Stroke, Headache, and HTN Flashcards

Question

Red flags: hx in headache

Answer 1

- “worst”, “different” - Sudden onset - New - Exertional - Fever - Stiff neck - Vision loss/eye sx’s - ALOC - Focal deficit on exam - Trauma/fall - Coumadin - Etoh - Syncope - HIV, cancer - Sickle cell disease - Multiple patients from same location

Answer 2

-Subarachnoid Hemorrhage -Hemorrhagic CVA -Subdural/Epidural Hematoma -Meningitis -Idiopathic (Benign) Intracranial Hypertension -Hydrocephalus -Glaucoma -Giant Cell (Temporal) Arteritis – older people – have temporal pain and often also have lymphoma -Cavernous Sinus Thrombosis – usually follows a dental infection -Carbon Monoxide -Tumor, mets -Abscess, encephalitis Etc… -Migraine, tension, cluster, others after the above -Cavernous Sinus Thrombosis: septic thrombosis, usually a complication of face/periorbital/sinus/dental infection. HA, CN abnormalities, fever, unilateral eye sx’s that progress bilaterally are hallmarks. Fulminant process, very sick pt. CT with contrast followed by MRI with contrast. ICU admit, big antibiotics, ophthalmology and general and/or neurosurgery consults.

Answer 3

-Mental status, temperature and blood pressure Eye exam, including fundoscopy -Neuro exam: CN, strength, sensory, gait, cerebellar -Neck: Meningeal Signs -HEENT: periorbital/dental/facial infection? Older pt’s palpate the temporal artery! -Rash -After the Hx and PE cross the unlikely Dx’s off the list. Tx/test for most likely – be able to “tell the story” of each and why it is off or on your list

Answer 4

-Sudden, “worst HA”, especially if onset during exertion -HA plus fever, stiff neck -HA plus vomiting and no hx same sx’s in past -HA plus neuro findings (CN, focal findings) New HA after/with facial, sinus, dental infection -HA in young, obese female, +/-papilledema -HA plus seizure or syncope -HA plus trauma, fall or EtOH >50, new HA (likely not new migraine Dx after age 50) -New HA plus cancer, HIV, pregnancy, coumadin

Answer 5

- Sudden, worst HA - HA plus fever, stiff neck - ALOC plus HA - HA in young, obese female - New HA in HIV pt - Looking for infection, blood, increased intracranial pressure - CT generally precedes lumbar puncture - No LP if midline shift, blood or mass on CT (herniation...) -You are immunocompetent if CD4 > 200

Answer 6

- If no Red Flags on Hx/PE: - Labs: D-stick, Upreg. Special: ESR*, PT/INR* - Treatment – migraine or non-specific HA - IV hydration – esp w/ vomiting - NSAID, anti-emetic, antihistamine IM/IV (NSAIDS: oral; IM/IV Ketorolac, Anti-emetics – Metoclopramide, Compazine or Phenergan IM/IV, Antihistamines – Benadryl IM/IV) - Steroids – Dexamethasone 8-10mg IM/IV - Serotonin blockers: DHE, triptans – migraine specific - Avoid narcotics! - Home if: - Pain less/gone - Can take po’s/walk - No new neuro deficit or change in VS - Give return precautions, should not drive self home - Rx oral NSAID, anti-emetic and/or triptan: Dx specific

Answer 7

- Really, really common - High? Check it yourself, both arms, correct sized cuff - BP readings change during an ED visit! - Most important questions: - Is this an accurate reading? - How rapidly did it get this high? - Does the patient have symptoms? - Is there evidence of end-organ damage? - Most important concept: - Autoregulation in HTN sets perfusion pressures high - chronically - Precipitous drop in BP = less perfusion - If slow onset, pt stable – treat slowly

Answer 8

-is HTN causing the red flag or is the red flag causing the HTN - Headache: sudden or severe or new HA w/ HTN - Neuro complaints: weakness, confusion, ataxia: CVA, encephalopathy - Visual changes: CVA, optic ischemia, papilledema - Chest pain: ACS; TAD (pulses equal?) - SOB, DOE, edema: L/R pump failure: new CHF? - Abdominal/Back pain: AAA - Urine changes – foamy, blood? Think new renal failure - Syncope: CVA, SAH - Seizure: CVA, hemorrhage, Tox - On meds – still HTN – consider secondary causes or under-tx - Pregnancy – preeclampsia, eclampsia - Hyperthyroid, Tox - End-organ damage usually involves kidney, heart, brain Secondary causes of HTN: CPR squared: 2 C’s, 2 P’s, 2 R’s - C’s: Cushing’s, Coarctation of the aorta - P’s: Hyperparathyroidism, pheochromocytoma - R’s: Renal parynchemal dz (glomerular, polycystic), renal vascular dz - Others: Diabetic nephropathy, sleep apnea, obesity, thyroid, stimulants

Answer 9

New Dx of HTN – persistent readings >160/100 - No prior dx/tx but no sx’s, appears well - Repeat BP after pain control - Initiate work up, secure f/u - Begin meds: if SBP >180, high risk for cardiac event w/in 1yr - Discharge home, educate Hypertension – poorly controlled - Long-standing dx, no sx’s, appears well - Out of meds common, no secure follow-up - Testing as outpt if secure f/u - Give meds in ED, refill meds - BP must respond to tx - Discharge home, educate - New HTN Testing: CBC, CMP, UA, Upreg, Tox screen, EKG, CXR; Urine microalbumin, TSH, Lipids (as outpt?) - New HTN tx: Amlodipine, HCTZ, ACEI, etc...start with one w/ close f/u** - Recheck BP while labs are cooking after tx in ED

Answer 10

Hypertensive Urgency - DPB 120-140mmHg or persistent systolic BP >180 - Usually “poorly controlled” HTN – not sudden - In HTN urgency, NO signs/sx’s of end-organ damage - They are at imminent risk - Order labs, UA, EKG, CXR - Oral tx in ED while waiting for labs/diagnostics - Home with Rx if BP responds and still NO signs/sx’s - Secure f/u - Educate - Their numbers are very high but they have NO signs of end organ damage

Answer 11

Hypertensive Emergency (Malignant HTN) - DBP >130 or persistent sys BP >180 w/ signs/sx’s - Hx HTN; rapid, acute elevation - End-organ dysfunction is evident – flash pulmonary edema is common - Symptoms: chest pain, SOB, ALOC, etc - Lab/Diagnostics - Reduce BP in the ED – goal is 25% reduction of MAP over 30-60min. (IV: Labetolol, Nicardipine, Nitrates) - Tx end-organ damage - Admit all - MAP = [(2 x diastolic)+systolic] / 3 - Normal range = 70-110 - MAP <60 risks underperfusion of organs

Stroke, Headache, and HTN Flashcards

(35 cards)