WK 11- Neurological Emergencies Flashcards
(63 cards)
What are the differentials for headache- especially if febrile
- Malaria (people in Townsville travel a lot)
- Dengue, chikungunya, (Zika),
- Other arboviruses
- Meningitis, encephalitis
- Q fever
- Leptospirosis
- Rickettsial disease- scrub typhus
What history would be noted in someone with meningitis/encephalitis
FEVER (may not have fever now, could be hypothermic, but must have had fever)/neck stiffness/vomiting/photophobia, ALOC (altered LOC due to lack of perfusion/oxygen or due to the result of the infection of the brain tissue)
What history would be noted in someone with dengue
FEVER, Wet Season?, overseas travel (possible exposure), Retro-orbital headache, severe aches and pains,
What history would be noted in someone with a brain tumour
Do not hurt initially (cause pain when they grow and build up pressure), Persistent headache, worse in mornings, focal neurology, vomiting (CSF pressure increase) Past hx cancer (breast cancer)
What other non sinister causes of head ache are there
Alcohol, drugs
- Coffee use–> especially withdrawa
- Eye strain
- Viral symptoms
- Earache, tooth problems→ ie. temperoarteritis
- Stress
- Muscular aches in the neck/upper back
What important questions are required in regards to pain history of the headache
Important to note description and onset of paint→ was it sudden onset? (sudden onset often indicates acute bleed), what were they doing when the headache came on (does it happen when they sit up→ epidural leak of CSF), how do they describe it→ ‘thunderclap’ ‘like being hit with an axe/sledgehammer’
On examination, what are the key points that should be noted for headache
- Conscious state→ GCS
- Pupils→ dilated? Responsive?
- Focal neurology
- Fever→ infective, rheumatological disorders
- Neck pain→ is there stiffness or pain
- Photosensitivity
- Rash
- Posture of patient
What is coning
squeezing of the brain and brainstem through the foramen magnum as a result of swelling → may lea to loss of basic cardiorespiratory function
What is an altered level of consciousness
-is any state other than fully alert and aware
Two possible underlying pathophysiological mechanisms:
- Global impairment of cerebral cortices
-Impairment of reticular activating system
in brainstem
How can you assess altered level of consciousness
Glasgow Coma scale
-Eyes, Verbal, Motor
Gives score out of 15. Still get 3 if you’re dead!
What are the GCS scores for;
- Mild brain injury
- Moderate brain injury
- Severe brain injury
Mild= GCS of 14/15 Moderate= GCS 9-13 Severe= GCS below 9
What are the primary and secondary classifications of headache
- Primary = migraine/cluster/tension headaches
- Secondary = due to a specific pathology e.g. Meningitis, brain tumour
What are examples of neurological primary injuries
- Concussion→ technically not detectable on CT
- Contusion
- Laceration
- Diffuse axonal injury
What are examples of neurological secondary injuries
Cerebral ischeamia→ hypoxia, hypoventilation, decreasing ICP, decreasing BP, inadequate cerebral blood flow
-Hypoglycaemia→ DKA
-cerebral perfusion pressure= BP- ICP (intercranial pressure)
→ first 5 minutes are enough to reduce oxygenation to brain
How do you manage a neuro emergency (primary survey)
- Airway, Breathing→ maintain oxygenation
- Circulation→ maintain adequate BP to maintain cerebral perfusion pressure (as if you decrease BP you will decrease cerebral perfusion)→ aim for 100mmHg
- Disability= determine using glasgow coma scale
- Glucose→ hypo lead to DKA
How do you maintain ICP
- adequate fluid resuscitation→ you want it to be to a target to give the least possible amount to prevent potential harm
- Decreasing ICP→ drain IC haemorrhage, possibly hypertonic saline/mannitol (gradient drags fluid out of cranial vault)
What are the 4 examples of traumatic brain injury
- extradural haematoma (EDH)
- subdural haematoma (SDH)
- subarachnoid haemorrhage (SAH)
- intracranial haemorrhage (ICH)
What is meningism
Meningism involves the triad (3-symptom syndrome) of nuchal rigidity (neck stiffness), photophobia (intolerance of bright light), and headache.
What surface anatomy landmark(s) guide you to (L3/L4)?
-L4 is found at the top of the iliac crest–> draw a line straight across and feel for L3
Where do you want to put a LP and why
use lumbar as the spinal cord often terminated at L2→ means that by using a lower intervertebral space you will avoid hitting the spinal cord
Complications of LP
haemorrhage, infection, coning, headache, nerve damage
What structures must the needle traverse (from skin inwards) to reach the CSF?
1- Skin
2- Facia and SC fat
3- Surpaspinous ligament (outside of vertebrae)
4- Interspinous ligament
5- Ligamentum flavum (base of the vertebrae)→ creates pop-first main resistance
6- Epidural space and fat (epidural anesthesia needle stops here)
7- Dura
8- CSF space
How might coning manifest
→ Cushings triad– bradycardia and hypertension with altered respiration
Pupil change late
Rapid deterioration and death
What bacteria are the most likely causes of bacterial meningitis in a young adult group?
Young adult – N. meningitides and S. Pneumonia
