3- Neurologic Emergencies Flashcards
What is considered normal ICP in adults?
≤ 15 mmHg
Following a significant increase in ICP, what can brain injury result from?
Brainstem compression
Reduction in cerebral perfusion pressure (CPP)
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?
Increased ICP
(bradycardia, HTN, and respiratory depression = Cushing’s triad)
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?
Decorticate posturing
Lesion in corticospinal tract from cortex to upper midbrain
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?
Decerebrate posturing
Damage to corticospinal tract at level of brainstem
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?
26-30 mmHg
What med is used for osmotic diuresis in the management of increased ICP?
Mannitol
Aside from resuscitation and Mannitol, what else is included in the management of increased ICP?
Elevate head of bed to 30 deg
Treat fever aggressively (mechanical cooling)
ICP < 20
STAT neurosurgery consult
Continued ICP monitoring is indicated for at risk pts, GCS < 8 and aggressive medical care. What is the gold standard of ICP monitoring?
Intraventricular monitors
(allows for CSF drainage, disadvantages = infection, hemorrhage w/ placement)
In pts with skull fracture, aside from AMS, CN/ neuro deficits, and scalp lacerations/ contusions, when should the airway be protected?
Bony “step-off” of skull
Periorbital/ retroauricular ecchymosis
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?
Linear
Pt experiences linear skull fracture to temporal bone. What should you be concerned for?
Can disturb vascular structures w/ sig bleeding
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?
Observe in ED for 4-6 hours, discharge w/ home supervision
What type of fracture requires significant force/ direct blow and often involves injury to brain parenchyma?
Depressed skull fracture
(segment of skull driven below level of adjacent skull)
What should be avoided in the eval of open depressed fractures?
Examined but NOT probed
What is the general management for a depressed skull fracture?
CT scan, admit to neurosurgery
What type of skull fracture can produce a dural tear resulting in communication between the subarachnoid space, paranasal sinus, and middle ear?
Basilar skull fracture
What might you note on PE of basilar skull fracture if leakage of CSF?
Clear/ blood-tinged rhinorrhea/ otorrhea
Basilar skull fracture can lead to what additional injuries/ complications?
(aside from CSF leak, infection, CN injury)
IC hemorrhage, epidural hematoma (through temporal bone)
What is the management for a basilar skull fracture?
Admit for observation (regardless of need for surgery)
Neurosurgical/ neurology consult
Close neurologic monitoring
Penetrating skull fractures typically involve significant brain injury and ICH. What is the management?
(gunshot wounds, stab wounds, blast injuries)
Consult neurosurgery immediately
IV abx
What type of skull fracture is most commonly a/w a GSW and what is the management?
Tangential skull fracture, risk for ICH
Emergenct CT scan
What is 1st line imaging for skull fractures?
Non-contrast CT
Then MRI secondary for vascular injury
+/- CT cervical spine (+ findings/ AMS)
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?
Concussion (mild TBI)
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?
Brain contusion
What is the common mechanism of injury for a closed head injury?
Coup (primary impact)/ contrecoup (secondary impact)
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?
Urgent neuroimaging and neurosurgical consultation
When is it indicated to send a pt home after presenting with a closed head injury?
GCS = 15
Normal PE/ CT head
No predisposition to bleeding
Responsible monitor available for home
What is caused by shearing of white matter tracts from traumatic, sudden deceleration injury (blunt trauma) leading to severe intracranial injury?
Diffuse axonal injury (DAI)
(axon disruptions, swelling, cell death)
What head injury is a/w posttraumatic coma and is a frequent cause of persistent vegetative state?
Diffuse axonal injury (DAI)
What is the imaging/ management for DAI?
CT scan
No surgical intervention
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?
DAI
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?
Epidural (between skull and dura mater, usually middle meningeal artery)
CT scan showing lens-shape and bleeding that does not cross suture lines is concerning for what type of hematoma?
Epidural
Pt with brain atrophy (elderly/ alcoholic) presents with hx of traumatic fall. What type of hematoma are you concerned for?
Subdural (between dura mater and arachnoid, tearing of bridging veins)
CT scan showing crescent-shape and bleeding that crosses suture lines is concerning for what type of hematoma?
Subdural
When are sxs experienced for acute, subacute, and chronic subdural hematoma?
Acute- w/i 24-48 hrs after onset
Subacute- 3-14 days after onset
Chronic- > 2 weeks after onset
What is included in the management for intracranial hematomas?
Emergent neurosurgical consult +/- anti-coag reversal (necessary if surgical intervention)
Craniotomy w/ hematoma evacuation vs observation w/ serial head CT
Most cases of subarachnoid hemorrhages are non-traumatic. What is the most common cause?
Aneurysm
(high associated mortality)
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?
Subarachnoid hemorrhage
What rule can help you r/o SAH and what is included in it? (6)
Ottawa SAH rule
- Age ≥ 40
- Neck pain/ stiffness
- Limited neck flexion
- Witnessed LOC
- Onset during exertion
- Thunderclap HA
In addition to BP control and maintaining euvolemia, what is included in the management of SAH?
