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3. E Med & Surgery > 3- Neurologic Emergencies > Flashcards

3- Neurologic Emergencies Flashcards

1
Q

What is considered normal ICP in adults?

A

≤ 15 mmHg

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2
Q

Following a significant increase in ICP, what can brain injury result from?

A

Brainstem compression

Reduction in cerebral perfusion pressure (CPP)

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3
Q

Pt presents w/ HA, N/V, papilledema, uni/ bilateral fixed pupil, decreased consciousness, decorticate/ decerebrate posturing, and bradycardia, HTN, and respiratory depression. What are you concerned for?

A

Increased ICP

(bradycardia, HTN, and respiratory depression = Cushing’s triad)

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4
Q

Pt presents with flexor response, flexion with adduction of arms and extension of legs. What is this called and where are you concerned for a lesion?

A

Decorticate posturing

Lesion in corticospinal tract from cortex to upper midbrain

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5
Q

Pt presents with extensor posturing, extension, adduction, and internal rotation of the arms and extension of the legs. What is this called and where are you concerned for a lesion/ damage?

A

Decerebrate posturing

Damage to corticospinal tract at level of brainstem

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6
Q

Resuscitaion/ ABCs of increased ICP management includes avoiding hypoxia, maintaining O2 sat > 90%, keeping BP w/i range and hyperventilation to a PCO2 of what range?

A

26-30 mmHg

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7
Q

What med is used for osmotic diuresis in the management of increased ICP?

A

Mannitol

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8
Q

Aside from resuscitation and Mannitol, what else is included in the management of increased ICP?

A

Elevate head of bed to 30 deg

Treat fever aggressively (mechanical cooling)

ICP < 20

STAT neurosurgery consult

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9
Q

Continued ICP monitoring is indicated for at risk pts, GCS < 8 and aggressive medical care. What is the gold standard of ICP monitoring?

A

Intraventricular monitors

(allows for CSF drainage, disadvantages = infection, hemorrhage w/ placement)

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10
Q

In pts with skull fracture, aside from AMS, CN/ neuro deficits, and scalp lacerations/ contusions, when should the airway be protected?

A

Bony “step-off” of skull

Periorbital/ retroauricular ecchymosis

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11
Q

What type of skull fracture typically has no associated neuro sxs, most commonly occurs in the temporoparietal, frontal, and occipital regions and warrants a neurosurgery consult?

A

Linear

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12
Q

Pt experiences linear skull fracture to temporal bone. What should you be concerned for?

A

Can disturb vascular structures w/ sig bleeding

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13
Q

Pt presents with linear skull fracture. If CT shows no underlying brain injury and pt does not exhibit any neuro deficit, what is the appropriate management?

A

Observe in ED for 4-6 hours, discharge w/ home supervision

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14
Q

What type of fracture requires significant force/ direct blow and often involves injury to brain parenchyma?

A

Depressed skull fracture

(segment of skull driven below level of adjacent skull)

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15
Q

What should be avoided in the eval of open depressed fractures?

A

Examined but NOT probed

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16
Q

What is the general management for a depressed skull fracture?

A

CT scan, admit to neurosurgery

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17
Q

What type of skull fracture can produce a dural tear resulting in communication between the subarachnoid space, paranasal sinus, and middle ear?

A

Basilar skull fracture

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18
Q

What might you note on PE of basilar skull fracture if leakage of CSF?

A

Clear/ blood-tinged rhinorrhea/ otorrhea

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19
Q

Basilar skull fracture can lead to what additional injuries/ complications?

(aside from CSF leak, infection, CN injury)

A

IC hemorrhage, epidural hematoma (through temporal bone)

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20
Q

What is the management for a basilar skull fracture?

A

Admit for observation (regardless of need for surgery)

Neurosurgical/ neurology consult

Close neurologic monitoring

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21
Q

Penetrating skull fractures typically involve significant brain injury and ICH. What is the management?

(gunshot wounds, stab wounds, blast injuries)

A

Consult neurosurgery immediately

IV abx

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22
Q

What type of skull fracture is most commonly a/w a GSW and what is the management?

A

Tangential skull fracture, risk for ICH

Emergenct CT scan

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23
Q

What is 1st line imaging for skull fractures?

A

Non-contrast CT

Then MRI secondary for vascular injury

+/- CT cervical spine (+ findings/ AMS)

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24
Q

What is defined as trauma-induced alteration in mental status +/- LOC typically resulting from a direct blow w/ an impulsive force transmitted to the head?

A

Concussion (mild TBI)

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25
Q

What is defined as areas of bruising a/w localized ischemia, edema, and mass effect usually resulting from direct external contact force or acceleration/ decceleration trauma?

A

Brain contusion

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26
Q

What is the common mechanism of injury for a closed head injury?

A

Coup (primary impact)/ contrecoup (secondary impact)

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27
Q

What is indicated if a pt presents with a closed head injury along with any AMS, associated sxs, fracture, ≥ 60 yo, predisposition to bleeding, amnesia > 30 min, high impact injury, and intoxication?

