3 - Neurological Emergencies Flashcards
What is a bulbar palsy and how does it present?
LMN lesion of CN 9, 10 and 12 causing issues with speech and swallowing
- Flaccid fasiculating tongue
- Absent or normal jaw jerk reflex
- Absent gag reflex
- Nasal quiet speech
What are the cause of an acute bulbar palsy
(Image important)
- GBS
- Myasthenia Gravis
- Stroke (Lateral Medullary Syndrome)
- MND
- Syringobulbia
What is a pseudobulbar palsy?
A bilateral lesion of the corticobulbar tracts so affects CN 9, 10 and 12
UMN lesion of speech and swallow
Has to be bilateral lesion as CN nuclei have bilateral input
How does pseudobulbar palsy present?
Presentation
- Spastic tongue
- Increased jaw jerk reflex
- Slow deliberate speech
- Increased gag reflex
- Emotional lability
What are some causes of pseudobulbar palsy?
- Vascular: bilateral internal capsule stroke
- Degenerative: MND, progressive supranuclear palsy
- Autoimmune: MS
- Upper brain stem tumours
- Trauma
How is the pseudobulbar affect treated?
Dextromethorphan and Quinidine
Why is temporal arteritis an emergency?
Bilaterally sight threatening vasculitis!!!!!
Also a stroke risk
What symptoms should make you consider temporal arteritis?
- Headache
- Scalp tenderness
- Jaw claudication
- Sudden unilateral blindness
- Amaurosis Fugax
- History of PMR
- >55
What investigations should you do if you suspect GCA?
- CRP and ESR: raised
- FBC: normocytic anaemia, raised platelets
- LFTs: raised ALP
- Temporal artery biopsy: within 14 days of starting steroids, take around 3-5cm due to skip lesions, if nothing then biopsy asymptomatic side too
What is the management for a suspected case of GCA?
- Immediate high dose steroids: before TAB (60mg PO prednisolone) to prevent blindness and stroke
- Low dose aspirin
- PPI: Gastric protection
- Bisphosphonate and Adcal: Bone protection
What is the prognosis with GCA?
Usually a 2 year course then full remission if tapered slowly
Wean down prednisolone as symptoms improve and ESR declines
What are some signs of respiratory distress?
- Tachypnoea
- Nasal Flaring
- Tracheal tug
- Use of accessory muscles
- Intercostal, subcostal and sternal recession
- Pulsus paradoxus
- Abnormal sounds
How do you manage a respiratory arrest?
- Call for help
- Check pulse every 2 minutes
- Head-tilt-Chin-lift (if C-Spine injury do jaw thrust)
- Bag Valve Mask every 5-6 seconds
- Consider oral or nasopharyngeal adjunct
- Prepare for advanced airway e.g laryngeal mask
- 15L supplemental oxygen through BVM
What are some neurological causes of respiratory distress/arrest?
- Drive Failure: centrally acting drugs, tonsillar herniation due to raised ICP, Stroke
- Transmission Failure: GBS, MG, Spinal Cord Lesion, MND
- Action Failure: Muscular dystrophies, myopathies
How can you manage respiratory distress?
Ix:
- CXR
- ABG
- Review drug chart e.g opioids
- U+Es
Mx:
- Oxygen
- CPAP
- Consider need for invasive ventilation
Head trauma patients are treated with an ABCDE approach. What are some alterations made in the A to E process when there is head trauma?
- Do not use nasopharyngeal airway as can cause damage if skull fracture
- Do not do Head-tilt-Chin-lift if C-Spine injury, do Jaw Thrust
What is the immediate management for a patient with a head injury?
- Stabilise C-spine, Airway, Breathing and Circulation
- Assess GCS: If 8 or less need urgent ICU involvement to manage airway
- Assess antegrade/retrograde amnesia
- Neurological examination: start neuro obs
- Consider need for imaging
Whay is the criteria for performing a CT head scan within 1 hour of head injury? (immediately)
- GCS <13 on initial assessment
- GCS <15 at 2 hours after the injury on assessment in ED
- Suspected open or depressed skull fracture
- Any sign of basal skull fracture (haemotympanum, ‘panda’ eyes, CSF from the ear or nose, Battle’s sign)
- Post-traumatic seizure
- Focal neurological deficit.
- More than 1 episode of vomiting.
What parameters are included in neuro obs and how often should they be taken?
What is the criteria for performing a CT head scan within 8 hours following head injury?
Any loss of consciousness or amnesia since the injury AND ONE OF:
- Aged 65 or more
- History of bleeding or clotting disorders (inc taking warfarin)
- High-impact injury (e.g fall>1m or >5 stairs or struck by moving vehicle)
- Retrograde amnesia >30 minutes
For suspected cervical spine injuries, when should you perfor a CT cervical spine within an hour?
- GCS <13 on initial assessment
- Patient has been intubated
- Definitive diagnosis of cevical spine injury is needed urgently e.g beforre surgery
- Patient is having other body areas scanned e.g multitrauma
- See image
When should you discuss a patient with a headinjury with the neurosurgeons?
