migraines

Dopamine agonist treatments for migraine

Prochloperazine (Compazine) | Metoclopramide (Reglan)

5-HT agonist for migraine

Erogtamine, sumatrytphan DHE 45

Steroids for migraine

Dexamethasone (Decadron)

Anti-inflammatory for migraine

Ketoralac (Torodol)

Treatment for Temporal arteritis

biopsy and steroids immediately

Which type of seizure is the most concerning and causes changes in mental status?

Tonic-clonic

Which type of seizure is this: Brief eposodes of unresponsiveness usually no motor activity. Pt does not remember the event

Absence seizure

True or false: partial seizures have bilateral tremors and loss of consciousness.

False. Usually does not cross midline. There is no change in mental status

What is the most common mimic of a seizure?

Syncope

SICK DRIFTER for DDx of seizures

``` Substrate infection cation's (Na, Ca, mag) Kids (eclampsia) drugs rum (alcohol) Illness (chronic seizure disorder) Fever Trauma Extra toxins Rat poison ```

True or false: Todds paralysis causes bilateral deficits

false. Unilateral. Todds paralysis is a residual neuro deficit occurs after a seizure

True or false: First time seizures need an urgent full work up.

True

ED seizure workup for first time or atypical seizures

Head CT, CMP, LFT's Lactate, prolactin (both will be increased after a seizure) Consider tox screen, ETOH

Acute Seizure medications

Potentiate Gaba --Benzodiazapines - -Lorazapam 0.1 mg/kg - -diazepam 5-10mg q4min up to 30 Inhibition of Na dependent action potentials - -phenytoin: 20mg/kg - -phosphenytoin 20mg/kg Inhibition of Ca channels - -valproic acid - -gabapentin

When a patient does not return to baseline mental status before another seizure starts or if a seizure lasts more than 5 min

Status Epilepticcus

Treatment for status epilepticcus

Oxygen, ECG monitor, keep safe Glucose Lorezapam (ativan) 0.1mg/kg IVP

True or false: You should treat eclampsia seizures with Magnesium and Benzodiazapines

True. Eclampsia presents with seizures, proteinuria, and edema. May occur up to 8 weeks post partum

PRES syndrome

Posterior reversible encephalopathy syndrome - -seizures - -AMS

True or false: Simple febrile seizures longer than 15min

``` False. Simple febrile seizures <15min duration age 6months - 5 years Otherwise healthy Key - child had fever and the mental status is normal a few min after the seizure ```

Complex febrile seizures features

Duration >15 min Any focal neurological features after or during seizure outside age range (6month -5year)

Work up for peds 1st time seizure

Check glucose! | CBC, blood culture, metabolic panel, LP

Exam preformed to assess for CVA (not the FAST)

NIHSS | national institutes of health stroke scale

True or false: tPA can be given within 5 hours of symptom onset?

False. tPA must be given within 3 hours, 4hours at stoke centers

The 6 must haves before giving tPA?

``` Non-contrast head CT NIHSS score Make sure no stroke mimics Blood pressure under control Go though exclusion criteria get consent from patient / family ```

Ross - common Neuro complaints Flashcards

(91 cards)