A

Urgent neuroimaging and neurosurgical consultation

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28
Q

When is it indicated to send a pt home after presenting with a closed head injury?

A

GCS = 15

Normal PE/ CT head

No predisposition to bleeding

Responsible monitor available for home

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29
Q

What is caused by shearing of white matter tracts from traumatic, sudden deceleration injury (blunt trauma) leading to severe intracranial injury?

A

Diffuse axonal injury (DAI)

(axon disruptions, swelling, cell death)

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30
Q

What head injury is a/w posttraumatic coma and is a frequent cause of persistent vegetative state?

A

Diffuse axonal injury (DAI)

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31
Q

What is the imaging/ management for DAI?

A

CT scan

No surgical intervention

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32
Q

CT scan showing blurring of grey-to-white matter margin, small lesions in white motor tracts, cerebral hemorrhages, or cerebral edema is concerning for what?

A

DAI

33
Q

Adolescent or young adult pt presents with hx of trauma and skull fracture. Presentation includes brief LOC followed by a lucid interval and rapid deterioration. What type of hematoma are you concerned for?

A

Epidural (between skull and dura mater, usually middle meningeal artery)

34
Q

CT scan showing lens-shape and bleeding that does not cross suture lines is concerning for what type of hematoma?

A

Epidural

35
Q

Pt with brain atrophy (elderly/ alcoholic) presents with hx of traumatic fall. What type of hematoma are you concerned for?

A

Subdural (between dura mater and arachnoid, tearing of bridging veins)

36
Q

CT scan showing crescent-shape and bleeding that crosses suture lines is concerning for what type of hematoma?

A

Subdural

37
Q

When are sxs experienced for acute, subacute, and chronic subdural hematoma?

A

Acute- w/i 24-48 hrs after onset

Subacute- 3-14 days after onset

Chronic- > 2 weeks after onset

38
Q

What is included in the management for intracranial hematomas?

A

Emergent neurosurgical consult +/- anti-coag reversal (necessary if surgical intervention)

Craniotomy w/ hematoma evacuation vs observation w/ serial head CT

39
Q

Most cases of subarachnoid hemorrhages are non-traumatic. What is the most common cause?

A

Aneurysm

(high associated mortality)

40
Q

Pt presents with “worst HA of their life” or “thunderclap” HA and hx of exertion or valsalva immediately preceding onset of HA. What are you concerned for?

A

Subarachnoid hemorrhage

41
Q

What rule can help you r/o SAH and what is included in it? (6)

A

Ottawa SAH rule

  • Age ≥ 40
  • Neck pain/ stiffness
  • Limited neck flexion
  • Witnessed LOC
  • Onset during exertion
  • Thunderclap HA
42
Q

In addition to BP control and maintaining euvolemia, what is included in the management of SAH?

A

CT

+ LP if CT (-) and SAH suspected (or CTA)

Neurosurgical/ interventional neuroradiologist referral

43
Q

What is the most common complication of SAH?

A

Increased ICP

44
Q

What is the 2nd most common cause of stroke?

A

Intracranial hemorrhage

(neuro/ medical emergency- can lead to permanent disability/ death)

45
Q

What is the inital goal of tx of ICH?

A

Preventing hemorrhage extension

46
Q

What is the most common non-traumatic cause of ICH?

A

HTN

47
Q

What imaging is indicated for ICH?

A

Emergent non-contrast CT

(MRI helpful for smaller lesions)

48
Q

What is included in the management for ICH?

A

BP control (140-160/90)

Glucose between 140-180

Emergent neurosurgical consult + admit to ICU

49
Q

What is the management for a stroke?

A

Non-contrast CT (w/i 20 min)

ASA if CT shows non-hemorrhagic CVA (w/i 24-48 hrs)

Emergent neuro consult

50
Q

What are the 3 most predictive exam findings for dx of ischemic stroke?

A

Facial paresis

Arm drift/ weakness, arm or leg paresis

Abn speech

51
Q

When managing a pt with ischemic stroke, what is the protocol if they are NOT a candidate for IV thrombolysis?

A

Allow for permissive HTN, no intervention unless > 220/ 120

52
Q

When managing a pt with ischemic stroke, what is the protocol if they ARE a candidate for IV thrombolysis?

A

Sx onset < 4.5 hrs

BP goal: ≤ 185/ ≤ 110

Infusion ≤ 60 min from ED arrival

(informed conset b/c risk of hemorrhage)

53
Q

Post-traumatic status epilepticus (secondary cause) typically occurs how long after injury?

(secondary- results from another identifiable neuro condition/ infection)

A

W/i 1st week

54
Q

How is status epilepticus defined?

A

Seizure ≥ 5 min continuously

OR

≥ 2 discrete seizures w/ incomplete recovery

55
Q

What is the use of NM blocking agents used for intubation in status epilepticus management?

A

Block motor function but do NOT stop seizure activity

(MUST be on continuous EEG for monitoring)

56
Q

Pt presents with status epilepticus and has a known seizure disorder. What do you check?

