2: Neuro Emergencies

Question 1

Which mentation change(s) indicate brainstem involvement?

Answer 1

Stuporous & comatose

Question 2

What are examples of systemic causes of mentation changes?

Answer 2

Toxins
Metabolic Issues
Cardiovascular Events

Question 3

What is the treatment approach for mentation changes?

Answer 3

Correct Temp/metabolic derangements
Treat what you can at the moment (Toxin if applicable, blood pressure, etc)
Evaluate signs of increased ICP
Maintain CPP
Decrease ICP (Mannitol or Hypertonic, Craniectomy)

Question 4

What are signs of increased ICP?

Answer 4

Cushing’s Effect
Pupil Changes
Proprioceptive/CN deficits
Decerebrate posture

Question 5

What are the methods for decreasing ICP?

Answer 5

Decreasing edema: Mannitol or Hypertonic Saline
Increase space: Craniectomy or lesion removal

Question 6

What clinical signs do you see with the Cushings’ Reflex?

Answer 6

Severe hypertension with reflex bradycardia

Question 7

Definition of Status Epilepticus?

Answer 7

Failure of seizure to terminate
Any seizure lasting >5 min or >2 seizures without return to normal consciousness

Question 8

What are some systemic effects of status epilepticus?

Answer 8

hypertension, tachycardia, arrhythmias, hyperglycemia, respiratory compromise, hyperthermia, acidosis, myoglobinuria

Question 9

Death from status epilepticus is a result of which processes?

Answer 9

Brain herniation
Ventricular arrhythmias
Respiratory compromise
Renal failure (after days of myoglobinuria)

Question 10

What is the immediate treatment for status epilepticus?

Answer 10

Check temperature & initiate active cooling, O2 supplementation,
Anti-Seizure Drugs:
Fast: Diazapam or Midazolam; 3 failed benzos-> anesthetic dose of propofol
Long: Phenobarb/Keppra

Question 11

Why is it important to also start a long-acting seizure drug when treating status epilepticus?

Answer 11

Benzodiazepines only stay in the brain for ~5min.
Most patients will need a long term long acting anyway

Question 12

What are the two major groups of etiologies of status epilepticus?

Answer 12

Reactive, Epileptic

Question 13

What are two major causes of reactive status epilepticus?

Answer 13

Metabolic & Toxic

Question 14

What are the three categories of epilepsy?

Answer 14

EUC
Idiopathic
Structural

Question 15

The first step in treating a traumatic brain injury is determined by what factor?

Answer 15

Is the patient seizing?
If yes, stop seizure
If no, systemic eval

Question 16

What are the 3 categories evaluated by the Modified Glasgow Coma Score?

Answer 16

Motor Activity, Brain Stem Reflexes, Level of consciousness

Question 17

What are the tiered treatments of TBIs?

Answer 17

Tier 1- Fluid therapy, ventilation
Tier 2- Mannitol/Hypertonic, 30º Head Elevation
Tier 3- Surgical decompression, hyperventilation, hypothermia