CT
+ LP if CT (-) and SAH suspected (or CTA)
Neurosurgical/ interventional neuroradiologist referral
What is the most common complication of SAH?
Increased ICP
What is the 2nd most common cause of stroke?
Intracranial hemorrhage
(neuro/ medical emergency- can lead to permanent disability/ death)
What is the inital goal of tx of ICH?
Preventing hemorrhage extension
What is the most common non-traumatic cause of ICH?
HTN
What imaging is indicated for ICH?
Emergent non-contrast CT
(MRI helpful for smaller lesions)
What is included in the management for ICH?
BP control (140-160/90)
Glucose between 140-180
Emergent neurosurgical consult + admit to ICU
What is the management for a stroke?
Non-contrast CT (w/i 20 min)
ASA if CT shows non-hemorrhagic CVA (w/i 24-48 hrs)
Emergent neuro consult
What are the 3 most predictive exam findings for dx of ischemic stroke?
Facial paresis
Arm drift/ weakness, arm or leg paresis
Abn speech
When managing a pt with ischemic stroke, what is the protocol if they are NOT a candidate for IV thrombolysis?
Allow for permissive HTN, no intervention unless > 220/ 120
When managing a pt with ischemic stroke, what is the protocol if they ARE a candidate for IV thrombolysis?
Sx onset < 4.5 hrs
BP goal: ≤ 185/ ≤ 110
Infusion ≤ 60 min from ED arrival
(informed conset b/c risk of hemorrhage)
Post-traumatic status epilepticus (secondary cause) typically occurs how long after injury?
(secondary- results from another identifiable neuro condition/ infection)
W/i 1st week
How is status epilepticus defined?
Seizure ≥ 5 min continuously
OR
≥ 2 discrete seizures w/ incomplete recovery
What is the use of NM blocking agents used for intubation in status epilepticus management?
Block motor function but do NOT stop seizure activity
(MUST be on continuous EEG for monitoring)
Pt presents with status epilepticus and has a known seizure disorder. What do you check?
Anticonvulsant levels
What is included in the general management for pt with status epilepticus?
ABCs, 2 IVs, EEG monitoring, admit to neuro ICU
What is included in the pharmacologic management of a pt with status epilepticus?
Benzo + antiseizure drug
→ continued seizures: can repeat x 1 + intubate
→ continued seizures: IV infusion of midazolam or propofol or pentobarbital
What are the c-spine nexus criteria in which if ALL 5 criteria are met, no imaging is needed?
- Absence of posterior midline tenderness
- N level of altertness
- No evidence of intoxication
- No abn neuro findings
- No painful, distracting injuries
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?
Jefferson/ “burst” fx (C1, atlas)
Xray → CT
What type of fx is highly unstable and occurs from extreme hyperextension as a result of abrupt deceleration?
Pedicle fracture/ Hangman’s (C1, axis)
Odontoid (dens) fractures are caused by forceful flexion or extension and are classified as type I-III. How are the types distinguished?
Type I- above transverse ligament, stable
Type II- base of dens, unstable
Type III- through upper body of C2, unstable
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?
Burst fx
Absent reflexes, flaccid muscles, loss of sensation, priapism in men, and urinary retention are sxs a/w what SCI (spinal cord injury)?
Complete, acute < 1 day
Hyperreflexia, (+) Babinski, and spasticity are sxs a/w what type of SCI?
Complete, 1-3 days later
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?
Incomplete SCI- anterior (ventral)
(anterior 2/3 of spinal cord)
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?
Incomplete SCI- central cord syndrome
(medial aspect of central cord)
Pt who presents with motor weakness, hyperreflexia, gait ataxia, and paresthesia but with initally preserved bladder function is indicative of what type of SCI?
Incomplete SCI- posterior (dorsal) cord syndrome
(bilateral involvement of dorsal columns and corticospinal tracts)
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?
Incomplete SCI- Brown Sequard
(lateral hemi section, dorsal column unilaterally, good prognosis)
SCI can result in what complication?
Neurogenic shock
(cervical spine injury most common)
What is included in the management for a SCI aside from ABCs?
Immobilize spine
Urinary cath ASAP
X-ray → CT/ MRI
Neurosurgery consult ASAP
What condition is a surgical emergency involving compression of lumbar, sacral, and coccygeal nerve roots, and can be a/w hx of malignancy?
Cauda Equina Syndrome
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)
Cauda Equina Syndrome
What is the management for Cauda Equina syndrome?
Dexamethasone 10mg IV
Emergent MRI w/ or w/o contrast
Assess spinal stability (spinal surgeon)
Urgent orthopedic surgical consult
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?
Guillen Barre’
What typically precedes the onset of the neurologic disease of Guillen Barre’?
Mild URI/ gastroenteritis by 1-3 weeks
C. jejuni
Pt who presents with absent/ depressed DTRs, CN involvement, respiratory weakness, dysautonomia and no fever is concerning for what?
Guillen Barre’
How is Guillen Barre’ diagnosed, aside from clinical presentation?
CSF studies (elevated protein, N WBC)
EMG-NCS (during course of admission)
What is the treatment for Guillen Barre’?
Admit to ICU
IVIG/ plasmapheresis (during course of admission)