A

Anticonvulsant levels

57
Q

What is included in the general management for pt with status epilepticus?

A

ABCs, 2 IVs, EEG monitoring, admit to neuro ICU

58
Q

What is included in the pharmacologic management of a pt with status epilepticus?

A

Benzo + antiseizure drug

→ continued seizures: can repeat x 1 + intubate

→ continued seizures: IV infusion of midazolam or propofol or pentobarbital

59
Q

What are the c-spine nexus criteria in which if ALL 5 criteria are met, no imaging is needed?

A
  1. Absence of posterior midline tenderness
  2. N level of altertness
  3. No evidence of intoxication
  4. No abn neuro findings
  5. No painful, distracting injuries
60
Q

What type of fracture is highly unstable, caused by vertical compression transmitted to lateral masses of the atlas, and results in fractures of the anterior/ posterior arches of C1? What imaging is needed?

A

Jefferson/ “burst” fx (C1, atlas)

Xray → CT

61
Q

What type of fx is highly unstable and occurs from extreme hyperextension as a result of abrupt deceleration?

A

Pedicle fracture/ Hangman’s (C1, axis)

62
Q

Odontoid (dens) fractures are caused by forceful flexion or extension and are classified as type I-III. How are the types distinguished?

A

Type I- above transverse ligament, stable

Type II- base of dens, unstable

Type III- through upper body of C2, unstable

63
Q

What type of fx affects the lower cervical vertebra, is caused by direct axial load, and involves displaced fragments that can enter the spinal cord?

A

Burst fx

64
Q

Absent reflexes, flaccid muscles, loss of sensation, priapism in men, and urinary retention are sxs a/w what SCI (spinal cord injury)?

A

Complete, acute < 1 day

65
Q

Hyperreflexia, (+) Babinski, and spasticity are sxs a/w what type of SCI?

A

Complete, 1-3 days later

66
Q

Pt who presents with motor impairment, reflex changes, bilateral loss of pain/ temp, and bladder dysfunction, but with preserved tactile, propropception, and vibratory sesation is indicative of what type of SCI?

A

Incomplete SCI- anterior (ventral)

(anterior 2/3 of spinal cord)

67
Q

Pt who presents with motor impairment in UE > LEs, variable sensory loss below level of injury, loss of DTRs at level of injury, but with preserved vibration and propropception is indicative of what type of SCI?

A

Incomplete SCI- central cord syndrome

(medial aspect of central cord)

68
Q

Pt who presents with motor weakness, hyperreflexia, gait ataxia, and paresthesia but with initally preserved bladder function is indicative of what type of SCI?

A

Incomplete SCI- posterior (dorsal) cord syndrome

(bilateral involvement of dorsal columns and corticospinal tracts)

69
Q

Pt who presents with ipsilateral motor paralysis, loss of proprioception/ vibration, and contralateral loss of pain/ temp, but with preserved bladder function is indicative of what type of SCI?

A

Incomplete SCI- Brown Sequard

(lateral hemi section, dorsal column unilaterally, good prognosis)

70
Q

SCI can result in what complication?

A

Neurogenic shock

(cervical spine injury most common)

71
Q

What is included in the management for a SCI aside from ABCs?

A

Immobilize spine

Urinary cath ASAP

X-ray → CT/ MRI

Neurosurgery consult ASAP

72
Q

What condition is a surgical emergency involving compression of lumbar, sacral, and coccygeal nerve roots, and can be a/w hx of malignancy?

A

Cauda Equina Syndrome

73
Q

Pt presents with LBP w/ radiation into leg(s), leg weakness, plantar flexion/ ankle reflex weakness, and perineal sensory loss. What condition are you concerned for?

(perineal sensory loss- saddle anesthesia, urinary retention, decreased anal sphincter tone, sexual dysfunction)

A

Cauda Equina Syndrome

74
Q

What is the management for Cauda Equina syndrome?

A

Dexamethasone 10mg IV

Emergent MRI w/ or w/o contrast

Assess spinal stability (spinal surgeon)

Urgent orthopedic surgical consult

75
Q

What condition is defined as acute onset of peripheral neuropathy (immune-mediated), is the most common demyelination neuropathy, and is a/w distal → proximal symmetric, ascending muscle weakness?

A

Guillen Barre’

76
Q

What typically precedes the onset of the neurologic disease of Guillen Barre’?

A

Mild URI/ gastroenteritis by 1-3 weeks

C. jejuni

77
Q

Pt who presents with absent/ depressed DTRs, CN involvement, respiratory weakness, dysautonomia and no fever is concerning for what?

A

Guillen Barre’

78
Q

How is Guillen Barre’ diagnosed, aside from clinical presentation?

A

CSF studies (elevated protein, N WBC)

EMG-NCS (during course of admission)

79
Q

What is the treatment for Guillen Barre’?

A

Admit to ICU

IVIG/ plasmapheresis (during course of admission)

3. E Med & Surgery (19 decks)

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