- Significant abnormalities on CT
- Persistent GCS of 8 or less
- Deteriorating GCS
- Focal neurology
- Seizure without full recovery
- CSF LEAK
What are some complications of a head injury?
Early
- Extradural/subdural haemorraghe
- Seizures
Late
- Subdural
- Seizures
- Diabetes Insipidus
- Parkinsonism
- Dementia
What are some causes of impaired conscious level/coma?
Metabolic: drugs, alcohol, CO, hypoglycaemia, hypothermia, sepsis, hypoxia
Neurological: trauma, meningitis, tumour, stroke, haemorraghe, epilepsy
How do you manage a patient that has arrived in ED comatosed?
A to E:
- Consider intubation if GCS<8
- Give O2 and treat any seizures
- Protect cervical spine
- Checl BM
- IV naloxone if opioid intoxication, IV flumazenil if benzodiazepine intoxication and airway compromise
Full Body Exam
Collalteral History:
- How they were found
- Recent complaints and PMHx inc DHx
- Drug or Alcohol Exposure
Arrange Urgent CT head
How do you calculate GCS?
Best response
How may spinal cord compression present?
- Bilateral leg weakness (arms if C-spine)
- Sensory level
- Preceding back pain
- Bladder and anal sphincter (involved late, hesitancy/frequency/retention)
- LMN sign at level of lesion, UMN below: remember acute cord compression may show LMN signs e.g reduced reflexes but actually be UMN
What are some causes of spinal cord compression?
- Trauma
- Metastases from BLTKP
- Infection (especially TB in at-risk patients)
- Disc prolapse
- Epidural haematoma (on warfarin)
- Myeloma
How is suspected spinal cord compression investigated and managed? (same as CES)
Ix
- Urgent whole spine MRI
- PR Exam
- CXR: metastases, TB
- Bloods: FBC, ESR, B12, U+Es, LFTs, PSA, serum electrophoresis
Mx
- Urgent dexamethasone if malignancy given daily with PPI cover
- Surgical decompression (laminectomy) within 48 hours as otherwise permanent neurological deficits
What are some differential diagnoses for spinal cord compression?
- Transverse myelitis
- MS
- GBS
- Spinal artery thrombosis or aneurysm
What is the difference in presentation between spinal cord compression and cauda equina syndrome?
How can metastases cause spinal cord compression?
- Collapse of vertebrae
- Extension of tumour into cord
What is the difference in presentaion between cauda equina and conus medullaris syndrome?
CES
- Back and radicular leg pain
- Asymmetrical atrophic areflexic paralysis of legs (LMN)
- Sensory loss in root distribution
- Decreased sphincter tone
Conus Medullaris
- Mixed UMN/LMN
- Leg weakness
- Early urinary retention and constipation
- Back pain
- Sacral sensory disturbance
What is the definition of a stroke?
Cerebrovascular event that is caused by abnormal perfusion of cerebral tissue
Sudden onset of rapidly developing focal or global neurological disturbance, which lasts more than 24 hours
Ischaemic or Haemorraghic
How are strokes classified?
-
Ischaemic (85%): Oxford/Bamford Classification
- Haemorraghic (15%): Intracerebral or SAH
What are some causes of stroke?
- Ischaemic: Thrombosis, Emboli, Dissection
- Haemorraghic: HTN, AV malformation, Trauma, Bleeding disorders, Vasculitis
What are some risk factors for a stroke?
- Smoking
- Diabetes mellitus
- Hypertension
- Hypercholesterolaemia
- Obesity
- Atrial fibrillation
- Carotid artery disease
- Age
- Thrombophilic disorders (e.g. antiphospholipid syndrome)
- Sickle cell disease
What is the blood supply to each part of the brain?
Anterior Circulation: From ICA
Posterior Circulation: From Vertebrobasilar circulation
What are the different classifications of stroke in the Bamford/Oxford classification?
Remember criteria at bottom of table
What are some of the signs and symptoms of the following types of strokes:
- Haemorraghic
- Anterior Ischaemic
- Posterior Ischaemic
Haemorraghic
- Headache
- Altered mental status
- Nausea & Vomiting
- Hypertension
- Seizures
- Focal neurological deficits
Anterior Ischaemic
- Unilateral contralateral weakness and/or sensory deficit: face and/or arms and/or legs
- Homonymous hemianopia
- Higher cerebral dysfunction: dysphasia, visuospatial dysfunction (e.g. neglect, agnosia)
Posterior Ischaemic
- Dizziness
- Diplopia
- Dysarthria & Dysphagia
- Ataxia
- Visual Field defects
- Brainstem syndromes (ipsilateral cranial nerve lesions with contralateral sensory and motor limb deficits)
What is Wallenburg and Locked-In Syndrome?
Wallenburg/Lateral Medullary syndrome
- Posterior inferior cerebellar artery occlusion
- Nystagmus, Vertigo, Ipsilateral Horner’s syndrome, Ipsilateral facial sensory loss, Dysarthria & dysphagia
- Diplopia
- Contralateral pain and temperature loss